What does it mean to be Autistic? In clinical psychology we currently use the Diagnostic and Statistical Manual of Disorders, 5th Edition, Text Revision (DSM-5-TR) to diagnose Autism Spectrum Disorder. Autism, under this model of conceptualization, continues to be viewed and classified as a neurodevelopmental disorder. Many Autistic folks (both later-diagnosed or identified in earlier childhood) have found it more validating for their differences to be viewed as either having a disability, or having a different neurotype than others (such as neurotypical, ADHD, OCD, Bipolar, etc.).
I wanted to share my thoughts on how we can use more affirming, de-pathologizing language to describe Autistic traits and needs that can “map on” to the current DSM-5-TR criteria. When describing what it means to be Autistic in general, such an approach has been both validating and useful in my experience when working with Autistic clients (and honestly, with anyone I’m speaking to both professionally and personally about Autism). Thus, here are the current DSM-5-TR criteria for being diagnosed with Autism Spectrum Disorder, in addition to my reconceptualization of those symptoms as common traits and/or needs Autistic folks can have.
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following, currently or by history (examples are illustrative, not exhaustive; see text):
Rewording: Persistent differences in ways of preferred communication and interaction in different contexts as seen currently or by history:
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
Rewording: Difficulties reciprocating social and emotional patterns of communication. Some examples include: relating with others in ways deemed “abnormal” by neurotypical / shame-based standards, challenges having back and forth conversation with pacing, timing and/or content, not sharing emotions in neurotypical ways, difficulties starting social interactions or responding to them in ways labeled appropriate or “timely.”
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
Rewording: Difficulties utilizing, or preferences of not utilizing, non-verbal behaviors to communicate, including congruency between spoken and non-spoken communication, dislike of eye contact in different scenarios, challenges interpreting non-spoken communication, and/or preference for communicating without apparent facial expressions.
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Rewording: Preferences for making and keeping relationships and/or connections that may not align with neurotypical expectations. Examples include preferring to reply to text-based communication hours to days later, being content with extended periods of time without speaking to someone, challenges masking and adjusting to different social environments that are over-stimulating or create sensory-related overwhelm, seeking out social connections with those who share their interests or utilize neurodivergent love languages.
Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2).
Rewording: Specify level of support needs based on the person’s preferences, challenges, and aspirations for forming more connections and maintaining relationships.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
Rewording: Specific behaviors, thought processes, and/or activities repeatedly engaged in to soothe and cope with sensory, emotional, executive function, and/or social demands and stressors that are observable or describable by some of the following:
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
Rewording: Using one’s body or objects to repeatedly engage in an experience that provides soothing sensory input in order to to help regulate emotions, express joy, or relate with others.
Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
Rewording: Using routine, familiarity, and rituals to help ground one’s self in a sense of regulation and/or control. This can include use of daily habits or ways of speaking that are considered “correct,” safe, or that garner expected results.
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
Rewording: Deep, passionate energy for any subject(s) of interest, which can include a vast amount of knowledge about said subjects, a preference for engaging with them or activities based on them, or relating better with people who will reciprocate some form of relating around them (including info-dumping and parallel play).
Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
Rewording: Having hypo- and/or hyper-reactive nervous system responses to different sensory inputs (sight, sound, taste, touch, smell, vestibular, interoceptive) which can result in necessitated environmental changes or leaving specific environments to remain regulated.
Please note that all of the symptoms listed by the DSM-5-TR are to be carefully assessed if they were present during earlier developmental years, may have been masked by learned strategies, and that they can co-occur with other challenges such as having cognitive impairment, birth-related difficulties, differences in gene expression, and physical and/or emotional trauma during developmentally sensitive periods.
We absolutely should consider how cognitive difficulties and lower cognitive ability can be observed in Allistic people as well; they should not be conflated with the Autistic neurotype. This is especially important given that the DSM-5-TR continues to denote that Autism can be specified as co-occurring with such challenges, and that Autism Spectrum Disorder itself has grown conceptually from the earlier labels of “schizophrenic reaction” and Pervasive Developmental Disorder.
Let us strive to continue working on unlearning ableist viewpoints and expectations of each other. We are all trying to better understand how to help ourselves and our loved ones – when we discuss what it means to be Autistic, I think these traits and needs are a better starting point.
