DSM-5 Diagnostic Criteria for Autism May Lower Diagnosis Rates

This article originally appeared in the Fall 2019 issue of Columbia Nursing Magazine.

Approximately one in five individuals who would have received a diagnosis of autism spectrum disorder (ASD) using the previous Diagnostic and Statistical Manual of Mental Disorders criteria (in the fourth edition of the manual) does not meet the more-restrictive diagnostic criteria of the current DSM-5, an analysis from Columbia Nursing suggests.

As a result, individuals who have autism-like conditions and remain impaired but lack an official ASD diagnosis may not qualify for necessary services, wrote lead authors Kristine Kulage, MPH, director of research and scholarly development, and Arlene Smaldone, PhD, assistant dean of scholarship and research. “With more than one-fifth of individuals with notable social communication and interaction difficulties, coupled with disruptive, restrictive, repetitive behaviors who will no longer qualify for an ASD diagnosis, clinicians, researchers, and public health officials need to recognize that there are individuals lacking a diagnosis who remain in need of services,” the authors wrote.

To assess changes in the frequency of ASD diagnoses following publication of the DMS-5, Kulage, Smaldone, and colleagues conducted a systematic review and metanalysis of 33 studies conducted in the five years since the updated diagnostic criteria were published. They found that the more-restrictive criteria of the DSM-5 decreased the incidence of ASD diagnoses, although the decrease was lower than earlier estimates. “This may be because clinicians now have a greater comfort level with interpreting DSM-5 criteria. It could also indicate that fewer individuals are failing to receive an ASD diagnosis than what previous studies anticipated,” they wrote. Citing national data, the authors noted that nearly 30 percent of children in the United States with ASD are not receiving behavioral or medication treatment. It is the failure to diagnose ASD that, in some cases, may impede the timely and intensive treatment associated with improvement, they observed. “Our findings provide further insight regarding how the DSM-5 is being used nationally and internationally to diagnose, or fail to diagnose, those with ASD,” they wrote. “Future research is needed, as concerns remain for impaired individuals who, because of the change in diagnostic criteria for ASD, may no longer qualify for treatment but still demonstrate a need for services."

This study appeared in the March 9, 2019 online edition of the Journal of Autism and Developmental Disorders.