What is Autism?

Decoding the DSM-5 Criteria for Autism Spectrum Disorder (ASD)

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What is autism, really?

If you’re asking yourself this question, you are far from alone. Despite what you may have heard about it in your psychology class, autism is still being heavily researched and expanded on by researchers today. The book that psychiatrists and psychologists use to diagnose people is called The Diagnostic & Statistical Manual of Mental Disorders, or the DSM-5 for short.

This book has been expanded on and revised five times (hence the “-5” at the end), but it can be overly wordy—a beast to understand. I’m going to break down each section of the DSM-5 criteria for autism into digestible chunks so we can gain a foundational understanding of autism.

Before I begin, I want to note that the DSM-5 solely focuses on “deficits,” the negative impact of autism on an individual. While there are negative impacts of autism, receiving a diagnosis can sound like a death sentence. I’m here to tell you differently. There is more to autism than what the DSM-5 has to say about it. However, for the purpose of this post, I will leave it at that for now.

Autism, as defined in the DSM-5, is a developmental disorder that impacts the nervous systems and impairs the ability to communicate and interact. It is not supposed to be a trendy fad that antisocial kids throw around like a medal of honor. To understand what autism really is, we first need the foundational knowledge of how Autism Spectrum Disorder (ASD) is clinically diagnosed through the DSM-5.

Autism is diagnosed through the lens of five fundamental criteria:

A. Deficits in Social Communication & Interaction

B. Restricted, Repetitive Patterns of Behavior, Interests, or Activities

C. Symptoms Have Been Present Since Childhood

D. Symptoms Cause Significant Impairment

E. Intellectual Disability Does Not Necessarily Equal Autism

Let’s tackle Criteria A first, as it is the most important. The DSM-5 states that all three of the following points of Criteria A must be met to be clinically diagnosed with autism.

Criteria A: Deficits in Social Communication & Interaction

A: Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):

1. 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.

2. 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.

3. 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.

Notice the use of “persistent” in Criteria A. These social issues don’t just go away with time or maturity. They remain throughout one’s entire life, impacting multiple contexts—at home, at work, at school, out and about, etc. If you only see social deficits in one or even two different contexts, then you’re probably not autistic. There is likely something else going on.

There are several neurodivergent neurotypes acknowledged by the DSM-5 that are incredibly similar to autism, including ADHD (Attention Deficit Hyperactive Disorder), OCD (Obsessive Compulsive Disorder), and HSP (Highly Sensitive Person), to name a few. It is very common for people to get these neurodivergent neurotypes confused with each other.

The point remains: To be diagnosed with autism, symptoms must appear in childhood, and persist into adulthood.

Criteria A: Point 1

Let’s discuss the first required point for an autism diagnosis (if you need to reference it, please scroll back up). What does “abnormal social approach and failure of normal back-and-forth conversation” look like in real life?

It basically means constantly making social faux pas because you don’t understand the rules of social interaction. I’m not talking about not knowing what to say and generally feeling awkward during conversation (that is on the rise in everyone due to the disconnection brought by technology addiction). I’m talking about social anxiety because you have trouble both expressing yourself in ways that people understand and reading their body language to infer what they are saying.

This may look like leaping into a monologue about yourself or an interest when you meet someone. It could look like answering things very literally. It could also look like not understanding what the socially acceptable response is to the emotions of others. For example, if someone is crying, you may not know what the “correct” response is to their behavior. Essentially, the back-and-forth of neurotypical conversation doesn’t flow as smoothly for you.

Because of this, autistic people tend to bypass small talk in general and prefer deep conversations with others. They are not bothered by people cutting to the point and can be often described as rather blunt.

Criteria A: Point 2

The second required point for an autism diagnosis involves an atypical expression of nonverbal communication. One of the most common things people associate with autism is lack of eye contact, and this falls in that category, but it can also appear in more subtle ways. Instead of refusing to make any eye contact at all, you may just have a strong dislike for it, or you may attempt to make eye contact but do so “incorrectly.”

Another nonverbal issue autistic people have is using incorrect facial expressions. This includes someone who uses very emotive facial expressions but in the wrong context (contrary to popular belief that all autistic people have a neutral expression and monotone voice). Additionally, you might have a hard time reading or mimicking people’s body language. This often leads to a misinterpretation of people’s mood.

For example, I don’t always pick up on people’s true emotion behind their words, because reading tone of voice is particularly difficult for me. When I’m in a group conversation and someone says something that confuses me, I gauge how to react by other people’s reaction. I have found myself smiling when other people smile or laughing when other people laugh, even if I am confused as to why they’re laughing, because I don’t want people to know that I missed the point. This is the definition of masking—a tool autistic people use to hide their autistic traits from neurotypicals, so we don’t stand out like a sore thumb.

Criteria A: Point 3

The third required point is essentially difficulty making and keeping friends. At this point, if you already ticked the first two required points, this one will probably be a yes too; if you find it difficult to express yourself and read others, then making friends with people is going to be difficult. This doesn’t mean that autistic people don’t have friends. Moreso, it means that making new friends and/or maintaining current friendships is very challenging.

Friendships have been the hardest struggle all my life. When I was a child, I had this beautifully innocent view of friendship where friends remain friends forever. I learned the hard way that few people actually hold true to this standard of friendship or are willing to put in the work to maintain their friendships. To me, all the gossip, back-stabbing, and two-faced personalities that are commonly found among young female relationships didn’t make any sense to me. This made navigating female friendships very difficult.

In conclusion of Criteria A, you must check all three boxes, but you don’t have to relate with every example of course (because some contradict each other). So let’s discuss the next criteria…

Criteria B: Restricted, Repetitive Patterns of Behavior, Interests, or Activities

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):

1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat food every day).

3. 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 interest).

4. Hyper- or hypo-reactivity to sensory input or unusual interests 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).

Only two out of the four points are required for someone to be diagnosed with autism.

Criteria B: Point 1

The first point talks about stimming (or self-stimulatory behaviors), specifically through motions, objects, and/or speech. Stimming is a self-soothing tactic that all autistic people do in one form or another. In fact, everyone stims in one form or another. The difference between neurotypical stimming and autistic stimming is that autistic people need it to regulate their emotions. Stimming can look like flapping your hands or objects, or it can look like repetitive noises or repeating phrases.

Most people think that every autistic child lines up their toys rather than playing with them. While this is one type of repetitive pattern, there are many others that are not as widely known, such as echolalia and idiosyncratic phrases.

I don’t know about you, but I didn’t know what an idiosyncratic phrase was until I researched it for this post. Google defines an idiosyncratic phrase as “a unique expression or word usage that is characteristic of a particular individual, rather than being common or widely understood.” This can look like invented words or the use of familiar words in unusual ways. These words or phrases are often linked to specific people or experiences, and each one has a unique meaning to the individual using them. Think of them like a language known only to the autistic person.

Echolalia functions very similarly. It is the seemingly meaningless repetition of words or phrases or sounds that someone hears. This could look like repeating a phrase or question immediately after someone says it, or it could look like repeating a phrase later, like from a book or a movie.

An easy way to remember the difference between the two is this: Idiosyncratic phrases give meaning to meaningless words or noises, and echolalia takes the meaning away from meaningful words through repetition. They are two sides of the same coin.

When I was a child, I made up my own language. In fact, every member of my family had an odd sounding name that either sounded like a strange combination of words or gibberish. Now, my language has turned into more animal-like noises. Each one of them has a specific meaning, though most people would probably be put off by an adult making odd noises. Additionally, I often echolali (yup, I turned echolalia into a verb) through song lyrics, old videos that get stuck in my head, and movie quotes. I use all of these repetitively to either reduce stress or just for fun.

Criteria B: Point 2

The second point talks about difficulty with change in routine. A lot of autistic people must stick to their routines and have a lot of difficulty with spontaneity or change. Some people have been led to believe that autistic people will have a meltdown if their schedule is altered, and while that might be the case for some, it’s not commonplace. And if they did, it’s likely from more of a buildup of stress than it is that one change in their schedule. While this adherence to schedules may make autistic people seem controlling, you must remember that it’s an anxiety response. Routines and/or schedules make us feel safe.

Criteria B: Point 3

Point number three is talking about what is referred to as autistic “special interests.” I do not appreciate the wording of this particular point as whoever wrote it seems to be trying to make special interests seem as abnormal as possible. Special interests are the things that autistic people hyperfixate on or obsess over, and they bring us so much joy! They can literally be anything, from objects to hobbies to media to people.

The difference between a typical interest of someone who is not autistic to a special interest is merely the intensity. Autistic people devour their special interests. They may spend hours researching a particular thing and be able to tell you all sorts of facts about it. Or they may spend hours doing a certain hobby and forget that they need to eat and use the bathroom. These interests can stick around for a lifetime, or they can cycle through them periodically.

However, the intensity to which an autistic person fixates isn’t always visible. I was able to hide a lot of my fixations when I felt like they were too much for other people to handle by rewatching the same show for the fourth time in a row, creating Pinterest boards for each of my favorite characters, writing fanfiction, journaling, or listening to the same song over and over and over again. I was always thinking about whatever special interest(s) I was into at the time.

While this intensity isn’t a bad thing in and of itself, it can look pretty strange to neurotypicals who don’t understand why we are still talking about the same topic, watching the same show, or listening to the same song on repeat, etc. To them, we are simply obsessed, which I was taught is a bad thing. After learning I am autistic, I was finally able to give my brain some grace and eventually even permission to enjoy a special interest without feeling like I’m doing anything wrong.

It is important to note that there is another neurodivergent neurotype, ADHD, that often has “special interests.” Though they are called hyperfixations, they essentially mean the same thing. That is part of the reason the two neurotypes get confused with each other.

Criteria B: Point 4

The fourth point deals with sensory issues—both hypersensitivity and hyposensitivity—and this is about how autistic people sense the world and their surroundings. Hypersensitive autistic people avoid sensory stimulation. They may get overstimulated by bright lights, loud noises, large crowds, clutter, certain flavors in food, etc. Hyposensitive autistic people seek sensory stimulation, like glitter, spinning around, and touching different textures.

This is where the stereotype comes that autistic people don’t like to touch people or be touched. While that is certainly the case for some, I wouldn’t say it’s the majority. I am really sensitive to how close people are standing to me and don’t like when most people touch me, but I’m the complete opposite with people I’m comfortable with. I love hugs.

An autistic person can be both hyper- and hyposensitive, but they usually lean more heavily to one side. For example, I am much more hypersensitive to sensory stimuli than hyposensitive, but I could get lost staring at flames or sparkles, and when I see a texture that interests me, I have to touch it.

When I was a child, I couldn’t have anything stuck on my hands—food, sand, dirt, etc. My hands had to be clean, or I’d start waving them around, upset that I couldn’t get the sticky or grainy texture of my fingers. Additionally, I have to wear socks. I hate the feeling of crumbs or water on my toes, which always seem to be present on the kitchen floor, so I wear socks (sometimes paired with slippers) for protection. It’s not just the sensation of the crumbs on my feet that bother me, it’s the temperature of the cold floor or the rough texture of the couch rubbing against my skin that overwhelms me. Without socks, it’s almost impossible to pay attention to anything but these issues.

Criteria C: Symptoms Have Been Present Since Childhood

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

This is one of the newer additions to the criteria for autism, and I’m very happy that it was added, because this includes high-masking autistic individuals like me. It prevents those who don’t understand autism from receiving an incorrect diagnosis, because autism isn’t something you pick up in your life; it’s already with you when you’re born. The inclusion of masking also makes it less likely that high-masking individuals will be misdiagnosed by those who still embrace the old stereotypes of autism.

There are many autistic people who haven’t discovered or even considered the fact that they might be autistic, because the old way of thinking about autism is still taught in schools. You’ve all heard it: A young white boy who is obsessed with trains, doesn’t speak, and throws “tantrums” every time something in his routine changes. This limited view of autism hurts people like me who have learned to mask their autistic traits due to rejection or misunderstanding. We need to be seen too.

Criteria D: Symptoms Cause Significant Impairment

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

This one doesn’t really need explaining. It essentially states that even if you checked every other box for autism, you’re not autistic unless it’s severely impacting your life in a negative way.

I think this criteria is the most problematic. In fact, it almost contradicts Criteria C. Say you are an autistic person who grew up in a loving, accommodating family. Your family didn’t know you are autistic because that’s just the way you’ve always been. You are surrounded by a few friends who are also autistic, and you happen to find a job that accommodates your needs. You don’t live a stressful life, so even though you’re living in a world that doesn’t accommodate your needs, your immediate surroundings do for the most part. It likely hasn’t gotten to the point of severe distress. Does that make you any less autistic? Of course not.

I didn’t discover I was autistic until I was 23 years old. I grew up in a loving household that acknowledged my idiosyncrasies as a part of who I was. Not every autistic trait was accepted, per se, but I was loved. Making (and keeping) friends grew increasingly more difficult as I grew up, and I endured an unusual amount of rejection, but only when I sank into a deep void of anxiety and autistic burnout did my parents question, once again, if something truly was different about me.

Was I any less autistic when I was a child versus when I was in burnout? No. The severity of autism doesn’t ebb and flow like the tides of the ocean. If you are autistic, you have always been autistic. You won’t have “autistic days” where you’re feeling like the world is too much for you, then “normal days” when you feel like it isn't. Autistic traits are often more visible to others during times of stress or hardship because our ability to mask them has exhausted us to the point where we can’t hide them anymore.

Criteria E: Intellectual Disability Does Not Necessarily Equal Autism

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Wow, that’s a lot, but what it’s actually saying is quite simple. Before getting clinically diagnosed with autism, they have to rule out several other mental conditions as well, including intellectual disabilities, personality disorders, psychosis, etc. Autism used to be lumped together with intellectual disability, which is probably where a lot of the stereotypes came from.

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And that’s it. Those are the current criteria for autism. If you got to the bottom of this post and think you or someone you love may be autistic, you’re probably not feeling too great about it.

Don’t stop here.

I remember when I first read through the criteria and found myself in them, I felt like I was staring into a broken mirror—the negativity was overwhelming. But it doesn’t end here. Our understanding of autism is still expanding, and the DSM-5 fails to mention anything positive about being autistic. Trust me, there are positives. Stay with me and we’ll explore them together.

While the DSM-5 gives us a clear definition of how neurotypicals view autism, I don’t believe the criteria fully encapsulates everything there is to know about us; the reason for this is because the DSM-5 is a deficit-based model of autism. It bases autism on what is “normal” for neurotypical people, which paints every autistic trait in a bad light because the way our brains are wired is “abnormal.” But what others may see as deficits doesn’t necessarily mean they are—our brains are just wired differently. We see and experience the world through a completely different lens, and that doesn’t make us less than.

We are wonderfully unique, and we have something beautiful to offer this world.