You're Not Autistic Unless...

Discussing the Required Criteria for a Clinical Autism Diagnosis

With all of the information out there about autism, have you ever wondered what is actually required to get a clinical autism diagnosis? In this post, we will only be discussing the required criteria for autism, according to the DSM-5. Let’s dive in!

Quick Disclaimer: The DSM-5 is a deficit-based model of autism—only focusing on the negative impact of autism. I don’t believe its language is helpful or uplifting, so I will be replacing words like “deficit” and “abnormality” with “challenges.”

First, you need to understand that autism is diagnosed through the lens of five fundamental criteria:

1. Social Communication & Interaction Challenges

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

3. Symptoms Have Been Present Since Childhood

4. Symptoms Cause Significant Impairment

5. Intellectual Disability is Not Required

When people think of autism, they probably think of the four points under Criterion B for ASD: stimming, special interests, sensory sensitivities, or difficulty with changes in their routine. While these are all interesting topics of discussion, they are all people seem to talk about when it comes to autism. This can be really damaging and misleading, steering people to a potential misdiagnosis if this is all they know of autism.

What most people don’t realize is that only two of those points are required for an autism diagnosis. However, if someone exhibits one or more of these more well known behaviors, that does not mean they are autistic. There are several other required criteria for autism that a lot of people don’t even acknowledge. So before you clock yourself or someone you know as autistic, let’s discuss the lesser known but crucial criteria for an autism diagnosis.

Criterion A: Social Communication & Interaction Challenges

This is debatably the most important criterion for understanding autism, because it is the foundation of our understanding of the condition. Criterion A discusses social communication and interaction challenges that are present in multiple environments.

To be clinically diagnosed with autism, an individual must meet all three of these points:

1. Social-emotional reciprocity challenges

2. Nonverbal communication challenges

3. Challenges in developing, maintaining, and understanding relationships

Point 1: Social-Emotional Reciprocity

Because autism is a spectrum, this could look like a lot of different things. Examples from the DSM-5 include:

• Unusual social approach

• Challenges with normal back-and-forth conversation

• Reduced sharing of interests, emotions, or affect

• Difficulty initiating or responding to social interactions

What Can This Look Like in Autistic Adults?

I’ve split what each point can look like in autistic adults with my personal experiences. Please know, you do not need to check every single box to be autistic. However, if you relate with most of these examples, maybe you should consider the fact that you might be autistic too.

Autistic Adults May:	My Personal Experience:
Have a difficulty or inability to read social cues.	I often have a difficulty reading social cues that everyone else just seems to intuitively understand. This leads me to mimic other people’s reactions so I don’t appear dumb.
Repeat phrases that were just said or something they’ve heard earlier (echolalia).	Echolalia is one of my main stims. From movie quotes to random videos, I’ll often repeat phrases that don’t necessarily make sense just because it feels good.
Speak at length about your passions without recognizing the other person’s lack of engagement.	You mean people get bored when I talk at length about my passions?
Ask repetitive questions.	I was the queen of this as a child, and I still am. I like to know all the details, especially if someone is instructing me on how to do something. I need specifics so there are no misunderstandings.
Have trouble with the natural give-and-take of a conversation. A discussion may feel one-sided or scripted rather than a fluid exchange of thoughts and feelings.	Every conversation with people I’m not close with feels scripted. I never know what to say, because the things I’d like to talk about are often not interesting or weird to other people.
Struggle to express your feelings or to share your enjoyment of objects or activities with others.	I have no problem expressing my emotions; I just can’t always turn my thoughts into words. They often feel jumbled in my head, and when I pause to gather them, the conversation has already moved on.
Not respond to social cues or to others’ attempts to initiate interaction.	This happened more when I was a child. However, if I am overstimulated or exhausted from masking, I might be a minute behind processing everything around me. There were multiple times in school when a teacher would directly speak to me, and I would just nod my head without even internalizing what they said. These were some of the moments that kept me up at night.
Have trouble understanding or predicting what another person is thinking or feeling, which can lead to misunderstandings or being perceived as blunt, rude, or uninterested.	Blunt? No. I just say things exactly as they are while other people skirt around the truth because people can’t handle the truth if it slapped them in the face… Okay, I get it now.
Develop "masking" strategies to camouflage your challenges. While effective in some situations, these techniques are often exhausting and do not remove the underlying social difficulty. Examples of masking include: mimicking the mannerisms or social scripts of others, over-rehearsing conversation topics before a social interaction, or consciously maintaining eye contact, even though it feels uncomfortable.	My mask completely silenced me, because others convinced me that I’m too much. Around peers, I struggle to share anything about myself because I am so used to being rejected, or seen as weird or “childish.” Out of desperation to fit in, I mimic others’ mannerisms so I look like I understand what everyone is talking about and consciously maintain eye contact despite the discomfort.
Struggle to feign interest in topics they do not find engaging.	I’m always thinking about my fixations, and it can be really hard to put them aside to listen to or learn about something that bores me.
Miss subtle social hints or not recognize sarcasm.	All. The. Time.
Want to initiate a conversation with others but may be unsure how to do so, causing you to give up and seem disinterested.	Absolutely. Starting and ending conversations is really hard. I like talking to people once I’m talking to them, but it’s really hard to start a conversation.
Talk about factual topics but not spontaneously share personal experiences, which can make it hard for others to connect with you on a deeper level.	As much as I love deep conversations, I struggle to share anything personal with others because I don’t know when it’s “safe” to do so. I used to share everything about myself with friends before being bullied, abandoned, or backstabbed by them. Gauging when someone is actually trustworthy is really difficult for me, so avoiding sharing most personal details is the only way I know how to be safe.
Have difficulty understanding and responding to the emotions of others, which can lead to inappropriate social responses. This does not stem from a lack of compassion, but rather from a difficulty identifying and interpreting others' emotions.	The more comfortable with someone I am, the easier it is to automatically respond to strong emotions. With others though, I feel completely frozen. I don’t know whether they need a hug or whether I should say something or just leave them alone.

Point 2: Nonverbal Communication

Examples from the DSM-5 include (but are not limited to):

• Poorly integrated verbal and nonverbal communication

• Abnormalities in eye contact and body language

• Deficits in understanding and use of gestures

• Total lack of facial expressions and nonverbal communication

What Can This Look Like in Autistic Adults?

Autistic Adults May:	My Personal Experience:
Avoid eye contact, find it uncomfortable or distracting, or use eye contact in an unusual or overly intense way.	Eye contact is something I have to consciously think about. I don’t like making eye contact most of the time because it’s so uncomfortable, but others perceive me as disinterested if I’m not making the right amount of eye contact.
Struggle to align their tone of voice, body posture, or facial expressions with what they are saying.	There is definitely a disconnect between the words that come out of my mouth and my body language. For example, my facial expressions are expressive when I’m comfortable, but when I’m not, I don’t always know which facial expression to use for any given scenario (so I mimic others). I don’t want to appear like I’m not interested in what they’re saying, so I attempt to make the right facial expression to express interest without under- or over-doing it.
Not recognize implicit social cues from others' posture or movements or display a lack of spontaneous, communicative body language when interacting with others.	In most social contexts, my nonverbal responses are often lagging behind others because I’m watching their reactions to what is being said. I might laugh a little late, change my facial expression to match another person’s, or repeat what someone already said.
Have a "flat" or limited range of facial expressions, or the complete opposite.	In this scenario, I’m the latter. When I’m comfortable, I’m extremely expressive with my face. My emotions are on my sleeve unless I’m masking.
May struggle to use gestures, like pointing, to signal shared attention, or misinterpret the gestures of others.	Not really. I understand gestures.  Autism is a spectrum, so I’m not going to check every box for it.
Have unique differences in the pitch, volume, rhythm, and intonation (prosody) of speech. Their voice may sound monotonous, robotic, or inappropriately loud or soft for the context.	I’ve definitely had moments, especially as a child, where I spoke inappropriately loud for the context of the situation. That isn’t common anymore since I don’t say much around others now.

Point 3: Developing & Maintaining Relationships

Examples from the DSM-5 include (but are not limited to):

• Difficulties adjusting behavior to suit various social contexts

• Difficulties in sharing imaginative play or in making friends

• Absence of interest in peers

What Can This Look Like in Autistic Adults?

Autistic Adults May:	My Personal Experience:
Not realize that a professional demeanor is needed in a work meeting, and interact with their boss in the same casual way they would with a friend.	There have definitely been times where I speak to my boss in a much more informal way than I should. Both of us are direct people, and sometimes, I don’t realize that my directness can come off as mildly inappropriate for a professional setting.
Desire friendships, but struggle to form them due to different social approaches. Their attempts to connect with peers can appear unusual or unsuccessful.	Making friends was so much easier when I was a child. I went to a small hybrid school that only had 20-40 people in my grade. Back then, my playful, rather intense personality wasn’t weird to 2 out of 3 of my friends, so it was easier to be myself. After one of them started bullying me out of the blue, I got my first taste for how complicated female friendships could be. After moving to a different state and starting afresh, making real friendships with women only became harder. I wouldn’t be able to tell you why, only that everyone seemed to label me as “weird” as soon as I gave them a peek of the real me.
Prefer spending time alone over social activities. This can be partly due to the draining effort of navigating social rules and expectations, though they still desire connection.	Yes and no. I am actually extremely social, but only with my family. I would choose to hang out with them 90% of the time. And of course, my husband is my favorite person in the whole world, so I’d always choose to hang out with him over being by myself. For everyone else, I have to pretend I’m not “weird” or something. It’s exhausting.
Not pick up on subtle social cues that indicate a change in expected behavior is implicitly requested. For instance, they may not realize that they are overstaying their welcome in a conversation or a group setting.	This happened much more frequently as a child. Sometimes, it was really hard to pick up on sudden yet subtle changes like that. However, my studies on body language and nonverbal communication aided my understanding in implicit social cues.

Criteria C - E

In addition to Criterion A, Criteria C - E are also required for an autism diagnosis. I’ve already thoroughly explained these three criteria in another post, so I’ll keep this section brief.

Criterion C: Symptoms Have Been Present Since Childhood

The symptoms of autism we’ve already discussed must be present from childhood. The traits may appear to ebb and flow as the child learns to mask or experiences autistic burnout, but they are definitely still there, and they have been all along.

What Can This Look Like in Autistic Adults?

You may have…

• A history of having one-sided conversations because you are focused on a narrow range of topics or have difficulty sharing interests and emotions with others

• A past lack of understanding or difficulty using body language, facial expressions, or eye contact, and having trouble "reading" social cues from others

• Had a lifelong struggle with making friends and maintaining relationships

Criterion D: Symptoms Cause Significant Impairment

To be diagnosed with ASD, symptoms must cause significant impairment in multiple or all areas of your life. In my opinion, Criterion D is problematic because it doesn’t acknowledge high maskers or account for the fact that being autistic isn’t a death sentence.

What Can This Look Like in Autistic Adults?

You may…

• Have difficulty maintaining eye contact or understanding body language

• Take things very literally, leading to misunderstandings in conversation

• Have anxiety in social situations

• Have trouble making friends or maintaining relationships

• Be perceived as blunt or rude, even without meaning to

• Have challenges with professional development or job performance due to social or communication difficulties

• Have trouble with the "small talk" or nuances of conversation

• Have anxiety or become stressed when routines are disrupted

• Have difficulty with day-to-day tasks like grocery shopping or public transportation due to sensory sensitivities

• Have emotional or behavioral challenges that significantly impact the ability to function independently

Criterion E: Intellectual Disability is Not Required

Before getting clinically diagnosed with autism, they have to rule out several other mental conditions that used to be lumped together with it.

Final Thoughts

If you would like more information on these criteria, please check out this post where I decode the criteria for autism: What is Autism?

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