Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and social interaction and the presence of restricted, repetitive behaviors. Social communication deficits include impairments in aspects of joint attention and social reciprocity, as well as challenges in the use of verbal and nonverbal communicative behaviors for social interaction. Restricted, repetitive behaviors, interests, or activities are manifested by stereotyped, repetitive speech, motor movement, or use of objects; inflexible adherence to routines; restricted interests; and hyper- and/or hypo-sensitivity to sensory input.
This definition is consistent with the diagnostic criteria for ASD detailed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013). The criteria specified in the DSM-5 reflect a number of changes from those in the DSM-IV, the most notable of which are
- elimination of the Pervasive Developmental Disorders category that included diagnoses of Autistic Disorder, Asperger's Disorder, Childhood Disintegrative Disorder, Rett's Disorder, and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). The DSM-5 criteria for ASD encompass the social and behavioral deficits typically associated with these populations (Note: The DSM-5 lists Rett syndrome as a separate diagnosis in which disruptions of social interaction may be observed during the regressive phase);
- omission of criteria related to delay in or lack of development of spoken language and, instead, allowance for the clinician to specify whether ASD occurs "with or without accompanying language impairment";
- change in age of onset from "prior to 3 years" to the presence of symptoms "in the early developmental period";
- recognition of unusual reactions to sensory input (e.g., hyper- or hypo-reactivity to sensory input, unusual interest in sensory aspects of environment).
According to the DSM-5, individuals who meet the specified criteria are given the diagnosis of "autism spectrum disorder (ASD)" with one of three levels of severity. Level of severity is defined in terms of the amount of support needed in the area of social communication and with restricted, repetitive behaviors, recognizing that severity may vary by context and fluctuate over time. Severity ratings are used for descriptive purposes only and not to diagnose or determine eligibility for services (American Psychiatric Association, 2013). See Paul (2013) for a more detailed discussion of DSM-5 changes and potential practice implications.
The scope of these pages includes ASD across the lifespan. For more detailed information and resources about social communication disorders in school-age children (5-21), including information about social communication deficits without repetitive behaviors, see the Social Communication Disorders Practice Portal page.
Impact of DSM-5 on Practice
There is some research to suggest that most individuals previously diagnosed with pervasive developmental delay (PDD) based on DSM-IV criteria would also receive a diagnosis of ASD using DSM-5 criteria (Huerta, Bishop, Duncan, Hus, & Lord, 2012). Additional research will be needed to evaluate the impact of the new DSM-5 criteria on the diagnosis of ASD.
It is important to differentiate between ASD and social communication disorders (i.e., difficulty with social communication skills—including pragmatic language—but without restricted or repetitive patterns of behavior). Speech-language pathologists (SLPs) will be instrumental in making this differential diagnosis and ensuring that individuals with ASD and those with social communication disorders gain access to services.
In addition, SLPs will need to advocate for inclusion of language intervention for individuals diagnosed with ASD and ensure that individuals with ASD also receive a diagnosis of language disorder (LD), when they meet the criteria. Regardless of the presence or absence of difficulties acquiring the form and content of language, all individuals with ASD are eligible for speech-language pathology services due to the pervasive nature of the social communication impairment.
Challenges Faced by the Communication Partner
At its core, communication is a social process; therefore, the social communication issues experienced by individuals with ASD also impact their communication partners. Family members, friends, teachers, SLPs, and other service providers who interact with someone with ASD are faced with the challenge of learning to respond to subtle bids for communication, interpreting the functions of problem behavior, and modifying the environment to foster active, social engagement. Peers often feel ineffective when engaged in social exchanges with an individual with ASD and may avoid that person and/or react in a negative way (e.g., teasing or bullying) to social overtures, which can have a negative impact on the development of appropriate social skills.
Given the challenges experienced by communication partners, treatment considers the whole range of service delivery models, including traditional pull-out; home-, classroom-, and community-based models; and collaborative consultation models. Service delivery focuses on natural learning environments and includes education and training of family members, teachers, peers, and other professionals.
The goal of family-centered practice is to create a partnership so that the family fully participates in all aspects of the individual's care. The participation of families in services aimed at addressing the needs of the individual with autism can serve to ameliorate the stress experienced by family members (National Research Council [NRC], 2001).
Cultural, linguistic, and socioeconomic factors affect families' access to and selection and usage of services. The range of services offered include counseling, education and training, coordination of services, and advocacy for practices that incorporate family preferences and address family priorities.
Through this partnership, support may take different forms at different times, including coordinating services for the family, procuring resources and information, teaching the family or other significant communication partners specific skills, and advocating for or with the family. It can also result in greater consistency in activities and routines across different contexts and communication partners. See family-centered practice.