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O R I G I N A L P A P E R

Comparison of ICD-10R, DSM-IV-TR and DSM-5 in an AdultAutism Spectrum Disorder Diagnostic Clinic

C. Ellie Wilson Nicola Gillan Deborah Spain Dene Robertson

Gedeon Roberts Clodagh M. Murphy Stefanos Maltezos Janneke Zinkstok

Katie Johnston Christina Dardani Chris Ohlsen P. Quinton Deeley

Michael Craig Maria A. Mendez Francesca Happe Declan G. M. Murphy

Published online: 16 March 2013

Springer Science+Business Media New York 2013

Abstract An Autism Spectrum Disorder (ASD) diagnosis

is often used to access services. We investigated whetherASD diagnostic outcome varied when DSM-5 was used

compared to ICD-10R and DSM-IV-TR in a clinical

sample of 150 intellectually able adults. Of those diagnosed

with an ASD using ICD-10R, 56 % met DSM-5 ASD

criteria. A further 19 % met DSM-5 (draft) criteria for

Social Communication Disorder. Of those diagnosed with

Autistic Disorder/Asperger Syndrome on DSM-IV-TR,

78 % met DSM-5 ASD criteria. Sensitivity of DSM-5 was

significantly increased by reducing the number of criteria

required for a DSM-5 diagnosis, or by rating uncertain

criteria as present, without sacrificing specificity.Reduced rates of ASD diagnosis may mean some ASD

individuals will be unable to access clinical services.

Keywords Autism Spectrum Disorder Diagnosis

Prevalence DSM-5

Introduction

Autism Spectrum Disorder (ASD) is a neurodevelopmental

disorder with a prevalence currently estimated at 1 in 80

individuals (Pinborough-Zimmerman et al.2012). In recent

years there has been a rise in reported rates of ASD. The

reason for this is unclear, but changes in diagnostic practice

are likely to have contributed (Fombonne 2005). Also, a

formal diagnosis of an ASD is often used as a gatekeeper

for services and support. Therefore changes in diagnostic

practice may have important implicationsboth for clini-

cal prevalence rates and for an individuals care options.

An Autism Spectrum Disorder is diagnosed on the basis

of three domains: impaired social interaction, abnormal

communication, and restricted and repetitive behaviours

and interests. Using current diagnostic criteria in the

International Classification of Diseases (ICD-10R; World

Health Organization 1993) and the Diagnostic and Statis-

tical Manual (DSM-IV-TR; American Psychiatric Associ-

ation 2000), ASD comes under the umbrella term of

Pervasive Developmental Disorder (PDD) and an individ-

ual may be defined as having one of four diagnostic sub-

types according to the range of symptoms and the presence/

absence of factors such as developmental language delay

and intellectual disability (i.e., Asperger Syndrome,

Childhood Autism/Autistic Disorder, Atypical Autism,

Francesca Happe and Professor Declan Murphy are joint senior

authors.

Data from this manuscript were presented at the International Meeting

for Autism Research, Toronto, Canada, May 2012.

Francesca Happe is part of the DSM-5 workgroup on

neurodevelopmental disorders.

C. E. Wilson (&) N. Gillan D. Spain G. Roberts

C. M. Murphy S. Maltezos J. Zinkstok C. Dardani

P. Q. Deeley M. Craig M. A. Mendez D. G. M. Murphy

Department of Forensic and Neurodevelopmental Science,

Institute of Psychiatry, Kings College, London SE5 8AF, UK

e-mail: [email protected]

C. E. Wilson N. Gillan D. Spain D. Robertson

G. Roberts C. M. Murphy S. Maltezos J. Zinkstok

K. Johnston C. Ohlsen P. Q. Deeley M. Craig

M. A. Mendez D. G. M. Murphy

Behavioural Genetics Clinic, Maudsley Hospital, South London

and Maudsley NHS Foundation Trust, London SE5 8AZ, UK

F. Happe

Department of Social Genetic Developmental and Psychiatry

Centre, Institute of Psychiatry, Kings College,

London SE5 8AF, UK

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PDD-unspecified). There are, however, problems with

current diagnostic algorithms. First, distinguishing the

social and communication domains is somewhat arbi-

trary since almost any example of communication is social

and vice versa, and, several social and communication

symptoms are covered by multiple criteria. For instance,

behaviors indicative of poor socio-emotional reciprocity

are currently covered in three criteriapoor emotionalreciprocity (social domain), lack of sharing enjoyment and

interests (social domain), and poor reciprocal conversation

(communication domain) (see Appendix1). Second, there

is a lack of evidence for significant differences between

ASD diagnostic subtypes (once IQ matched) in etiology,

neuropsychological profile, treatment or outcome, and poor

clinical agreement when diagnosing (Ozonoff 2012).

Unclear guidance on how to define people who have

symptoms of ASD but do not meet full criteria also con-

tributes to disagreement between clinicians.

To address these problems, the Neurodevelop-

mental Disorders Workgroup, convened by the AmericanPsychiatric Association (APA), has proposed a number of

significant changes to the diagnostic criteria for ASD

(Happe 2011; Swedo et al. 2012). The social and com-

munication impairment criteria will be combined into a

single set, thus reducing the current triad of impairments

to two domains. In the social and communication domain

there will be three criteria, instead of the current total of

eight, and each criteria will include several examples of

behaviors from across the lifespan that might indicate the

presence of that symptom. Next, the previously distinct

diagnostic subtypes will be collapsed into a single category

of Autism Spectrum Disorder. People who do not present

with the full range of symptoms will no longer be eligible

for an ASD diagnosis, since there is no atypical or not

otherwise specified category (as in ICD-10R, DSM-IV-

TR). Instead, a new diagnostic category called Social

Communication Disorder (SCD) has been proposed. This is

defined as being outside the autism spectrum, but will

provide diagnostic coverage for those individuals with

symptoms in the social-communication domain, but who

have never displayed repetitive, restricted behaviours or

interests. The intention is that the changes to the diagnostic

algorithm will reduce the wide variability between indi-

viduals on the autistic spectrum, by more clearly defining

the symptoms required for diagnosis and by reducing the

potential for clinicians to disagree.

The effect of the proposed changes on diagnostic out-

comes has been investigated in children and adolescents

with several studies reporting that the specificity of the

proposed DSM-5 criteria is good, but sensitivity is rela-

tively poor, when judged against current ICD-10R or

DSM-IV-TR criteria (Frazier et al. 2012; Matson et al.

2012; Mattila et al. 2011; McPartland et al. 2012; Taheri

and Perry 2012; Worley and Matson 2012). This high-

lights a key concern of some: that the new criteria will fail

to capture individuals currently receiving an ASD diag-

nosis who are on the broader spectrum according to

DSM-IV-TR or ICD-10R criteria (e.g., Pervasive Devel-

opmental Disorder-not otherwise specified; PDD-NOS).

As a consequence it is feared by some that these indi-

viduals will be denied access to services. Reassuringly,however, a large study of children diagnosed within the

PDD category according to DSM-IV-TR suggested that

sensitivity of DSM-5 is very good (0.91) although sensi-

tivity in this study was much lower (0.53) (Huerta et al.

2012).

The effect of the proposed changes for adults has

received relatively little attention. This is of importance

because ASD is a lifelong condition therefore most people

with ASD are adults. Moreover, the number of individuals

presenting for first diagnosis in adulthood is rapidly

increasing: at the National ASD assessment service at the

South London and Maudsley in the UK, the number ofASD assessments per month increased fourfold between

2005 and 2010 (Murphy et al. 2011). Further, diagnosis is

particularly challenging in this group because a develop-

mental history is often unavailable and/or unreliable; and

presentation is frequently complicated by additional

mental health conditions (Carpenter2012). The only prior

study that explored the agreement between current and

proposed ASD criteria in adults included only individuals

with (mostly profound) intellectual disability living in

residential centers (Matson et al. 2012); they reported that

approximately one third of the individuals who met DSM-

IV-TR criteria no longer met them using the draft DSM-5.

This study was a valuable first step. However, the

majority of the ASD population does not have profound

intellectual impairment (Baird et al. 2000) and such

people are assessed within mental health or social/edu-

cational services. Also, it is unknown what proportion of

individuals would qualify for the new, alternative diag-

nosis of SCD.

Our primary aim, therefore, was to investigate how

diagnostic outcomes of the DSM-5 algorithm differed from

both ICD-10R and the DSM-IV-TR when applied in a

clinical health service; and to compare all three algorithms

to so-called gold-standard research diagnostic assessment

tools (the Autism Diagnostic Interview-Revised (ADI-R;

Lord et al. 1994) and Autism Diagnostic Observation

Schedule (ADOS-G; Lord et al.2000). Our secondary aims

were to investigate whether diagnostic outcomes were

affected by participant characteristics (age, sex, IQ, pres-

ence of additional mental health conditions), or alterations

to the formulation of the proposed algorithm. Specifically,

the impact of reducing the number of criteria required for a

formal diagnosis was examined, and also the treatment of

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criteria where the clinician was uncertain or had insuffi-

cient information to code the item.

Method

Participants

Participants included 158 individuals consecutively asses-

sed for ASD in a specialist National tertiary ASD diag-

nostic clinic for adults between January and May 2011. The

clinic is situated within the South London and Maudsley

NHS Foundation Trust. People are typically referred by

their local family physician/general practitioner (GP) or

consultant psychiatrist for a second opinion. In 8 cases

diagnosis was inconclusive due to a history of acquired

head injury or the presence of severe psychotic symptoms

during assessment. Data from these cases were excluded

from the study. The remaining 150 participants were aged

1865 years, with a mean age of 31 years. There were 110males (mean age 32 years) and 40 females (mean age

31 years). Seventy-three patients already had a diagnosis of

a mental health condition (most commonly depression,

anxiety, Obsessive Compulsive Disorder (OCD), or

Attention Deficit Hyperactivity Disorder (ADHD)), and

only 7 of these had previously been diagnosed with ASD.

Measures

The ADI-R and ADOS-G are gold-standard research

diagnostic assessment tools for ASD. The ADI-R is a semi-

structured interview with the parent or caregiver assessing

ASD traits during childhood, and the ADOS-G is assess-

ment completed with the patient assessing current traits of

ASD. High levels of testretest reliability have been

reported for both the ADI-R (in all domains, j[ 0.6; Hill

et al. 2001), and the ADOS-G (in social and communica-

tion domains, j[ 0.7; Lord et al. 2000). Well-validated

self-rating questionnaires were used to assess levels of

other mental health conditions. The Obsessive Compulsive

Inventory-Revised (OCI-R; Foa et al. 2002) was used to

assess traits of OCD, and has high internal consistency

when used among patients with OCD (a = .83) and

patients with other anxiety disorders (a = .88), (Abramo-

witz and Deacon 2006). Symptoms of ADHD were asses-

sed using the Barkleys Current and Childhood Symptom

Scales (Barkley and Murphy 2005), which is a self- and

informant-rated questionnaire used widely in clinical

assessments for ADHD in adults (Barkley 2011). Finally,

the Hospital Anxiety and Depression Scale (HADS; Zig-

mond and Snaith1983) was used to assess levels of anxiety

and depression, and has high levels of internal consistency

when used in general population adult sample, (a = .90)

(Lisspers et al.1997).

Clinical Assessment

Assessment included a detailed psychiatric assessment

using ICD-10R research diagnostic criteria and, wherepossible (i.e., where parents were available, able and

willing), an ADI-R. In the event that no parent was avail-

able for the ADI-R the person seeking diagnosis was asked

to undergo the ADOS-G. In some cases both assessment

tools were required to gather enough relevant information.

Seventy-one individuals were assessed using the ADI-R, 62

were assessed with the ADOS-G, and 17 were assessed

using both ADI-R and ADOS-G.

All information obtained was compiled by the multi-

disciplinary clinical teama consultant psychiatrist, junior

doctor, and ADI-R/ADOS-G administrator (nurse or psy-

chologist)who together decided whether each criterionon the ICD-10R algorithm was fulfilled (see Appendix1).

If a patient met full ICD-10R criteria (a total of at least six

symptoms must be presenteither currently or by his-

torywith at least two from the first domain and one from

each of the second and third domains) and the symptoms

were noted before the age of 3, they were diagnosed with

Childhood Autism (if they exhibited a language delay) or

Asperger Syndrome (if there was no evidence of a lan-

guage delay). In line with ICD-10R guidelines, if a patient

exhibited some autistic symptoms but did not meet full

ICD-10R diagnostic criteria they were diagnosed with

Pervasive Developmental Disorder, unspecified (PDD-

unspecified) or Atypical Autism. For the purposes of this

study these two sub-threshold diagnostic groups were

collapsed into a single PDD-unspecified group. In some

cases it was not possible to decide confidently whether or

not a symptom was present due to a lack of information, or

because information obtained from patient and parent

contradicted each other. In this event the criterion was

coded as Unclear, and the team made the clinical diag-

nostic decision based on the gestalt of the information

received. Of the 150 consecutive assessments, 113 were

diagnosed with an ASD using ICD-10R criteria. Of these,

28 participants were subtyped as having Childhood Aut-

ism, 48 Asperger Syndrome, and 37 PDD-unspecified.

Additional mental health conditions were also diagnosed

in accordance with the ICD-10R (with the exception of

adult ADHD which, in keeping with UK guidelines, was

assessed using DSM-IV-TR), and the supplementary self-

report questionnaires were used to help inform assessment

of OCD, ADHD, depression and anxiety (respectively, the

OCI-R, Barkleys Current and Childhood Symptom Scales,

and the HADS).

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Where there was clinical suspicion that a participant

might have intellectual disability (F70-73 in ICD-10R) or a

significant lacuna in a neuropsychological function, they

were referred for testing of general intellectual and exec-

utive functioning. These participants (N = 35) were tested

using the Weschler Abbreviated Intelligence Scale-III,

(WAIS III; Wechsler 1997) which revealed a mean Per-

formance IQ of 87 (SD = 16, range 55132) and a meanVerbal IQ of 95 (SD = 18, range 60133). Mean full-scale

IQ could not be calculated in 16 participants due to large

discrepancies between Performance IQ and Verbal IQ; in

the remaining 19 mean full-scale IQ was 90 (SD= 17,

range 53129) and only 2 participants had an IQ below 70.

The remaining 115 participants, not referred for such

testing, were estimated to be in the normal range of general

intellectual function based on educational attainment,

employment, and informant report.

Procedure

For each participant the diagnostic outcome (ASD/not

ASD; ICD-10R subtype of ASD; ADI-R and ADOS-G

scores; presence of additional mental health problems) was

reviewed by the research team. Information from the

ICD-10R algorithm was used to determine whether each

criterion on the proposed DSM-5 algorithm would be sat-

isfied, and this was supplemented by anonymized reports

from the ADI-R, ADOS-G, and the psychiatric interview.

Appendix2shows how information in the ICD-10R maps

onto the DSM-5. Each criterion could be coded as Yes,

No, or Unclear. A participant was considered to meet

criteria for ASD on the DSM-5 only when all three criteria

in A and at least 2 out of 4 criteria in B were coded as

Yes, as suggested in the criteria last posted by APA. If a

participant did not meet criteria for ASD on the DSM-5 it

was determined whether they would meet criteria for the

alternative diagnosis of Social Communication Disorder

(SCD). Re-coding was completed by pairs of researchers,

and for 40 sets of participant data the re-coding was

reviewed at consensus meetings with the whole team (10

researchers) to ensure agreement.

Data were also re-coded to complete the DSM-IV-TR

algorithm (demonstrated in Appendix 1), on which par-

ticipants could be diagnosed as either ASD (Autistic

Disorder/Asperger Syndrome) if they fulfilled at least six

criteria, with at least 2 in domain A and 1 from each of

domains B and C, or not ASD.

Factors affecting agreement between ICD-10R, DSM-

IV-TR and DSM-5 were also investigated. Participant

characteristics (age, sex, IQ, additional mental health

conditions) were compared between ASD positive and

negative groups, and the effect of being assessed using the

ADI-R, ADOS-G, or both, was also investigated. The

effect of altering the DSM-5 algorithm was examined in

two ways: by relaxing the number of criterion required for

diagnosis, and by considering criteria that were coded as

Unclear as either met or not met. To examine the effect of

relaxing the number of criteria required for diagnosis the

thresholds were reduced in Criteria A (from 3 to 2), or in

Criteria B (from 2 to 1), or both. To examine the effect of

including or excluding the Unclear items, the DSM-5algorithm was re-coded by considering Unclear items to

be present. This was relevant because the DSM-5 allows

criteria to be met by history, and allowing or disallowing

the Unclear criteria is likely to be crucial in many adult

cases where multiple informants are not available.

It was hypothesized that, (a) prevalence of Childhood

Autism or Asperger Syndrome diagnosed using ICD-10R

criteria would be similar to that using DSM-IV-TR and

DSM-5, (b) most participants diagnosed with ASD on the

ICD-10R but not the DSM-5 would be diagnosed with

SCD, and (c) altering the DSM-5 algorithm would have

significant effects on the rate of positive DSM-5 ASDdiagnosis.

Results

Conclusions of Initial Diagnostic Assessments

ICD-10R Versus DSM-5 (Table1)

Of the 150 participants, 113 (75 %) met criteria for an ASD

according to the ICD-10R (Childhood Autism, Asperger

Syndrome or PDD-unspecified). In contrast, however,

according to the DSM-5, only 63 (42 %) met ASD criteria:

this was a highly significant decline, v2(1) = 35.6,

p\ 0.001. A further 21 (14 %) participants met DSM-5

criteria for SCD. Overall, therefore, of those individuals

positive for ASD on ICD-10R, 74 % (84 of 113) met criteria

for ASD or SCD on DSM-5. Nevertheless, the proportion of

individuals with no diagnosis at all (ASD or SCD) remained

significantly higher when applying the DSM-5 criteria

instead of ICD-10R (v2(1) = 62.5,p\ 0.001). None of the

participants that were ASD negative using ICD-10R met

diagnostic criteria for ASD (or SCD) according to the

DSM-5, thus specificity of the DSM-5 was 100 %.

DSM-IV-TR Versus DSM-5 (Table1)

The rate of ASD positive diagnosis using DSM-5 (42 %)

was also significantly lower than the rate of Autistic Dis-

order or Asperger Syndrome assessed using DSM-IV-TR

(53 %), v2(1)[ 82.5, p\0.001. Additionally, two indi-

viduals were diagnosed with ASD on the DSM-5, but not

with Autistic Disorder or Asperger Syndrome on the


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DSM-IV-TR, therefore specificity of the DSM-5 according

to the DSM-IV-TR was 0.97.

Agreement with ADI-R and ADOS-G Results (Table2)

Agreement between diagnosis according to the ICD-10R/

DSM-IV-TR/DSM-5 and outcomes of the ADI-R and

ADOS-G was calculated where this information wasavailable. When measured against results of the ADI-R, the

sensitivity of the ICD-10R and the DSM-IV-TR was higher

than the DSM-5 (respectively 0.97, 0.97 and 0.79; both

McNemarsp = 0.07), but their specificity was marginally

lower. For the ADOS-G, sensitivity was also higher on the

ICD-10R and the DSM-IV-TR than the DSM-5 (respec-

tively 0.6, 0.7 and 0.5; McNemars p = 0.07/0.01) and

specificity was very similar.

Factors Affecting Agreement Between ICD-10R

and DSM-5

Participant Characteristics: Age, Gender, IQ, Diagnostic

Subtype and Additional Mental Health Conditions

Of the participants that were ASD positive using the ICD-

10R, there were no differences with respect to age, gender

or IQ (where available) for those individuals that were

ASD positive versus negative on the DSM-5.

There was, however, a significant difference in rate of

DSM-5 ASD positive diagnosis between ICD-10R sub-

types, v2(2) = 31.58, p\ 0.001. Significantly more par-

ticipants diagnosed with ICD-10R Childhood Autism or

Asperger Syndrome met DSM-5 criteria for ASD thanthose in the PDD-unspecified group (Table3, Column A).

The difference between ICD-10R defined Childhood

Autism and Asperger Syndrome was not significant,

v2(1) = 1.64, p = 0.2.

With respect to additional mental health conditions, a

significant difference was only found for OCD: higher rates

of OCD were found in the group that were ASD positive on

the DSM-5 than those that were ASD positive only on the

ICD-10R, v2(1) = 4.58, p = 0.03 (Fig. 1).

Table 1 Outcome of initial assessment of 150 participants according

to the ICD-10R, and outcome of data re-coded according to DSM-IV-

TR and DSM-5: % (N)

Above/below ASD

threshold

Diagnosis of below ASD

threshold participants

ASD full-

threshold

Below ASD

threshold

PDD-

unspecified or

SCD

No

diagnosis

ICD-10R,

% (N)

51 (76) 50 (74) 25 (37) 25 (37)

DSM-IV-TR,

% (N)

53 (80) 47 (70) N/A N/A

DSM-5,

% (N)

42 (63) 58 (87) 14 (21) 44 (66)

Table 2 Percentage of participants in each diagnostic group scoring above and below threshold on ADI-R and ADOS-G, and sensitivity and

specificity of each diagnostic algorithm compared to ADI-R/ADOS-G. % (N)

ADI-R below

cut-off (%)aADI-R above

cut-off (%)aADOS-G below

cut-off (%)bADOS-G above

cut-off (%)b

ICD-10R: Below ASD threshold (not ASD/PDD

unspecified)

96 (27) 4 (1) 75 (35) 25 (15)

ICD-10R: ASD (Asperger Syndrome/Childhood

Autism)

36 (17) 64 (30) 32 (12) 68 (25)

ICD-10RSensitivity: 0.97*

Specificity: 0.61

Sensitivity: 0.63*

Specificity: 0.74

DSM-IV-TR: ASD negative 96 (27) 4 (1) 75 (36) 25 (12)

DSM-IV-TR: ASD positive 36 (17) 64 (30) 28 (11) 71 (28)

DSM-IV-TR Sensitivity: 0.97*Specificity: 0.61

Sensitivity: 0.70**Specificity: 0.77

DSM-5: ASD negative 83 (29) 17 (6) 64 (36) 36 (20)

DSM-5: ASD positive 38 (15) 63 (25) 36 (11) 65 (20)

DSM-5Sensitivity: 0.81

Specificity: 0.66

Sensitivity: 0.50

Specificity: 0.77

* Difference between ICD-10R/DSM-IV-TR and DSM-5: McNemars p\ 0.1

** Difference between ICD-10R/DSM-IV-TR and DSM-5: McNemars p\ 0.05a ADI-R cut-off scores: Social = 10; Communication = 8; Repetitive behaviors/interests = 3b DOS-G cut-off scores: Communication = 3; Social interaction = 6; Communication ? Social = 10


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Finally, of the participants that were ASD positive

using the ICD-10R, there was no significant effect of

using different ASD assessment tools (ADI-R, ADOS-G,or both) on the outcome of the DSM-5, v2(2) = 4.20,

p = 0.12.

Effects of Relaxing the DSM-5 Algorithm (Table 3, Column

C)

For the 113 participants that were ASD positive on the

ICD-10R, the sensitivity of the DSM-5 increased signifi-

cantly (and specificity remained at 100 %) when thresholds

for Criteria A or B, or both, were relaxed (all v2

(1)[

20.0,ps\ .001).

Of the 80 participants that were ASD positive on the

DSM-IV-TR, sensitivity of the DSM-5 increased to 99 %

when thresholds A and B were both relaxed, however

specificity was significantly reduced.

Uncertainty on the DSM-5 Algorithm: ASD Diagnostic

Outcome When Criteria Coded as Unclear Were

Considered to Be Present

Of the participants diagnosed with ASD on the ICD-10R,

74 % received a diagnosis of ASD on the DSM-5 whencriteria that were Unclear were treated as Yes; this was

a significant increase from 56 % when Unclear was coded

as No (v2(1) = 51.46, p\ .001). Specificity remained at

100 %.

Discussion

This is the first study to investigate how the DSM-5 cri-

teria for ASD might perform in a specialist diagnostic

clinic for adults without significant intellectual disabil-

itywho form a large proportion of individuals withASD.

Our findings suggest that the specificity of the DSM-5

criteria, as compared to the currently used ICD-10R and

DSM-IV-TR criteria, is good. However, sensitivity is rel-

atively poor. For instance, 44 % of the participants that

received a diagnosis of an ASD according to ICD-10R did

not meet DSM-5 criteria. Similarly, 22 % of the individ-

uals that met criteria for Asperger Syndrome or Autistic

Disorder on DSM-IV-TR would not qualify for a DSM-5

Table 3 Percentage of participants that would be diagnosed with:

(A) ASD on DSM-5; (B) Social Communication Disorder (SCD) on

DSM-5; (C) ASD on DSM-5 if number of criterion required in

Criteria A was reduced from 3 to 2, and/or the number of criterion

required in Criteria B was reduced from 2 to 1 % (N)

A B C

ICD 10R/DSM-IV-TR

diagnosis

DSM-5

ASD

DSM-5

SCD

DSM-5 ASD:

relax A

DSM-5 ASD:

relax B

DSM-5 ASD:

relax A and B

ICD-10R, % (N) Not ASD, (N=

37) 0 0 0 0 0ASD, (N = 113) 56 (63) 19 (21) 69 (78)** 70 (79)** 87 (98)**

Childhood autism, (N = 28) 82 (23) 11 (3) 86 (24) 93 (26) 96 (27)

Asperger Syndrome, (N = 48) 69 (33) 15 (7) 83 (40)* 83 (40)* 98 (47)**

PDD-unspecified, (N = 37) 19 (7) 30 (11) 38 (14)* 35 (13)* 65 (24)**

DSM-IV-TR, % (N) Not ASD, (N=70) 3 (2) 13 (9) 14 (10)* 10 (7)* 27 (19)**

ASD, (N = 80) 77 (61) 15 (12) 85 (68)* 90 (72)** 99 (79)**

* Difference between full criteria and relaxed threshold: McNemars p\0.05

** Difference between full criteria and relaxed threshold: McNemars p\ 0.001

Fig. 1 Percentage of participants in ICD-10R/DSM-5 diagnostic

groups that met criteria for additional mental health conditions. GAD

General Anxiety Disorder, OCD Obsessive Compulsive Disorder,

ADHD Attention Deficit Hyperactivity Disorder, None: No addi-

tional/alternative mental health condition. *p\ 0.05; **p\ 0.01


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diagnosis of ASD. This is consistent with the only previous

study that investigated agreement between current and

proposed ASD criteria in intellectually disabled adults with

ASD (Matson et al. 2012), and is cause for concern since

these individuals, who have genuine difficulties and are

most likely on the spectrum, may not be able to access

services available to the ASD population if the DSM-5 is

used to define eligibility (i.e., if it is used as an entrycriteria).

The decline in sensitivity was highlighted when per-

formance of each diagnostic algorithm was measured

against results of gold-standard assessment tools. Both

the ICD-10R and DSM-IV-TR had a 97 % chance of

reporting a true ASD positive diagnosis according to the

outcome of the ADI-R, and this fell to 81 % when using the

DSM-5a marginally significant decline. The chance of

reporting a true negative, however, was slightly better

when using the DSM-5 as compared to current diagnostic

algorithms. Comparison with the ADOS-G revealed similar

results, although there was a lower chance of true positivesacross all algorithms. It should be noted the ADI-R and

ADOS-G were developed in order to align with the DSM-

IV-TR, therefore the finding that the assessment tools fit

better with current algorithms than with the DSM-5 is not

entirely unexpected. Nevertheless, disagreement between

diagnostic algorithms and gold-standard research assess-

ment tools may lead to confusion in both research and

clinical settings, therefore revisions of the assessment tools

is likely to be required for use in adult populations.

Given the evidence that a significant proportion of

individuals currently considered to be on the autism spec-

trum may not be included in the DSM-5 ASD category, it is

important to clarify what factors are associated with the

likelihood that an individual will meet criteria. Encourag-

ingly, there was no evidence of an effect of age or sex on

diagnostic outcome, suggesting no particular demographic

is more or less likely to receive an ASD diagnosis. We also

found no effect of IQ in the subset of participants for which

this information was available. This subset was a fairly

small group, therefore conclusions are drawn with caution,

however the results show no indication that higher-func-

tioning people are more likely to be missed by the proposed

DSM-5 criteria than lower functioning peoplea concern

which has been raised in recent studies with children

(McPartland et al.2012).

In the current study, the difference in rate of DSM-5

ASD positive diagnosis between the ICD-10R subtypes of

Childhood Autism and Asperger Syndrome was non-sig-

nificant. This suggests that adults with an Asperger Syn-

drome diagnosis will be at no greater risk of missing out on

an ASD diagnosis when using DSM-5 than adults with

Childhood Autism, and supports the DSM-5 proposal to

combine these diagnoses into a single category. However,

the third ICD-10R subtypePDD-unspecifiedhad a

significantly lower rate of ASD diagnosis using DSM-5

than both of the other two diagnostic subtypes. This is not

necessarily cause for concern: people with a PDD-

unspecified diagnosis did not actually meet full diagnostic

criteria on the ICD-10R eitherinstead they showed sig-

nificant ASD traits and were considered to be on the

spectrum. What is perhaps of concern is that a quarter ofpeople with an ICD-10R ASD diagnosis would not qualify

foreitherASD orSCD on the DSM-5, and the majority of

those affected were of the PDD-unspecified subtype. This

is the first study to report the proportion of people that

would qualify for the new SCD diagnosis as currently

drafted, but our results suggest this alternative category,

which was intended to provide diagnostic coverage to

many of those who will not qualify for the ASD diagnosis,

may not solve the problem of the comparatively poor

sensitivity of the DSM-5 relative to ICD-10R.

The present data suggest that the sensitivity of the draft

DSM-5 criteria, compared at least to ICD-10R and DSM-IV-TR, can be improved. Several authors have suggested

that increased sensitivity without reduced specificity might

be achieved by relaxing the proposed criteria (Frazier et al.

2012; Kapp and Neeman 2012; McPartland et al. 2012).

Our results supported this: it was found that relaxing

thresholds in DSM-5 for social communication and social

interaction (Criteria A), and/or repetitive patterns of

behaviour, interests, and activities (Criteria B) allowed the

inclusion of almost all people currently diagnosed with

Childhood Autism or Asperger Syndrome, and the majority

of those with PDD-unspecifiedwhile maintaining speci-

ficity. Therefore relaxing one, or both, criteria will likely

allow the inclusion of more people currently considered to

be ASD using ICD-10R and DSM-IV-TR, without weak-

ening the boundaries between ASD and non-ASD. In

addition, clear guidance on how to deal with uncertainty in

the DSM-5 classification system will be particularly

important; the latest drafts of the DSM-5 criteria allow

criteria to be met by history or current state, which may

help where information is missing or uncertain. Rating

criteria that were unclear as present versus absent had

significant effects on the rates of DSM-5 ASD diagnosis.

While this is the first study to examine the draft DSM-5

criteria in adults with ASD who do not have intellectual

disabilities, some limitations should be noted. Like other

studies comparing existing criteria to the DSM-5 draft,

existing clinical notes and instruments that were used pri-

marily for allocating current (ICD-10R) diagnostic cate-

gories were analyzed. It remains to be seen whether using

the DSM-5 criteria in the clinic during assessment in a

prospective fashion would result in different findings. For

example, sensory sensitivities are not part of current clin-

ical criteria and might be more thoroughly assessed in


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future in clinics where DSM-5 criteria are adopted.

Nonetheless one potentially useful feature of the present

study, in contrast to many others, is the relatively large

number of participants (25 %) who were assessed for ASD

but found to be negative using current criteria. This

allowed examination of specificity of the different diag-

nostic measures. Finally, it should be noted, of course, that

it remains unclear whether existing ICD-10R or DSM-IV-TR criteria should be considered the gold-standard

against which new criteria are compared; in the absence of

biomarkers, the exact definition of ASD and its boundaries

remain a matter for debate.

Conclusions

The specificity of the DSM-5 criteria, as compared to the

currently used ICD-10R and DSM-IV-TR criteria is good

but sensitivity is relatively low. This may be improved

(without adversely affecting specificity) by relaxingDSM-5 criteria and by careful consideration of missing or

uncertain symptom information.

Acknowledgments Funding was provided by the Medical Research

Council (MRC, UK), the EU Autism Imaging Study (AIMS) network

(Grant Agreement: 115300), and the National Institute for Health

Research Biomedical Research Centre for Mental Health at Kings

College London, Institute of Psychiatry and South London and

Maudsley National Health Service Foundation Trust. The authors

wish to thank all the participants involved in this study. Also the

administrative support staff at the Behavioural Genetics Clinic:

Frances Harwood, Pauline Domingo and Marie Simpson.

Appendix 1

ICD-10R algorithm, with corresponding DSM-IV-TR

items provided alongside each criterion. Of the participants

that were diagnosed with ASD on the ICD-10R, the pro-

portion of participants that were coded Yes, No and

Unclear for each item is given.

ICD-10R Algorithm (Corresponding DSM-IV

item provided for each criterion).

ICD-10R: ASD

positive group

1 Qualitative abnormalities in reciprocal social

interaction are manifest in at least two of the

following areas:

Yes No Unclear

a. Failure adequately to use eye-to-eye gaze,

facial expression, body posture, and gesture to

regulate social interaction

DSM-IV-TR: 1a: Marked impairment in the use of

multiple nonverbal behaviours such as eye-to-

eye gaze, facial expression, body postures, and

gestures to regulate social interaction.

78.8 13.3 8.0

Appendix continued



ICD-10R: ASD

positive group

b. Failure to develop (in a manner appropriate to

mental age, and despite ample opportunities)

peer relationships that involve a mutual sharing

of interests, activities, and emotions

DSM-IV-TR: 1b: Failure to develop peerrelationships appropriate to developmental

level

92.0 3.5 4.4

c. Lack of socio-emotional reciprocity as shown

by an impaired or deviant response to other

peoples emotions; or lack of modulation of

behaviour according to social context; or a

weak integration of social, emotional, and

communicative behaviours

DSM-IV-TR: 1d: Lack of social or emotional

reciprocity

79.6 7.1 13.3

d. Lack of spontaneous seeking to share

enjoyment, interests, or achievements with

other people (e.g. a lack of showing, bringing,

or pointing out to other people objects of

interest to the individual).

DSM-IV-TR: 1c: a lack of spontaneous seeking to

share enjoyment, interests, or achievements

with other people (e.g., by a lack of showing,

bringing, or pointing out objects of interest)

38.1 24.8 37.2

2. Are there restricted, repetitive patterns of

behavior, interests, and activities, as manifested

by at least one of the following:

Yes No Unclear

a. A delay in, or total lack of, development of

spoken language that is not accompanied by an

attempt to compensate through the use of

gesture or mime as an alternative mode of

communication (often preceded by a lack of

communicative babbling);

DSM-IV-TR: 2a: delay in, or total lack of, thedevelopment of spoken language(not

accompanied by an attempt to compensate

through alternative modes of communication

such as gesture or mime)

23.9 51.3 24.8

b. Relative failure to initiate or sustain

conversational interchange (at whatever level of

language skills is present), in which there is

reciprocal responsiveness to the

communications of the other person

DSM-IV-TR: 2b: in individuals with adequate

speech, marked impairment in the ability to

initiate or sustain a conversation with others

94.7 0 5.3

c. Stereotyped and repetitive use of language or

idiosyncratic use of words or phrases

DSM-IV-TR: 2c: stereotyped and repetitive use oflanguage or idiosyncratic language

38.9 50.4 10.6

d. lack of varied spontaneous make-believe or

(when young) social imitative play

DSM-IV-TR: 2d: lack of varied, spontaneous

make-believe play or social imitative play

appropriate to developmental level

51.3 24.8 23.9

3. Restricted, repetitive, and stereotyped patterns

of behaviour, interests, and activities are

manifest in at least one of the following areas:

Yes No Unclear


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Appendix continued



ICD-10R: ASD

positive group

a. An encompassing preoccupation with one or

more stereotyped and restricted patterns of

interest that are abnormal in content or focus; or

one or more interests that are abnormal in their

intensity and circumscribed nature though notin their content or focus

DSM-IV-TR: 3a: encompassing preoccupation

with one or more stereotyped and restricted

patterns of interest that is abnormal either in

intensity or focus.

66.4 20.4 13.3

b. Apparently compulsive adherence to specific,

non-functional routines or rituals

DSM-IV-TR: 3b: apparently inflexible adherence

to specific, nonfunctional routines or rituals

56.6 25.7 17.7

c. Stereotyped and repetitive motor mannerisms

that involve either hand or finger flapping or

twisting, or complex whole body movements

DSM-IV-TR: 3c: stereotyped and repetitive motor

mannerisms (e.g. hand or finger flapping or

twisting, or complex whole-body movements)

17.7 65.5 16.8

d. Preoccupations with part-objects or non-

functional elements of play materials (such as

their odor, the feel of their surface, or the noise

or vibration that they generate).

DSM-IV-TR: 3d: persistent preoccupation with

parts of objects

27.4 50.4 22.1

Appendix 2

DSM-5 algorithm indicating the proportion of participants

diagnosed with ASD on the ICD-10R that were coded

Yes, No and Unclear for each item. Criteria from

ICD-10R that contribute to each DSM-5 criterion are

indicated, and underlined sections indicate sections not

explicitly in ICD-10R criteria.

DSM-5 Algorithm ICD-10R:

ASD positive group

Criteria from

ICD-10R

CRITERION A: Are

there persistent deficits

in social

communication and

social interaction across

contexts, not accounted

for by general

developmental delays,

and manifest by ALL

THREE of the

following:

Yes No Unclear

Appendix continued

DSM-5 Algorithm ICD-10R:ASD

positive group

2b; 1c; 1d 1. Deficits in social-

emotional reciprocity;

ranging from abnormal

social approach and

failure of normal backand forth conversation/

through reduced sharing

of interests, emotions,

and affect and response

to total lack of initiation

of social interaction?

94.7 1.8 3.5

1a; 2. Deficits in nonverbal

communicative

behaviors used for

social interaction;

ranging from poorly

integrated- verbal and

nonverbal

communication,

through abnormalities

in eye contact and

body-language, or

deficits in

understanding and use

of nonverbal

communication, to total

lack of facial expression

or gestures?

80.5 13.3 6.2

1b; 2d (but must

be shared

imaginative

play)

3. Deficits in developing

and maintaining

relationships,

appropriate to

developmental level

(beyond those withcaregivers); ranging

from difficulties

adjusting behavior to

suit different social

contexts through

difficulties in sharing

imaginative play and in

making friends to an

apparent absence of

interest in people?

93.8 2.7 3.5

CRITERION B: Are

there restricted,

repetitive patterns of

behavior, interests, and

activities, as manifestedby AT LEAST TWO of

the following:

Yes No Unclear

2c; 3c; 3d 1. Stereotyped or

repetitive speech, motor

movements, or use of

objects (such as, simple

motor stereotypies and

echolalia, repetitive use

of objects, or

idiosyncratic phrases)?

54.9 33.6 11.5


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Appendix continued

DSM-5 Algorithm ICD-10R:ASD

positive group

2c; 3b 2. Excessive adherence to

routines, ritualized

patterns of verbal or

nonverbal behavior, or

excessive resistance tochange (such as,

motoric rituals,

insistence on same

route or food, repetitive

questioning, or extreme

distress at small

changes)?

57.5 25.7 16.8

3a; 3d 3. Highly restricted,

fixated interests that is

abnormal in intensity or

focus (such as, strong

attachment to or

preoccupation with

unusual objects,

excessively

circumscribed or

perseverative interests)?

66.4 22.1 11.5

3d 4. Hyper- or hypo-

reactivity to sensory

input or unusual interest

in sensory aspects of

environment (such as,

apparent indifference to

pain/heat/cold, adverse

response to specific

sounds or textures,

excessive smelling or

touching of objects,

fascination with lightsor spinning objects)?

18.6 31.0 50.4

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