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J Autism Dev Disord (2013) 43:25152525

DOI 10.1007/s10803-013-1799-6

ORIGINAL PAPER

Comparison of ICD-10R, DSM-IV-TR and DSM-5 in an Adult


Autism 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 whether
ASD 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

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: ellie.wilson@kcl.ac.uk
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

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 clinical 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 Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000), ASD comes under the umbrella term of
Pervasive Developmental Disorder (PDD) and an individual may be defined as having one of four diagnostic subtypes 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,

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


current diagnostic algorithms. First, distinguishing the
social and communication domains is somewhat arbitrary 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 emotional
reciprocity (social domain), lack of sharing enjoyment and
interests (social domain), and poor reciprocal conversation
(communication domain) (see Appendix 1). 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 contributes to disagreement between clinicians.
To address these problems, the Neurodevelopmental Disorders Workgroup, convened by the American
Psychiatric Association (APA), has proposed a number of
significant changes to the diagnostic criteria for ASD
(Happe 2011; Swedo et al. 2012). The social and communication 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-IVTR). 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 individuals 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 outcomes 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 relatively 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

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and Perry 2012; Worley and Matson 2012). This highlights a key concern of some: that the new criteria will fail
to capture individuals currently receiving an ASD diagnosis who are on the broader spectrum according to
DSM-IV-TR or ICD-10R criteria (e.g., Pervasive Developmental Disorder-not otherwise specified; PDD-NOS).
As a consequence it is feared by some that these individuals 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 sensitivity 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 of
ASD assessments per month increased fourfold between
2005 and 2010 (Murphy et al. 2011). Further, diagnosis is
particularly challenging in this group because a developmental history is often unavailable and/or unreliable; and
presentation is frequently complicated by additional
mental health conditions (Carpenter 2012). 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 DSMIV-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/educational services. Also, it is unknown what proportion of
individuals would qualify for the new, alternative diagnosis 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, presence 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 insufficient information to code the item.

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


(Lisspers et al. 1997).

Method

Clinical Assessment

Participants

Assessment included a detailed psychiatric assessment


using ICD-10R research diagnostic criteria and, where
possible (i.e., where parents were available, able and
willing), an ADI-R. In the event that no parent was available 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 multidisciplinary clinical teama consultant psychiatrist, junior
doctor, and ADI-R/ADOS-G administrator (nurse or psychologist)who together decided whether each criterion
on the ICD-10R algorithm was fulfilled (see Appendix 1).
If a patient met full ICD-10R criteria (a total of at least six
symptoms must be presenteither currently or by historywith 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 language 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 (PDDunspecified) 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 diagnostic 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 Autism, 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 selfreport 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).

Participants included 158 individuals consecutively assessed for ASD in a specialist National tertiary ASD diagnostic 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 110
males (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 semistructured interview with the parent or caregiver assessing
ASD traits during childhood, and the ADOS-G is assessment 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 communication 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), (Abramowitz and Deacon 2006). Symptoms of ADHD were assessed 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; Zigmond and Snaith 1983) was used to assess levels of anxiety
and depression, and has high levels of internal consistency

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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 executive functioning. These participants (N = 35) were tested
using the Weschler Abbreviated Intelligence Scale-III,
(WAIS III; Wechsler 1997) which revealed a mean Performance IQ of 87 (SD = 16, range 55132) and a mean
Verbal 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 satisfied, and this was supplemented by anonymized reports
from the ADI-R, ADOS-G, and the psychiatric interview.
Appendix 2 shows 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 participants 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, DSMIV-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

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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-5
algorithm 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 ASD
diagnosis.

Results
Conclusions of Initial Diagnostic Assessments
ICD-10R Versus DSM-5 (Table 1)
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 (Table 1)
The rate of ASD positive diagnosis using DSM-5 (42 %)
was also significantly lower than the rate of Autistic Disorder or Asperger Syndrome assessed using DSM-IV-TR
(53 %), v2(1) [ 82.5, p \ 0.001. Additionally, two individuals 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 (Table 2)
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 was
available. 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
McNemars p = 0.07), but their specificity was marginally

Table 1 Outcome of initial assessment of 150 participants according


to the ICD-10R, and outcome of data re-coded according to DSM-IVTR and DSM-5: % (N)
Above/below ASD
threshold

Diagnosis of below ASD


threshold participants

ASD fullthreshold

Below ASD
threshold

PDDunspecified 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)

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


ICD-10R and the DSM-IV-TR than the DSM-5 (respectively 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 ICD10R, 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 subtypes, v2(2) = 31.58, p \ 0.001. Significantly more participants diagnosed with ICD-10R Childhood Autism or
Asperger Syndrome met DSM-5 criteria for ASD than
those in the PDD-unspecified group (Table 3, 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 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 (%)a

ADI-R above
cut-off (%)a

ADOS-G below
cut-off (%)b

ADOS-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-10R

Sensitivity: 0.97*

Sensitivity: 0.63*

Specificity: 0.61

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*

Sensitivity: 0.70**

Specificity: 0.61

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-5

Sensitivity: 0.81

Sensitivity: 0.50

Specificity: 0.66

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 \ 0.05
a

ADI-R cut-off scores: Social = 10; Communication = 8; Repetitive behaviors/interests = 3

DOS-G cut-off scores: Communication = 3; Social interaction = 6; Communication ? Social = 10

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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

ICD 10R/DSM-IV-TR
diagnosis
ICD-10R, % (N)

DSM-IV-TR, % (N)

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)

DSM-5
ASD

DSM-5
SCD

DSM-5 ASD:
relax A

DSM-5 ASD:
relax B

DSM-5 ASD:
relax A and B

Not ASD, (N = 37)

ASD, (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)**

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

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

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

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 significantly (and specificity remained at 100 %) when thresholds

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


74 % received a diagnosis of ASD on the DSM-5 when
criteria 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 criteria for ASD might perform in a specialist diagnostic
clinic for adults without significant intellectual disabilitywho form a large proportion of individuals with
ASD.
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 relatively 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 individuals that met criteria for Asperger Syndrome or Autistic
Disorder on DSM-IV-TR would not qualify for a DSM-5

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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 entry
criteria).
The decline in sensitivity was highlighted when performance 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 positives
across all algorithms. It should be noted the ADI-R and
ADOS-G were developed in order to align with the DSMIV-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 assessment 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 spectrum 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. Encouragingly, 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-functioning 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-significant. This suggests that adults with an Asperger Syndrome 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,

2521

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 PDDunspecified diagnosis did not actually meet full diagnostic
criteria on the ICD-10R eitherinstead they showed significant ASD traits and were considered to be on the
spectrum. What is perhaps of concern is that a quarter of
people with an ICD-10R ASD diagnosis would not qualify
for either ASD or SCD 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 DSMIV-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 specificity. 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 weakening 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 primarily for allocating current (ICD-10R) diagnostic categories 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 clinical criteria and might be more thoroughly assessed in

123

2522

J Autism Dev Disord (2013) 43:25152525

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 diagnostic measures. Finally, it should be noted, of course, that
it remains unclear whether existing ICD-10R or DSMIV-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.

Appendix continued

Conclusions

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


reciprocity

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 relaxing
DSM-5 criteria and by careful consideration of missing or
uncertain symptom information.

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).

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 proportion 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

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

92.0

3.5

4.4

79.6

7.1

13.3

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);

23.9

51.3

24.8

94.7

5.3

38.9

50.4

10.6

51.3

24.8

23.9

Yes

No

Unclear

DSM-IV-TR: 1b: Failure to develop peer


relationships appropriate to developmental
level
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: 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)

DSM-IV-TR: 2a: delay in, or total lack of, the


development of spoken language (not
accompanied by an attempt to compensate
through alternative modes of communication
such as gesture or mime)
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

ICD-10R Algorithm (Corresponding DSM-IV


item provided for each criterion).

ICD-10R: ASD
positive group

c. Stereotyped and repetitive use of language or


idiosyncratic use of words or phrases

1 Qualitative abnormalities in reciprocal social


interaction are manifest in at least two of the
following areas:

Yes

No

Unclear

DSM-IV-TR: 2c: stereotyped and repetitive use of


language or idiosyncratic language

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


facial expression, body posture, and gesture to
regulate social interaction

78.8

13.3

8.0

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


multiple nonverbal behaviours such as eye-toeye gaze, facial expression, body postures, and
gestures to regulate social interaction.

123

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
3. Restricted, repetitive, and stereotyped patterns
of behaviour, interests, and activities are
manifest in at least one of the following areas:

J Autism Dev Disord (2013) 43:25152525

2523

Appendix continued

Appendix continued

ICD-10R Algorithm (Corresponding DSM-IV


item provided for each criterion).

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 not
in their content or focus

66.4

20.4

13.3

56.6

25.7

17.7

DSM-5 Algorithm

ICD-10R:ASD
positive group

2b; 1c; 1d

1. Deficits in socialemotional reciprocity;


ranging from abnormal
social approach and
failure of normal back
and 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 with
caregivers); 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 manifested
by AT LEAST TWO of
the following:

Yes

No

Unclear

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

DSM-IV-TR: 3a: encompassing preoccupation


with one or more stereotyped and restricted
patterns of interest that is abnormal either in
intensity or focus.
b. Apparently compulsive adherence to specific,
non-functional routines or rituals
DSM-IV-TR: 3b: apparently inflexible adherence
to specific, nonfunctional routines or rituals
c. Stereotyped and repetitive motor mannerisms
that involve either hand or finger flapping or
twisting, or complex whole body movements

17.7

65.5

16.8

27.4

50.4

22.1

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


mannerisms (e.g. hand or finger flapping or
twisting, or complex whole-body movements)
d. Preoccupations with part-objects or nonfunctional 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

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.

Criteria from
ICD-10R

DSM-5 Algorithm

ICD-10R:
ASD positive group

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

2c; 3c; 3d

123

2524

J Autism Dev Disord (2013) 43:25152525

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 to
change (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)?
4. Hyper- or hyporeactivity 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 lights
or spinning objects)?

66.4

22.1

11.5

18.6

31.0

50.4

3d

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