International Journal of School & Educational Psychology
ISSN: 2168-3603 (Print) 2168-3611 (Online) Journal homepage: http://www.tandfonline.com/loi/usep20
DSM-5 Diagnostic Criteria for Autism Spectrum
Disorder With Implications for School
Psychologists
Amy N. Esler & Lisa A. Ruble
To cite this article: Amy N. Esler & Lisa A. Ruble (2015) DSM-5 Diagnostic Criteria for Autism
Spectrum Disorder With Implications for School Psychologists, International Journal of School
& Educational Psychology, 3:1, 1-15, DOI: 10.1080/21683603.2014.890148
To link to this article: http://dx.doi.org/10.1080/21683603.2014.890148
Published online: 03 Feb 2015.
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Date: 02 November 2016, At: 12:39
International Journal of School & Educational Psychology, 3, 1–15, 2015
Copyright q International School Psychology Association
ISSN 2168-3603 print/ISSN 2168-3611 online
DOI: 10.1080/21683603.2014.890148
ARTICLES
DSM-5 Diagnostic Criteria for Autism Spectrum
Disorder With Implications for School Psychologists
Amy N. Esler
Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
Lisa A. Ruble
Department of Educational, School, and Consulting Psychology, University of Kentucky, Lexington, Kentucky, USA
Changes to the diagnosis of autism spectrum disorder (ASD) within the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric
Association, 2013) have important implications for school psychologists responsible for
evaluating children with ASD, interpreting results to caregivers, and informing policy makers
of needed revisions to eligibility criteria based on empirical understanding. The primary
purpose of this review is to describe changes to the DSM-5 and the empirical evidence behind
the modifications. A secondary goal is to describe implications for best practices in school
evaluations for ASD. Given the concerns about the DSM-5 expressed by caregivers and
individuals with ASD during the revision process, school psychologists who are aware of the
rationale for and implications of the changes will be better positioned to assist local policy
makers regarding diagnostic evaluations for ASD and address parental concerns regarding the
evaluation process and service implications for their child.
Keywords: Autism, assessment, clinical diagnosis, practice issues, DSM-5
OVERVIEW OF NEW DIAGNOSTIC CRITERIA FOR
AUTISM SPECTRUM DISORDER
The Diagnostic and Statistical Manual of Mental Disorders,
5th edition (DSM-5; American Psychiatric Association
[APA], 2013) went into effect May 2013, and with it came
significant revisions to the diagnosis of autism spectrum
disorder (ASD). These revisions have important implications
for school psychologists responsible for evaluating children
with ASD, interpreting results to caregivers, and informing
policy makers of needed revisions to eligibility criteria based
on empirical understanding. Changes to the DSM-5 resulted
Correspondence should be addressed to Amy N. Esler, Department of
Pediatrics, University of Minnesota, 717 Delaware St. SE, Minneapolis,
MN 55414, USA. E-mail: [email protected]
from decades of research, and future research will be
influenced by how ASD is now defined within the DSM-5.
Although the process of decision making for ASD in
educational settings is distinct from that of a clinical
diagnosis, the DSM informs how ASD is assessed within
public education systems. A large number of children with
ASD are identified for the first time through school
evaluations (Wiggins, Baio, & Rice, 2006). Many children
with ASD receive services beyond the school day (e.g.,
private therapies, county support services), and coverage for
these services can require a medical diagnosis, leading
parents to seek additional evaluations in the community.
School evaluations that closely reflect the DSM-5 may
reduce duplication of assessments, which would help
families access community services more readily, as well
as direct limited financial resources to treatment services.
2
A. N. ESLER AND L. A. RUBLE
Because many clinical evaluations include careful reviews of
past assessments, school evaluations can significantly
influence diagnostic decisions and provide critical information regarding a child’s behavior in natural social settings
that is unavailable in clinical settings. Medical professionals,
for example, are allotted less time for observation and direct
assessment than is achievable in schools and, thus, can miss
important nuances in a child’s social behavior.
The primary purpose of this paper is to describe changes to
the DSM-5 and the empirical evidence behind the
modifications. A secondary goal is to describe implications
of these changes for best practices in school evaluations for
ASD. Given the concerns about the DSM-5 that have been
expressed by professionals, caregivers, and individuals with
ASD, school psychologists who are aware of the rationale for
and implications of the changes will be better positioned to
assist local policy makers regarding diagnostic evaluations
for ASD and address parental concerns regarding the
evaluation process and service implications for their child.
From a Categorical to a Dimensional Approach
One of the more significant changes to the DSM-5 was the
combining of the separate, categorical diagnoses of autistic
disorder, Asperger’s disorder, and pervasive developmental
disorder, not otherwise specified (PDD-NOS) into one
diagnosis: autism spectrum disorder (ASD). While controversial, this change does not represent a stark departure
from current practice. In 1991, Happé and Frith (1991)
proposed the term “autism spectrum disorders” based on
concerns that the umbrella category of pervasive developmental disorder (PDD) lacked clearly specified deficits, and
trying to fit individuals into one of three categories was
often arbitrary, obscuring understanding of the heterogeneity of ASD. Most research to identify distinctive features
of Asperger’s, autism, and PDD-NOS failed to find any
reliable differences across PDD subtypes once IQ or
language were controlled. Distinctions among subtypes
were inconsistent over time and variable across clinicians
(e.g., Frith, 2004; Howlin, 2003; Lord et al., 2011;
Macintosh & Dissanayake, 2004; Ozonoff, South, & Miller,
2000; Prior et al., 1998; Snow & Lecavalier, 2011).
Furthermore, subtypes had poor predictive validity of child
outcomes (Miller & Ozonoff, 2000; Szatmari et al., 2009;
Szatmari, Bryson, Boyle, Streiner, & Duku, 2003) and thus
were uninformative for treatment planning. Indeed, while
the term was not adopted in the DSM-IV or ICD-10, “autism
spectrum disorders” became commonly used (Williams
et al., 2008).
The DSM-5 represents a move toward dimensionalization of disorders (e.g., Kraemer, 2007; Regier, 2007). The
categorical approach, represented by earlier versions of the
DSM, involves determining whether a disorder is present or
not. While categorization is necessary to some extent in
establishing a boundary between a disorder and normal
variation in development, the development and course of
childhood disorders are complex (Hudziak, Achenbach,
Althoff, & Pine, 2007). Disorders that arise in childhood
affect and are affected by development; what is considered
normal and abnormal can change with age and must be
taken into account within the diagnostic process. Diagnosis
of childhood disorders also relies on information from
multiple informants, such as parents, teachers, and the child.
When information across sources does not fully align, it can
be difficult to decide how to weigh the conflicting
information to arrive at a diagnostic decision (Hudziak
et al., 2007).
Dimensional approaches, in contrast, quantify the degree
to which a child manifests particular kinds of problems in
relation to variables known to influence development and
behavior, such as age and gender. The DSM-5 does not
substitute categorical diagnoses with dimensional; rather,
diagnoses (i.e., categories) contain dimensional information
to further specify and describe the disorder (Kraemer, 2007).
The text of DSM-5 offers more detail on the topography of
core symptoms of ASD at different ages; characteristics are
described for toddlers, school-aged children, and adults.
Social communication criteria provide examples of how
symptoms may manifest in mildly affected individuals
without language or cognitive deficits and in individuals with
impairments in these areas. Examples relevant for different
ages also are provided. For example, a possible symptom
within the social relationships criterion is an apparent lack of
interest in peers. This would be a relevant characteristic in
toddlers for whom establishing and maintaining friendships
are not yet developmentally expected.
Three Domains Become Two
The DSM-5 represents ASD symptoms across two domains
(social communication deficits and restricted, repetitive
behaviors), whereas the DSM-IV presented a triad of
symptoms, which separated social and communication
symptoms. While DSM-IV social interaction and communication domains were collapsed and reorganized in
DSM-5, individual symptoms are largely retained. The
DSM-5 version identifies a smaller number of more general
principles in social communication that are expected to be
present in all individuals with ASD regardless of age or
developmental level, but that can be manifested in many
different ways (Mahjouri & Lord, 2012). Social communication symptoms have been reconfigured as a dimensional
continuum of behaviors representing social-emotional
reciprocity, coordination of verbal and nonverbal communication, and establishing, maintaining, and understanding social relationships.
A large body of research supports that ASD symptoms are
best represented by a two-domain model (Constantino et al.,
2004; Frazier et al., 2012; Gotham, Risi, Pickles, & Lord,
2007; Norris, Lecavalier, & Edwards, 2012). Constantino
AUTISM SPECTRUM DISORDER: DSM-5 CRITERIA
et al.’s (2004) landmark factor analytic study revealed that
symptoms representing the DSM-IV clusters, Social Interaction and Communication, were best represented by a single
“social communication” factor. Furthermore, stereotyped
speech loaded on the repetitive behaviors factor rather than
social communication. Studies using the Autism Diagnostic
Observation Schedule (ADOS; Lord et al., 2000) also showed
symptoms were better represented by a two-factor solution of
Social Affect and Restricted/Repetitive Behaviors versus a
three-factor solution (Gotham et al., 2007). In the second
edition of the ADOS (ADOS-2; Lord, Luyster, Gotham, &
Guthrie, 2012a, 2012b), algorithms now reflect the two
symptom clusters of the DSM-5.
Reorganization of Symptom Criteria
The DSM-5 includes modifications to the descriptions of
social interaction and communication symptoms contained in
the DSM-IV, and increases the number of criteria that must
be met in the restricted, repetitive behavior domain. The
DSM-IV autistic disorder criterion of a delay or complete
lack of development in expressive language has been
removed, because research has shown this feature is neither
unique to nor universal in individuals with ASD (Hartley &
Sikora, 2009; Matson & Neal, 2010). The DSM-IV criterion
of limitation in or lack of development of imaginative play
has been narrowed to deficits in sharing imaginative play
with others. Further, unlike the DSM-IV, the DSM-5 requires
that all social communication criteria are met, either
currently or by history, for a diagnosis of ASD. These
changes were made to improve diagnostic specificity.
Restricted, repetitive behaviors now are organized across
symptoms of repetitive actions, fixated interests in narrow
or unusual areas, insistence on sameness, and unusual
responses to sensory stimuli. The rationale for this
organization also comes from factor analytic studies,
which lend support to separate symptom clusters of
repetitive sensory-motor behaviors (repetitive motor mannerisms, uses of objects, and sensory-seeking behaviors),
insistence on rituals and routines (Cuccaro et al., 2003;
Richler, Bishop, Kleinke, & Lord, 2007), and hypersensitivity to sensory stimuli (Bishop, Richler, & Lord, 2006;
Tadevosyan-Leyfer et al., 2003). The new criterion of
unusual responses to sensory stimuli has been added, and
individuals may show either hypersensitivity or hyposensitivity to touch, sight, smell, taste, or sound. The addition of
this criterion is supported by research showing that these
behaviors occurred frequently in young children (BenSasson, Carter, & Briggs-Gowan, 2009; Leekam, Nieto,
Libby, Wing, & Gould, 2007; Tadevosyan-Leyfer et al.,
2003) and were useful in distinguishing ASD from other
disorders (Richler et al., 2007; Wiggins, Robins, Bakeman,
& Adamson, 2009). Stereotyped speech is now encompassed within a general symptom area of repetitive actions
that also includes repetitive motor movements (hand and
3
finger mannerisms, repetitive whole-body movements) and
uses of objects (e.g., lining up, spinning, sorting). Note that
these three behaviors—repetitive speech, motor movements, and use of objects—represented three separate
criteria under the DSM-IV: stereotyped speech (Communication), repetitive motor mannerisms (Restricted, Repetitive
Behaviors), and preoccupation with parts of objects
(Restricted, Repetitive Behaviors).
In the DSM-5, two restricted, repetitive domain criteria
must be met, either currently or by history. Support for
requiring multiple restricted, repetitive behaviors comes
from research showing these behaviors to be prevalent in
ASD, even in young children (Bishop et al., 2006; Ozonoff,
Heung, Byrd, Hansen, & Hertz-Picciotto, 2008; Richler
et al., 2007). Furthermore, in a large-scale longitudinal
study that included a group of children with developmental
delays, the presence of multiple repetitive behaviors was
predictive of ASD, but the presence of any one repetitive
behavior was not (Richler et al., 2007).
While there is a good foundation of research to support
two symptom domains and the organization of restricted,
repetitive behavior criteria, there is less research to support
the division of behaviors across social communication
criteria. Research has not yet identified consistent subdivisions of social communication symptoms in this way. There
are early indicators that the assignment of symptoms to
DSM-5 criteria may not be straightforward. Two separate
groups of researchers (Barton, Robins, Jashar, Brennan, &
Fein, 2013; Huerta, Bishop, Duncan, Hus, & Lord, 2012)
recently attempted to assign symptoms on the Autism
Diagnostic Interview-Revised (ADI-R; Rutter, LeCouteur,
& Lord, 2003) and ADOS to their corresponding DSM-5
criteria. The two groups disagreed on criterion assignment
for almost a third of the 54 ADI-R/ADOS symptoms. For
example, making an awkward overture could be considered
an “abnormal social approach” or “difficulty adjusting
behavior to suit different social contexts” depending on the
form and content of the overture (Barton et al., 2013).
Age of Onset and Functional Impairment
Finally, the DSM-IV required presence of symptoms before
age 3 years. Recognizing that some children may not show
clear symptoms until social expectations exceed their
capacities, the DSM-5 requires that symptoms must be
present early in life but no longer uses age 3 as a benchmark.
The symptoms of ASD also must result in impairment in
social, occupational, and/or other important areas of
functioning, with the caveat that individuals may be able to
reduce or mask some symptoms through intervention,
compensation, or environmental supports. Although specific
symptom criteria can be documented by history, ASD
symptoms should remain sufficient to cause current impairment (APA, 2013). Table 1 compares symptom criteria across
4
Social Interaction
1. Marked impairment in the use of multiple
nonverbal behaviors such as eye-to-eye gaze,
facial expression, body postures, and gestures to
regulate social interaction
Social Communication
1. Deficits in social-emotional reciprocity;
ranging from abnormal social approach and
failure of normal back-and-forth conversation;
to reduced sharing of interests, emotions, or
affect; to failure to initiate or respond to social
interactions.
2. Deficits in nonverbal communicative
behaviors used for social interaction; ranging
from poorly integrated verbal and nonverbal
communication; to abnormalities in eye contact
and body-language or deficits in understanding
and use of gestures; to a total lack of facial
expressions and nonverbal communication.
3. Deficits in developing, maintaining, and
understanding relationships, ranging from
difficulties adjusting behavior to suit various
social contexts; to difficulties in sharing
imaginative play or in making friends; to
absence of interest in peers.
3. Stereotyped and repetitive use of language or
idiosyncratic language
4. Lack of varied, spontaneous make-believe play
or social imitative play appropriate to
developmental level
2. In individuals with adequate speech, marked
impairment in the ability to initiate or sustain a
conversation with others
4. Lack of social or emotional reciprocity
Communication
1. 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)
3. 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 to
other people)
IDEA Autism
Social Interaction
1. Failure adequately to use eye-to-eye gaze, A developmental disability significantly affecting
facial expression, body posture and gesture to verbal and nonverbal communication and
social interaction, generally evident before age
regulate social interaction
three, that adversely affects a child’s educational
performance . . .
ICD-10 Childhood Autism
Communication
1. 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 alternative modes of communication
(often preceded by a lack of communicative
babbling)
2. Relative failure to initiate or sustain
conversational interchange (at whatever level
of language skills are present) in which there is
reciprocal to-and-from responsiveness to the
communications of the other person
3. Stereotyped and repetitive use of language or
idiosyncratic use of words or phrases
4. Abnormalities in pitch, stress, rate, rhythm and
intonation of speech
3. A lack of socio-emotional reciprocity as shown
by an impaired or deviant response to other
people’s emotions; or lack of modulation of
behavior according to social context, or a weak
integration of social, emotional and
communicative behaviors
2. Failure to develop peer relationships 2. Failure to develop (in a manner appropriate to
appropriate to developmental level
mental age, and despite ample opportunities) peer
relationships that involve a mutual sharing of
interests, activities, and emotions
DSM-IV Autistic Disorder
DSM-5 Autism Spectrum Disorder
TABLE 1
Comparison of DSM-5, DSM-IV, ICD-10, and IDEA Criteria
5
. . . Other characteristics often associated with
autism are engagement in repetitive activities and
stereotyped
movements,
resistance
to
environmental change or change in daily
routines, and unusual responses to sensory
experiences.
Note. Bolded text represents similarities in social communication criteria, and underlined text represents similarities in restricted, repetitive behavior criteria across all classification systems.
Restricted, Repetitive Behaviors
1. 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 although not abnormal in
their content or focus
2. Insistence on sameness, inflexible adherence to 2. Apparently inflexible adherence to specific, 2. Apparently compulsive adherence to specific,
routines, or ritualized patterns of verbal or nonfunctional routines or rituals
nonfunctional, routines or rituals
nonverbal behavior.
3. Highly restricted, fixated interests that are 3. Stereotyped and repetitive motor mannerisms 3. Stereotyped and repetitive motor mannerisms
abnormal in intensity or focus.
(e.g., hand or finger flapping or twisting, or that involve either hand or finger flapping or
complex whole-body movements)
twisting, or complex whole body movements
4. Hyper-or hyporeactivity to sensory inputor 4. Persistent preoccupation with parts of objects 4. Preoccupations with part-objects or nonunusual interest in sensory aspects of
functional elements of play materials (such as
environment.
their odor, the feel of their surface, or the noise or
vibration that they generate).
5. Distress over changes in small, nonfunctional,
details of the environment
Restricted, Repetitive Behaviors
Restricted, Repetitive Behaviors
1. Stereotyped or repetitive motor movements, 1. Encompassing preoccupation with one or more
use of objects, or speech.
stereotyped and restricted patterns of interest that
is abnormal either in intensity or focus
6
A. N. ESLER AND L. A. RUBLE
DSM-IV, ICD-10, and DSM-5, as well as the Individuals with
Disabilities Education Act (IDEA, 2004) autism criteria.
Specifiers and Severity
Following a dimensional approach, descriptions of criteria
and specifiers have been added to provide better guidance
on the manifestation of symptoms by age, gender, and in the
context of co-occurring disorders (e.g., intellectual disability). To provide more meaningful detail, including description of variables known to be associated with daily
functioning and predictive of outcome, diagnosticians should
now provide specifiers and severity ratings. Specifiers
indicate whether the individual has ASD “with or without
accompanying intellectual impairment” and “with or without
accompanying language impairment” and the level of
impairment, if present (e.g., single words, no intelligible
speech, mild/moderate/severe intellectual disability).
Severity is rated separately for social communication and
restricted, repetitive behavior domains. Because a diagnosis
requires that symptoms impair functioning, even the lowest
level of severity indicates the presence of noticeable
impairments or interference with functioning. Three levels of
severity are available: Level 1, Requiring support; Level 2,
Requiring substantial support; and Level 3, Requiring very
substantial support. Each level provides descriptions of the
extent to which social communication and repetitive behavior
deficits affect an individual’s functioning. The DSM-5 severity
ratings are designed to provide information on the extent to
which ASD impacts daily functioning. The DSM-5 attempts to
provide objective information for clinicians to use in choosing a
rating. For example, a Level 2 repetitive behavior should
appear frequently enough to be noticed by the “casual
observer” (APA, 2013, p. 52). Although severity ratings are
based on current behavior, the DSM-5 recognizes that a child’s
level of impairment may be fluid over time or vary by context.
A New Diagnosis: Social Communication Disorder
As part of the reclassification of PDDs, a new diagnosis was
created: social (pragmatic) communication disorder (SCD).
SCD is considered a language disorder, separate from ASD
and speech-language impairment, with deficits primarily in
social or pragmatic aspects of language. Pragmatic language
refers to deficits in integrating nonverbal cues to interpret
spoken language, understanding conversational language,
and understanding indirect language (Rapin & Allen, 1983).
This diagnosis may fit children with social communication
deficits who do not have a clear history of restricted,
repetitive behaviors.
Criticisms of DSM-5
Much public concern has accompanied the release of the
revised ASD criteria (Carey, 2012). Early studies of DSM-5
criteria suggested an alarming decrease in numbers of
individuals qualifying for an ASD diagnosis, especially for
those diagnosed with PDD-NOS. Most notably, McPartland, Reichow, and Volkmar (2012) found that, in their
sample, only 25% of children with Asperger Syndrome and
28% of children with PDD-NOS met the DSM-5 criteria for
ASD. Other studies also found that only a minority of
children with PDD-NOS would qualify for ASD (Barton
et al., 2013; Gibbs, Aldridge, Chandler, Witzlsperger, &
Smith, 2012; Mayes, Black, & Tierney, 2013; Taheri &
Perry, 2012). Arguments were made that relaxing the
required number of social communication criteria to be met
from three to two would improve sensitivity (Matson,
Hattier, & Williams, 2012), but others found that this
compromised specificity (Frazier et al., 2012; Huerta et al.,
2012; Taheri & Perry, 2012). Many of these studies were
performed using early drafts of the criteria that were more
restrictive; for example, initial drafts required all social
communication to be met based on current behavior. More
recent, large-scale studies did not find such significant
decreases in diagnoses (Frazier et al., 2012; Huerta et al.,
2012; Kent et al., 2013; Maenner et al., 2014; Mazefsky,
McPartland, Gastgeb, & Minshew, 2013). In one study
using a large, multisite data set (Huerta et al., 2012), over
90% of those diagnosed with DSM-IV PDDs retained an
ASD diagnosis using DSM-5 criteria. Another populationbased study looked at the medical and educational records
of 6,577 children who met criteria for a DSM-IV PDD
diagnosis and found that 80% retained a diagnosis of ASD
under DSM-5. Of those who lost their diagnosis, the most
common reason for the change was a lack of deficits in
nonverbal communication used for social interaction
(Maenner et al., 2014).
These later studies also pointed to improvements in
diagnostic accuracy. Huerta et al. (2012) found that DSM-5
criteria resulted in fewer false positives than DSM-IV,
though false positives were still higher than desired. Kent
and colleagues (2013) developed an algorithm of DSM-5
symptoms based on the Diagnostic Interview for Social and
Communication Disorders (DISCO) that resulted in an
equitable balance of high sensitivity and specificity.
A limitation of all of these studies is that analyses were
retrospective, using data collected under the DSM-IV, and
clinicians may not have attended to or documented
symptoms meeting DSM-5 criteria because they were not
considered relevant at the time (Maenner et al., 2014).
While these reviews were informative, researchers agreed
the full consequences of the revised criteria would not be
revealed until the DSM-5 was in place for a period of time
(King, Veenstra-Vanderweele, & Lord, 2013).
A popular concern voiced within the Asperger community was that the dimensional ASD category would lose
clinically meaningful distinctions that helped to convey the
types of interventions that may be warranted (Grant &
Nozyce, 2013). However, others argued that the defining
AUTISM SPECTRUM DISORDER: DSM-5 CRITERIA
elements of Asperger syndrome are intact in the DSM-5
through the application of intellectual and language
specifiers; people with DSM-IV labels of Asperger
syndrome are now captured by the specifiers of ASD
“without intellectual impairment” and “without language
impairment” (Baron-Cohen, 2013).
Another concern regards SCD. SCD was intended to fill a
diagnostic gap for children with needs similar to others with
ASD, but who either never showed repetitive behaviors or for
whom a thorough history that might have documented such
behaviors was not performed (Mahjouri & Lord, 2012).
Clinical researchers voiced strong concerns that SCD lacks
validity and reliability (Mandy, Charman, & Skuse, 2012;
Ozonoff, 2012; Tanguay, 2011), and a pragmatic language
disorder distinct both from SLI and ASD does not have
empirical support (Norbury, 2013; Tager-Flusberg, 2013).
After reviewing research on children with non-ASD social
communication deficits, Norbury concluded that the DSM-5
criteria for SCD do not appear to represent a coherent,
persistent clinical condition. She argued that social communication and pragmatic language deficits are separate entities,
with the latter being more closely tied to structural language
development (i.e., expressive and receptive language); thus,
the requirement that both deficits be present for a diagnosis of
SCD may be impossible to attain. She further cautioned that
culturally valid measures of social communication are
lacking. Norbury concluded that social communication and
pragmatic language impairments are best conceptualized as
symptoms, rather than a diagnostic entity.
Other critics (Ritvo, 2012) worried that SCD would become
plagued by the same problems that befell PDD-NOS in terms of
being overapplied to children who do not fit well into another
diagnostic category. Preliminary evidence supports this
concern. Results of DSM-5 work group preliminary field
testing showed a decrease in ASD cases compared to DSM-IV
but a 14% net increase in overall diagnosed cases due to
application of SCD (Swedo et al., 2012).
7
organize symptoms across two domains (social communication and restricted, repetitive behaviors) instead of three.
Should the ICD-11 retain separate categorical diagnoses,
there is concern that a lack of international consistency may
complicate research efforts into the causes, developmental
course, and best-practice interventions for ASD (Vivanti
et al., 2013).
DSM-5 IMPLICATIONS FOR SPECIAL EDUCATION
EVALUATIONS
The DSM-5’s emphasis on history and its increased
requirement of at least two restricted and repetitive behaviors
suggests that evaluations under DSM-5 will require greater
attention to detail. With its 12 criteria across three domains,
and because individuals were not required to meet all criteria
within each domain, the DSM-IV allowed for 2,027 symptom
combinations. The DSM-5 allows for only 11 combinations
(McPartland et al., 2012). However, this comparison is
somewhat misleading, as each new social communication
criterion can be met in multiple ways, and can be met based
on history or current behavior. One of the criticisms of
research suggesting large numbers of children would lose
their diagnosis under the DSM-5 was that the studies were
based on file review of old diagnoses given under the DSMIV. In other words, DSM-5 criteria were applied to existing
records containing evaluation data describing DSM-IV
symptoms. A possible implication is that DSM-IV methods,
on which many of our evaluation tools are based, may not
capture the full spectrum of behaviors included in the DSM5. Thus, for departments of education that seek to maintain
evidence-based diagnostic evaluations for children with
ASD, changes in the diagnostic process will need to include
careful and more thorough descriptions of ASD symptoms,
developmental history, and current developmental level.
Focus on History
DSM-5 and ICD-11
The International Classification of Diseases (ICD) is the
world’s standard tool for classifying and monitoring health
conditions (World Health Organization [WHO], 1992). The
criteria for pervasive developmental disabilities in the 10th
edition of the ICD are largely consistent with those of the
DSM-IV. Like the DSM-IV, ICD-10 contains separate
categorical diagnoses of autistic disorder, Asperger’s
syndrome, and pervasive developmental disorder, unspecified, and three symptom domains of social interaction,
communication, and stereotyped/repetitive behaviors
(WHO, 1992). A revision of the ICD is under way and
expected to be released in 2015. At the time of this writing,
it is unknown whether the ICD-11 will follow the DSM-5 in
collapsing the separate categories into one dimensional
diagnosis of ASD (Vivanti et al., 2013), or whether it will
The DSM-5’s emphasis on symptom presence by history
requires diagnosticians to focus on a child’s early
development. Special education eligibility decisions are
based on current concerns, but documenting a child’s early
history has always been a key element in determining
whether the ASD category is appropriate. This increases
diagnostic accuracy and allows for differentiating ASD from
other diagnoses with overlapping symptoms. For example, a
child with ADHD and a child with ASD may both
demonstrate socially inappropriate behavior and have few
friendships at school age, but the child with ASD is more
likely to have had an early history of lacking interest in peers.
Moreover, children with a history of restricted/repetitive
behaviors, but who are not currently showing noticeable
symptoms in this area, are likely still most appropriately
served under the ASD category due to social needs.
8
A. N. ESLER AND L. A. RUBLE
Specifiers Provide Structure for Eligibility and Service
Decisions
Intellectual and language-level specifiers identify areas of
need outside of core ASD symptoms that are relevant to
educational planning. Assessing a child’s intellectual and
language skills is critical to determining eligibility for ASD,
as deficits in social skills must be evaluated in relation to a
child’s overall level of development. Recent estimates
indicate that about 38% of children with ASD will experience
impaired intellectual skills (Centers for Disease Control and
Prevention [CDC], 2012), and 63% will have a language
disorder (Levy et al., 2010). Thus, evaluations that address
intellectual and language impairment specifiers will provide
important information for school psychologists and IEP
teams to consider a child’s characteristics and make
recommendations for level of support and services, including
informing decisions about least restrictive environment.
Similarly, severity ratings in the DSM-5 may provide a
useful structure for summarizing information from observation and interview measures in evaluation reports, to lead to
service and support decisions. For example, social communication severity ratings describe a child’s ability to interact with
general education peers and teachers without supports. A child
with mild social communication severity may do well with
coaching and instruction given within inclusive settings, while
a child with severe social communication deficits may need a
service plan that includes assistive/augmentative communication. Restricted/repetitive behavior severity ratings can
inform intervention planning by considering when behaviors
are disruptive to others and/or interfering with a child’s
learning opportunities. If a repetitive behavior is judged to be
mild, educators may be able to use it adaptively as a motivator
(e.g., a child with a strong interest in marine animals could be
motivated to work on writing tasks involving that topic).
A child with severe restricted/repetitive behaviors may be
prone to aggressive outbursts when his or her repetitive
behaviors are disrupted, and this may signal the need to
develop a Behavior Intervention Plan as part of the IEP
process.
ADJUSTING SCHOOL EVALUATIONS FOR THE
DSM-5
Address Early History
Best practice in ASD evaluation involves a multidisciplinary team gathering information across multiple sources,
including at minimum a detailed parent interview,
structured observation of behaviors related to ASD, and
direct assessment of developmental skills (cognitive,
language, adaptive). It is beyond the scope of this paper to
describe in detail the elements of an evidence-based
diagnostic evaluation. Several articles are recommended
that address best practices in assessment (Hammond,
Campbell, & Ruble, 2013; Ozonoff, Goodlin-Jones, &
Solomon, 2005). Instead, a brief review is provided for
those aspects most impacted by the DSM-5.
School evaluations for ASD should now include a parent
interview that covers early history as well as current
behavior. Semistructured, examiner-led interviews are the
preferred method for gathering developmental history
(Corsello et al., 2007). For many children with ASD, social
communication deficits emerge late in the first year of life
(Ozonoff et al., 2010; Wetherby et al., 2004; Zwaigenbaum
et al., 2005), although they develop and change with
maturation and intervention (Dawson, 2008). Developmental history interviews should focus on the unfolding of social
communication and behavior over time. Patterns of early
communication development also should be assessed,
including when the child began talking, the purposes for
which the child used communication, and the content of the
communication, as these factors are important for
distinguishing ASD from other disabilities. Between 25%
and 30% of parents of children with ASD report a regression
in language and/or other areas of development (e.g.,
Goldberg et al., 2003), and observational studies of early
ASD have found higher rates of regression (Ozonoff et al.,
2010). Regression in the first years of life represents strong
evidence for ASD, as skill loss does not typically occur
within other disorders (Pickles et al., 2009).
Comprehensive Coverage of Symptoms
The most accurate and reliable diagnostic decisions are
made by experienced clinicians using well-validated,
standardized measures (Lord et al., 2011). School-based
examiners should review existing diagnostic measures to
ensure that they will cover a wide range of behaviors
reflecting the core symptoms of ASD. Now that symptoms
in all social communication and two repetitive behavior
domains must be documented, it is advisable to select
measures containing multiple items per criterion due to the
inherent heterogeneity of ASD.
Important variables for reliability and validity of
diagnostic measures are sensitivity and specificity. Sensitivity indicates the ability of a measure to accurately
identify children who truly have the diagnosis (i.e., true
positives). Specificity indicates the measure’s ability to
correctly exclude children who do not have the diagnosis of
interest (i.e., true negatives). Diagnostic measures for ASD
and their psychometric properties are presented in Table 2.
Multiple sources of information
Thorough coverage of behavioral characteristics for ASD is
best achieved through combining information across
multiple measures (Risi et al., 2006). Whereas a diagnostic
or developmental history interview obtains comprehensive
information about a child’s past and current behavior, a
9
Examiner-child interactive
observation (30–60 min)
Coverage of current symptoms only
Examiner-completed rating form;
Nonverbal communication
Parent questionnaires (unscored) to Relationships
inform examiner ratings (5–10 min)
Current symptoms only
12 months-adult; any verbal level;
nvma . ¼ 12 months
Standard version: 2–6 years or 2 þ
years with impaired communication
and/or cognitive abilities
High-functioning version: 6þ years
who are verbally fluent and IQ . 80
3–22 years, any verbal or cognitive
level
16–30 months, any verbal or
cognitive level
ADOS-2
CARS-2
GARS/
GARS-2
M-CHAT
Repetitive behaviors
Rituals/routines
Fixated interests
Hyper/hypo-sensitivity
Restricted, Repetitive
Behavior Symptoms
Parent/caregiver checklist
Social/emotional reciprocity
Follow-up interview is recommended Nonverbal communication
for children who fail
Relationships
Current symptoms only
Parent/caregiver or teacher
Social/emotional reciprocity
questionnaire (5–10 min); Coverage Nonverbal communication
of past and current symptoms
Structured parent interview form
(unscored) for information about
development during early childhood;
Current symptoms only
Repetitive behaviors
Hyper/hypo-sensitivity
Repetitive behaviors
Rituals/routines
Hyper/hypo-sensitivity
Repetitive behaviors
Rituals/routines
Hyper/hypo-sensitivity
Social/emotional reciprocity
Repetitive behaviors
Nonverbal communication
Rituals/routines
Relationships (Modules 3 & 4) Fixated interests
Hyper/hypo-sensitivity
2 years-adult; any verbal level;
Examiner-parent/caregiver interview Social/emotional reciprocity
Nonverbal communication
cognitive abilities . ¼ moderate ID (90–180 min)
Coverage of past and current
Relationships
symptoms
ADI-R
Social Communication
Symptoms
Intended students
Measure
Administration
(continued)
ASD v. NS, with follow-up interview:
Se ¼ .97, Sp ¼ .9910
ASD v. NS, checklist alone:
Failing 2 critical items: Se ¼ .70, Sp ¼ .3811
Se ¼ .77, Sp ¼ .4312
Failing any 3 items:
Se ¼ .92, Sp ¼ .2712
Se ¼ .88, Sp ¼ .3811
Failing either cutoff:
Se ¼ .60, Sp ¼ .5013
ASD v. NS:
Se ¼ .83, Sp ¼ .687
Se ¼ .53, Sp ¼ .548
ASD only:
Se ¼ .389
None reported
AUT v. NS: Se ¼ .91–.98, Sp ¼ .84–942;
Se ¼ .82 –.94, Sp ¼ .80–.1.03;
Se ¼ .87 –.92, Sp ¼ .71–.764
Non-Autism ASD v. NS: Se ¼ .72 – .84,
Sp ¼ .76–.832;
Se ¼ .60 ¼ .95, Sp ¼ .75 –1.03;
Se ¼ .53 –.86, Sp ¼ .62–.634
Toddler ADOS-2, ASD v. NS: Se ¼ .88 –.91,
Sp ¼ .915
Se ¼ .95, Sp ¼ .836
ASD v. NS, age 3 þ : Se ¼ .89, Sp ¼ .591
ASD v. NS, under age 3: Se ¼ .83, Sp ¼ .721
Sensitivity/Specificity
TABLE 2
Psychometric Properties and Coverage of DSM-5 Symptoms in ASD Diagnostic Measures and ASD Checklists
10
Parent/caregiver questionnaire
Social/emotional reciprocity
(10 min)
Nonverbal communication
Lifetime Version: Coverage of past Relationships
and current symptoms
Current Version Current symptoms
only
4 þ years; nvma . ¼ 2 years
4–18 years, any verbal or cognitive Parent/caregiver or
level
teacher questionnaire (15–20 min)
Current symptoms only
SCQ
SRS-2
Repetitive behaviors
Rituals/routines
Fixated interests
Hyper/hypo-sensitivity
Repetitive behaviors
Rituals/routines
Fixated interests
Hyper/hypo-sensitivity
Restricted, Repetitive
Behavior Symptoms
ASD v. NS:
Se ¼ .78, Sp ¼ .6716;
Se ¼ .75, Sp ¼ .9619
Se ¼ .92, Sp ¼ .08 ( parent ratings)20
Se ¼ .84, Sp ¼ .41 (teacher ratings) 20
Se ¼ .76, Sp ¼ .8221
ASD v. NS: Se ¼ .85, Sp ¼ .7514
Se ¼ .88, Sp ¼ .7215
Se ¼ .86, Sp ¼ .7816
Se ¼ .71, Sp ¼ .7117
Se ¼ .74, Sp ¼ .5412
Se: .92, Sp ¼ .6218
AUT v. NS:
Se ¼ .96, Sp ¼ .8014
Se ¼ .78, Sp ¼ .7117
Sensitivity/Specificity
Note. Se ¼ sensitivity; Sp ¼ specificity; ID ¼ intellectual disability; NS ¼ nonspectrum; AUT ¼ autistic disorder; nvma ¼ nonverbal mental age; CARS-2 ¼ Childhood Autism Rating Scale,
2nd edition; GARS/GARS-2 ¼ Gilliam Autism Rating Scale; M-CHAT ¼ Modified Checklist for Autism in Toddlers; SCQ ¼ Social Communication Questionnaire; SRS-2 ¼ Social Responsiveness Scale,
2nd Edition.
1
Adapted from Risi et al. (2006). 2 Adapted from Gotham, Risi, Pickles, & Lord (2007). 3 Adapted from Gotham et al. (2008). 4 Adapted from de Bildt et al. (2009). 5 Adapted from Luyster et al. (2009).
6
Adapted from Guthrie, Swineford, Nottke, & Wetherby (2013). 7 Adapted from Eaves, Woods-Groves, Williams, & Fall (2006). 8 Adapted from Sikora, Hall, Hartley, Gerrard-Morris, & Cagle (2008).
9
Adapted from Lecavalier (2005). 10 Adapted from Robins, Fein, Barton, & Green (2001). 11 Adapted from Snow & Lecavalier (2008). 12 Adapted from Eaves, Wingert, & Ho (2006). 13 Adapted from
Matson, Kozlowski, Fitzgerald, & Sipes (2013). 14 Adapted from Berument, Rutter, Lord, Pickles, & Bailey (1999). 15 Adapted from Chandler et al. (2007). 16 Adapted from Charman et al. (2007). 17 Adapted
from Corsello et al. (2007). 18 Adapted from Witwer & Lecavalier (2007). 19 Adapted from Constantino et al. (2007). 20 Adapted from Aldridge, Gibbs, Schmidhofer, & Williams (2012). 21 Adapted from
Cholemkery, Kitzerow, Rohrmann, & Freitag (2013).
Social/emotional reciprocity
Nonverbal communication
Relationships
Administration
Intended students
Measure
Social Communication
Symptoms
TABLE 2 – (Continued)
AUTISM SPECTRUM DISORDER: DSM-5 CRITERIA
structured observation provides a snapshot of a child’s
current social communication and repetitive behaviors. The
ADI-R and the ADOS/ADOS-2 are the most researched
diagnostic measures and are considered the gold standard
for evidence-based diagnosis of ASD (e.g., Gray, Tonge, &
Sweeney, 2008). The ADI-R is a semistructured parent/
caregiver interview that covers behavior areas important to
accurate ASD diagnosis, including early history (not leaving
out whether a regression occurred), communication
impairments in verbal and nonverbal areas, social impairments, restricted and repetitive behaviors, and general
behaviors that may impact functioning (e.g., aggression,
seizures). Each question asks about the child’s current and
past behavior, with corresponding numeric ratings assigned
based on whether the parents’ descriptions reflect behaviors
consistent with ASD, behaviors that are slightly abnormal
and/or suggestive of ASD, or that do not reflect abnormality
of the type specified. The ADOS is a semistructured,
standardized assessment of communication, social interaction, and play or imaginative use of materials for
individuals who have been referred for possible ASD (Lord
et al., 2000). The second edition of the ADOS (ADOS-2;
Lord et al., 2012a, 2012b) consists of five modules, each of
which has its own schedule of activities for use with
individuals at a particular developmental and language
level, ranging from no expressive or receptive language to
verbally fluent adolescents and adults. Activities are
designed to provide a context for judging social
communication, play, and restricted, repetitive behaviors.
A recent study evaluated whether the ADI-R and ADOS
would adequately document DSM-5 symptoms, using a
research sample of individuals with ASD carefully characterized and diagnosed according to DSM-IV criteria (Mazefsky
et al., 2013). Behaviors from both measures were mapped onto
DSM-5 criteria. Using the ADOS alone, only 33% of
individuals with ASD met DSM-5 criteria. The ADI-R alone
captured 83%. The best agreement, 93%, came from using the
ADI-R and the ADOS together. Two similar studies (Huerta
et al., 2012; Barton et al., 2013) found that both measures
contained items representing each social communication
criterion. However, both studies showed that, for children who
were not verbally fluent, the ADOS did not capture the
restricted, repetitive behavior criterion involving routines/
rituals.
The ADI-R and the ADOS are both available in multiple
languages in multiple countries. However, they were
developed and normed in the United States and United
Kingdom (Lord et al., 2000; Lord et al., 2012a, 2012b;
Rutter et al., 2003) and may not be available in some
countries. While validation samples in the United States
included representative numbers of African American
children (Risi et al., 2006), children and families who
were not proficient in English generally were excluded.
These are limitations that must be considered when
choosing appropriate evaluation measures.
11
A strength of school-based evaluations is that they can
include observations of a child in his/her natural
environment. Observations may be particularly helpful in
adding information that may not be directly observable in
standardized tools such as the ADOS, including relationships with peers and deficits in understanding and adjusting
one’s behavior to a variety of social expectations. Regarding
nonfunctional routines and rituals, using information
reported by parents or teachers, observations can be targeted
to times of day and situations in which these rituals are
likely to occur to get a sense of the impact of these rituals on
the child’s functioning.
ASD checklists
Multiple checklists and questionnaires for ASD are available
for use in clinics and schools; however, their quality and
utility vary. For school purposes, questionnaires with strong
psychometric properties are best suited to screening to
identify children who should be referred for a full evaluation.
In practice, many schools substitute a checklist for a
developmental history/diagnostic interview. This may not be
adequate for reliable, valid identification of ASD, particularly
for children with mild features who tend to be underidentified by these measures (Corsello et al., 2007).
Conversely, checklists often over-identify children with
high levels of general problem behaviors (Cholemkery,
Kitzerow, Rohrmann, & Freitag, 2013; Hus, Bishop, Gotham,
Huerta, & Lord, 2013). Furthermore, most checklists focus
only on current behavior. A selection of ASD checklists and
their psychometric properties is included in Table 2 to assist
practitioners in selecting tools for educational evaluations.
Some checklists may be adequate for students being
reevaluated and for whom eligibility is not in question,
whereas students being evaluated for the first time may
require measures with a higher standard of psychometric
quality. Diagnostic measures and checklists were included in
this table if (a) studies of psychometric properties were
available from sources other than the measure’s authors to
provide independent validation, and (b) if measure results
were compared against independent clinical evaluation or
school classification.
Functional Skills
Assessment of functional skills informs Individualized
Education Program (IEP) goals, selection of services, level
of services and supports needed, and adaptations and
accommodations. Skills that predict later outcomes for
children with ASD are language level, cognitive skills,
adaptive skills, problem behaviors, and motor coordination.
In addition to specifiers of intellectual disability and
language impairment, the DSM-5 emphasizes the influence
of co-occurring disorders and associated features, including
ADHD, anxiety, depression, epilepsy, sleep problems,
12
A. N. ESLER AND L. A. RUBLE
eating and gastrointestinal problems, adaptive skill deficits,
motor deficits, and aggression or self-injury. Such cooccurring features should be covered in school evaluations
as needed based on the child’s current concerns.
Severity Ratings
Determining severity of ASD is often challenging, as ASD
symptoms are highly influenced by developmental impairment, especially in the area of language (Gotham et al., 2009).
A child with no intelligible speech is inherently more impaired
than a child who is verbally fluent, and ASD symptoms will
manifest differently in a nonverbal child than in a highly verbal
child of the same age. There also is evidence that children with
greater intellectual impairment show more severe repetitive
behaviors (e.g., Bishop et al., 2006). DSM-5 symptom criteria
try to capture these differences; for example, in evaluating
social reciprocity, a highly verbal child may make frequent but
awkward initiations, while a nonverbal child may only rarely
initiate. However, indicating level of severity can be useful in
informing educational decisions on level of services and
supports needed, as well as helping parents understand their
child’s needs.
The increased detail in symptom criteria and severity
ratings may provide guidance on conducting observations and
parent/teacher interviews to capture this information in more
objective ways. For example, school psychologists may want
to include information on the frequency and intensity of
repetitive behaviors and the extent to which these limit a
child’s participation in the general education setting.
Similarly, objective information on the frequency and number
of contexts in which a child initiates communication and
interaction, and the consistency with which he or she responds
to others’ social approaches, can inform severity ratings.
The assessment process is stressful for families of
children with ASD, and many parents are concerned about
their child’s future level of functioning. With the
elimination of the Asperger and PDD-NOS categories,
parents will likely have even more questions about the
severity of their child’s ASD (Weitlauf, Gotham, Vehorn, &
Warren, 2013). Severity ratings are designed to provide
further, objective information on the extent to which the
child’s functioning is affected. However, concerns exist as
to whether DSM-5 severity ratings are evidence-based and
specified clearly enough to ensure consistent application
across clinicians (Weitlauf et al., 2013). As with many
aspects of testing, DSM-5 severity ratings should serve as a
general guidepost, and more individualized data will be
needed to determine specific supports and services.
CONCLUSION
As experts in psychological diagnosis and classification,
school psychologists with detailed knowledge of the DSM-5
can provide advocacy and information to parents and policy
makers. Parents and educators should be reassured that
individual behaviors associated with ASD have not changed
substantially from DSM-IV to DSM-5, and our current
diagnostic measures remain relevant. As the DSM-5 is
implemented, educational eligibility criteria in special
education settings will need to be updated to reflect what has
been learned over the past two decades, and school
psychologists can play an integral role in that process.
Assessment is the first step in developing interventions to
address student needs. Adjusting educational evaluations to
gather information addressing DSM-5 criteria and specifiers
should lead to more accurate characterization of a child’s
needs, improving the ability to translate assessment findings
into intervention. The increased detail and structure of the
DSM-5 provide greater guidance to practitioners on areas to
prioritize for assessment, and severity ratings may provide
an objective structure for designing and summarizing
naturalistic observations and assessment findings in general,
leading to selection of services and supports. Greater
description of age and language influences on ASD
symptoms may help practitioners make more accurate
identification decisions. The increased detail required by the
DSM-5 reinforces the importance of using valid, standardized diagnostic tools for ASD, and several studies
documented that diagnostic accuracy was high when
DSM-5 symptoms were documented using detailed parent
report measures (Frazier et al., 2012; Kent et al., 2013) or
the ADI-R and ADOS together (Barton et al., 2013; Huerta
et al., 2012; Mazefsky et al., 2012).
Given the evidence that DSM-IV criteria lacked
specificity (Frazier et al., 2012; Huerta et al., 2012), it is
likely that ASD was being overdiagnosed. Although at least
three studies have found sensitivity commensurate with
DSM-IV and improved specificity (Frazier et al., 2012;
Huerta et al., 2012; Kent et al., 2013), concerns about
sensitivity have been raised by many. One of the main
implications of the changes to the DSM-5 is that evaluations
will need to provide greater detail on a child’s array of
symptoms, as well as their symptom history, to document
symptoms necessary for diagnosis.
Some questions remain about whether the improved
accuracy of DSM-5 criteria will be sustained once they are
put to widespread use in community-based evaluations. The
reorganization of symptoms into the three social communication and four restricted, repetitive behavior criteria, for
example, may be a source of inconsistency. Because all
social communication criteria must be met, clarity is needed
on which symptoms belong in what cluster. The lack of
clearly delineated criteria may lead to overdiagnosis if
clinicians apply the same behaviors to multiple criteria, or
underdiagnosis if they attribute too many to one.
As demonstrated by Barton et al.’s (2013) finding on
disagreement in symptom assignment, the DSM-5 is not
immune from differences in interpretation among even
AUTISM SPECTRUM DISORDER: DSM-5 CRITERIA
expert clinicians. Regarding restricted, repetitive behaviors, a
concern is whether it will be inordinately difficult to meet two
criteria now that stereotyped speech, repetitive uses of objects,
and repetitive motor mannerisms have been collapsed into one
criterion. Time will tell how identification of ASD adapts with
the DSM-5 and whether feared unintended consequences
materialize, such as difficulty qualifying for a diagnosis even
when needs are considerable.
ACKNOWLEDGEMENTS
The authors thank Elisabeth Johnson for her assistance with
manuscript preparation.
ABOUT THE AUTHORS
Dr. Amy N. Esler is an assistant professor in pediatrics, a licensed
psychologist, and the director of the Fragile X Clinic at the
University of Minnesota. Her research interests include early
diagnosis and intervention in autism spectrum disorder and cultural
influences on developmental disorders.
Dr. Lisa A. Ruble is a professor of school psychology at the
University of Kentucky. She teaches parent-teacher consultation
for ASD using the Collaborative Model for Promoting Competence
and Success (COMPASS) framework that has been tested in two
NIH-funded randomized controlled trials.
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