I have been diagnosed as autistic for 32 years, I have written many books on autism and am considered by many to be an expert in the field…. Turns out even experts need to learn things, as I discovered this week during a course I am actually on the teaching staff for!!
The topic in my course last week was all about the history of autism diagnoses in the DSM. If you don’t know about the DSM, it relates to five main iterations of a publication released by the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders. The first DSM was published in 1952 and as you would imagine contains some pretty dated diagnoses, many of which are now quite offensive! For example, homosexuality was in there and not just in the first iteration I hate to say. In the first iteration of the DSM, autism was called ‘childhood schizophrenia’. In fact, it wasn’t until the DSM III in 1980 that autism was included as a separate thing. In 1994 another big change was made with the addition of Asperger Syndrome and the concept of autism as a spectrum.
However, interesting though these things are, the thing which amazed me was in the DSM 5. You might remember when the DSM 5 was first published in 2013 that it did away with separate diagnostic terms for autism and introduced ‘Autism Spectrum Disorder’ and three ‘levels’. I believed – as I suspect did a lot of others – a few things about the levels but it turns out all of my understanding – and others’ presumably – were contrary to the intent of how the DSM with its three levels should be used.
Firstly, the DSM is not an assessment method. DSM identifies various different conditions but is not used to assess individuals. Tools like the ADOS are for applying / assessing whether a person should get an autism diagnosis. The DSM just describes what that diagnosis looks like.
Secondly. the autism levels relate to two areas of ‘impairment’ in the DSM – that being social communication and restrictive and repetitive patterns of behaviour. The three levels relate to those two domains. You can get a level of one against one domain and a level of three against the other (or whatever). As such, you might be a level 1 in social communication and a level 2 in restricted and repetitive patterns of behaviour. That doesn’t make you a level 1.5!
Thirdly, the autism levels are not static. They can fluctuate depending on situation and time. They can change even in the course of a day. For example, you might be a level 2 in one domain when you are at work and a level 1 in the same domain at home as these are different environments which impact on your capability and which diagnostic ‘level’ applies in a particular situation.
Finally, the level numbers are not a diagnosis. To say ‘I am a level 2’ doesn’t work. You might be a level 2 at the moment against one of the criteria but that may change related to situation and time. Someone recently said I should get re-assessed as a ‘level 2’. According to how the DSM is intended to be applied, you cannot diagnose someone as a ‘level 2.’ ‘Level 2 autism’ is not a diagnosis. The only autism diagnosis in the DSM 5 is autism spectrum disorder, and the levels are a way of understanding experience, presumably in order to know when, where and how to provide supports to enable autistic people to thrive.
I’m not sure if this blows your mind as much as it blows mine! I always thought the three levels were diagnoses in and of themselves but in fact they are not! This actually makes me feel a bit more friendly towards the DSM 5! Of course, diagnosis for neurodivergent people comes with some inherent issues and risks and a deficits-based view drawn only from a medical diagnosis and identification of only problems and impairments is a damaging thing. Diagnosis needs to be used as a tool to help to empower and promote self-determination, to access necessary supports and promote a sense of pride and self-esteem – not to further disadvantage people or make them doubt their capability. That being said, clinicians and neurodivergent people too can definitely benefit from knowing these things about how the DSM diagnostic criteria can be understood and correctly applied.
I am interested to know if I just missed a major piece of information that everyone else already knew with this or if it is new knowledge for others as well.










