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Levels of Autism: An Explanation
Elizabeth Quaye
| Publish Date April 22, 2024
levels of autism
The American Psychiatric’s Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides the criteria for ASD diagnosis based on specific symptom profiles. As part of these criteria, the DSM-5-TR outlines specifiers of symptom severity, which it categorizes as “levels.”

Autism spectrum disorder (ASD) is a complex developmental disorder involving persistent deficits in social communication and interaction in addition to restricted, repetitive behaviors, interests, and activities.1,2 The American Psychiatric’s Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) provides the criteria for ASD diagnosis based on specific symptom profiles.1 As part of these criteria, the DSM-5-TR outlines specifiers of symptom severity, which it categorizes as “levels.”1 This article describes the criteria and various levels of symptom severity used in the diagnosis of ASD.
Changes to the Autism Diagnosis

Autism was first identified as a distinct diagnosis in DSM-III, which was published in 1980.3 In DSM-IV-TR, a patient with symptoms of autism would likely be diagnosed with 1 of 4 disorders under the category of pervasive developmental disorder (PDD): autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or PDD not otherwise specified.4 However, because researchers determined that these 4 diagnoses were not consistently applied by different clinicians, PDD was replaced with autism spectrum disorder (ASD) in DSM-5.4 A patient who met the criteria for 1 of the 4 PDD diagnosis in DSM-IV-TR will likely meet the criteria for ASD in DSM-5.4
DSM-5-TR Criteria for Autism Spectrum Disorder

The DSM-5-TR criteria for ASD are summarized as follows1:

A. Persistent deficits in social communication and social interaction as manifested by all of the following:

Deficiencies in social-emotional reciprocity (examples: inability to engage in normal back-and-forth conversation, reduced sharing of interests/emotions/affect, failure to initiate or respond to social interactions);
Deficiencies in nonverbal gestures used in social interaction (examples: problems with eye contact, body language, or understanding/using gestures, lack of facial expressions and nonverbal communication); and
Deficiencies in developing, maintaining, and understanding relationships (examples: lack of interest in peers, difficulty making friends).

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following:

Repetitive motor movements, use of objects, or speech (examples: body rocking, arm or hand flapping, lining up toys, repeating words just spoken by another person);
Insistence on sameness, inflexible adherence to routine, or ritualized patterns of behavior (examples: difficulty with transitions, rigid thinking patterns, needing to eat the same food each day);
Highly restricted, fixated interests that are abnormal in intensity or focus (examples: a strong attachment to peculiar objects); and
Hypersensitivity or hyporeactivity to sensory input or abnormal interest in sensory aspects of the environment (examples: indifference to pain or temperature, adverse response to specific sounds or textures).

C. Symptoms must be present in the early developmental period.

D. Symptoms significantly impair social, occupational, or other important functional areas.

E. Deficits are not better explained by intellectual disability or global developmental delay.
Specifiers for the ASD diagnosis include the following1:

With or without accompanying intellectual impairment;
With or without accompanying language impairment;
Associated with a known medical or genetic condition or environmental factor;
Associated with another neurodevelopmental, mental, or behavioral disorder;
With catatonia, and
The current severity specifiers.

The 3 Levels of Autism Spectrum Disorder

The current severity specifiers consist of 3 levels, ranging from least severe (Level 1) to most severe (Level 3). The severity of each of the 2 main criterion — social communication and restricted, repetitive behaviors — should be rated separately.1
Level 1: Requires Support

Individuals with ASD categorized as Level 1 have the least severe symptoms and require the lowest level of support.

Social communication: Patients classified as Level 1 will have noticeable impairments unless supports are in place. They generally have difficulty initiating social interactions and will give atypical responses to others’ social overtures. Patients classified as Level 1 may have a reduced interest in social interactions. For example, a person specified as Level 1 might be able to speak full sentences and communicate, but would not be able to have a mutual, back-and-forth conversation. Additionally, their efforts to make friends often fail.1

Restricted, repetitive behaviors: These individuals’ rigid behavior limits their ability to function in 1 or more contexts. They tend to have challenges alternating between activities, and their independence is hindered by issues with organization and planning.1
Level 2: “Requires Substantial Support”

Patients with ASD classified as Level 2 have more severe symptoms that cause greater impairment and require substantial support.1

Social communication: Patients specified as Level 2 have marked deficits in verbal and nonverbal social communication skills. Even with support, their social impairments are apparent. They generally have limited ability to initiate social interactions, and will provide decreased or aberrant responses to others’ social overtures. For example, a patient classified as Level 2 might be able to speak basic sentences, but their interactions with others would be limited to narrow special interests, and their nonverbal communication would be odd.1

Restricted, repetitive behaviors: Individuals with ASD Level 2 have inflexible behavior, problems adjusting to change, or similar behaviors that are frequent enough to be obvious and interfere with functioning in various contexts. They also have distress and/or difficulty changing focus or action.1
Level 3: “Requires Very Substantial Support”

Patients with ASD specified as Level 3 have the most severe symptoms and require very substantial support.1

Social communication: Individuals classified as Level 3 have extreme deficits in verbal and nonverbal social communication that cause severe impairments in functioning. Their ability to initiate social interactions is very limited, and they will provide minimal response to others’ social overtures. They tend to only respond to very direct social approaches. For example, a patient specified as Level 3 would have very few words of intelligible speech and would rarely initiate interactions with others.1

Restricted, repetitive behaviors: Patients with Level 3 exhibit inflexible behaviors, problems adjust to change, or similar behaviors that interfere with every aspect of their lives. They experience tremendous distress and difficulty changing focus or action.1
How the Levels Are Used

Using the levels to clarify the severity of ASD symptoms gives clinicians and caregivers information they can use to tailor services and support specific to an individual patient’s needs. However, it is important to recognize that these levels are only used to describe the patient’s current symptomatology.1 Symptoms of ASD might fluctuate over time; can vary greatly based on the patient’s developmental level, age, environment, and other characteristics; and might fall below Level 1.1

While helpful, the levels should not be used to determine a patient’s eligibility for specific services or treatments; that requires an individualized assessment that takes into account the patient’s personal priorities and goals.1

References:

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing. Accessed February 28, 2022. https://www.appi.org/dsm5tr
What is autism spectrum disorder? American Psychiatric Association. 2023. Accessed February 7, 2024. https://www.psychiatry.org/patients-fam ... m-disorder
Autism in the DSM. The Autism History Project. Herman E. 2019. Accessed February 29, 2024. https://blogs.uoregon.edu/autismhistory ... n-the-dsm/
DSM-5 autism spectrum disorder fact sheet. American Psychiatric Association. Published 2013. Accessed February 8, 2024. https://www.psychiatry.org/File%20Libra ... sorder.pdf