July 24, 2025
Autism is a lifelong neurodevelopmental difference that shapes how a person sees and experiences their. For many adults seeking answers about their identity, a formal diagnosis can offer clarity, connection, and access to support. But how exactly is autism diagnosed? What role does the DSM-V play?
This blog explores the DSM-V, the primary diagnostic guide used in Australia, and how it shapes our current understanding of autism including its strengths, limitations, and the importance of interpretation in context.
I am not a diagnostician, I am not trained formally in applying the criteria in a clinical setting and as such please accept this post not as medical or clinical advice, but rather the observations and musings of an autistic person on the very set of rules that aims to identify me as such.
It stands for the "Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition" which is exactly why we just use the term DSM-V. While there has been changes from previous versions to improve the way Autism is categorised, recognised and described, the name of the book stays the same and is a bit clinical and old worldly for my liking.
Its aim is to classify a variety of conditions within the realms of mental health and neurodevelopment to provide clarity and consistency over diagnosis of these conditions as well as for the planning and implementation of services to support those who have received a diagnosis. While it is a publication by the American Psychiatric Association, the manual is a globally recognised and used piece of literature.
In Australia we also use the ICD-11 however the DSM-V seems to be the most common go to guide for most clinicians when it comes to autism and ADHD. Not to mention it being a reference point when determining things like programs, NDIS eligibility, education supports and workplace accomodations for the broader population.
Prior to 2013 autism was divided into several stand alone diagnoses:
Autistic DisorderI the revised fifth edition we saw the reclassification of these conditions into one single unified diagnostic term "Autism Spectrum Disorder".
The intent was to better reflect the diversity and variance of experiences and presentations, ultimately recognising that Autism is not a fixed "type" but a spectrum of traits that vary in intensity, visibility and impact from person to person and time to time.
A person must meet the three criteria in this section being:
A person must meet two out of the four criteria being:
In order to "meet" each criteria, the traits must have been present in early development, must impact functioning in aspects of daily living and can not have another explanation.
The criteria do provide a consistent and uniformed framework for clinicians, but as with any framework, they are only as effective as the person interpreting them.
A unified spectrum diagnosis helps professionals, families and support systems respond more consistently to people with a diverse range of needs
Recognition of what autistic folk have known all along, that autism is intrensicly linked with the sensory experience for many people.
Clinicians who treat the DSM-V as a rigid checklist and require obvious and visible social difficulties. This can often lead to a missed or misdiagnosis in those who don't present with stereotypical behaviours.
IMPORTANT: No one trait is required for a diagnosis. Demonstrating eye contact, for example, does not preclude a person from a diagnosis and is not an indication that they do not meet the criteria. The key is interpreting how their interactions are internally experienced, not how they are percieved by others.
The DSM-V is largely made up of research and data from caucasian boys. This means that it may not capture how autism may present in girls, women and non binary folk. Nor would it allow for variance across those who are from CALD backgrounds or those within other diverse communities like the LGBTIQA+ folk or even just how someone may present as an adult comapred to a young person!
These groups may often mask autistic traits or have traits that are not typical compared to the sample population of autistic people and as such this may result in underdiagnosis or misdiagnosis.
Being a clinical piece of literature the DSM-V uses clinical deficit terminology that can feel stigmatising and very out of sync with social models that promote strength based and person centred approaches and language. It does mean that a formal diagnosis will only ever focus on the "what's wrong" aspect and will always sit in a seperate space to the rest of a persons journey after diagnosis where they move to a more social approach in therapies and support.
While there is a need for these clinical findings, it means a large divide and lack of connection between a persons diagnosis and their actual support needs.
When functioning labels were removed they had to find a way to categorise or indicate where a persons support needs may sit on the spectrum. Being that there is no "one size fits all" approach it was essential that there was a way to identify the expected needs of a person in order for them to access services and supports through funding and government services.
There are 3 levels of support needs under the DSM-V:
"Needs Support"
For Example: May need assistance or support with organisation, flexible thinking or social situations.
"Needs Substantial Support"
For Example: Needs regular support with communication, transitions or changes, social interactions and day to day tasks.
"Needs Very Substantial Support"
For Example: Needs daily, ongoing support across multiple areas or domains of day to day life.
These levels are not fixed, they can change throughout a persons life and do not reflect a persons intelligence or identity. Many people can fluctuate through levels depending on their environment, masking, burnout or mental wellbeing.
Unfortunately this fluctuation is not captured at the time of diagnosis and a person may need to have their "level" reassessed. Especially if it's required to access supports and services where the level given at the time of diagnosis doesn't reflect their real world needs.
When applying the DSM-V with too much rigidity or too literally it can exclude people who don't fit into the stereotypes or expectations of the diagnostician. It can lead to those who mask or overcompensate to be overlooked and it can cause an over emphasis on surface level or observable behaviours rather than lived experience.
For example, an articulate adult who maintains eye contact, is educated, is employed or reports having social connections may be denied a diagnosis - even if these things cause them sensory overstimulation, exhaustion, fatigue, anxiety and they need to mask in order to maintain these behaviours.
This is where additional resources and guidelines that compliment the DSM-V are essential. Autism CRC publish approved guidelines and recommendations for practitioners that are accessible to anyone, you can find the current guideline here. This covers how to incorporate a person centred, holistic and neuroaffirming approach when applying the DSM-V to assess and diagnose autism.
The DSM-V, like any tool, needs a careful and considered approach in order to accurately assess a person for Autism. It is vital that guidelines from Autism CRC are used to compliment its application in clinical settings to ensure that levels of under diagnosis or missed opportunities for diagnosis are minimised.
Accuracy in diagnosis when applied thoughtfully and holistically can open the door for autistic people to receiving the supports they need, and in finding their tribe, being kind to themselves and reconciling and validating their lived experiences. In the same way, it can shut these doors when used too literally.
Autism is not a list of traits and behaviours. It is a way of being within the world.
If you feel like you might be looking further into your diagnostic journey or embarking on one for your child or loved one, there are so many resources that might help. Sometimes it's just knowing what to expect in order to take that first step, or maybe starting with a clean slate like a new GP, especially if you have experienced the sometimes dismissive nature of some doctors in the past.
Even simple things like lurking and watching facebook groups, self advocacy literature or videos, it can all help and if you prefer to self identify, that's fine too! We see you!
