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Cited by 95Autism Spectrum Disorder ResearchChild Nutrition and Feeding IssuesChild and Adolescent Psychosocial and Emotional Development

DSM-5 criteria for autism spectrum disorder maximizes diagnostic sensitivity and specificity in preschool children

Open access
Wiggins, Lisa D., Rice, Catherine E., Barger, Brian, Soke, Gnakub N., Lee, Li-Ching, Moody, Eric, Edmondson-Pretzel, Rebecca, Levy, Susan E.·2019·Social Psychiatry and Psychiatric Epidemiology
DOI 10.1007/s00127-019-01674-1PMC PMC6713264
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Abstract

Purpose The criteria for autism spectrum disorder (ASD) were revised in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The objective of this study was to compare the sensitivity and specificity of DSM-IV-Text Revision (DSM-IV-TR) and DSM-5 definitions of ASD in a community-based sample of preschool children. Methods Children between 2 and 5 years of age were enrolled in the Study to Explore Early Development-Phase 2 (SEED2) and received a comprehensive developmental evaluation. The clinician(s) who evaluated the child completed two diagnostic checklists that indicated the presence and severity of DSM-IV-TR and DSM-5 criteria. Definitions for DSM-5 ASD, DSM-IV-TR autistic disorder, and DSM-IV-TR Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) were created from the diagnostic checklists. Results 773 children met SEED2 criteria for ASD and 288 met criteria for another developmental disorder (DD). Agreement between DSM-5 and DSM-IV-TR definitions of ASD were good for autistic disorder (0.78) and moderate for PDD-NOS (0.57 and 0.59). Children who met DSM-IV-TR autistic disorder but not DSM-5 ASD (n = 71) were more likely to have mild ASD symptoms, or symptoms accounted for by another disorder. Children who met PDD-NOS but not DSM-5 ASD (n = 66), or vice versa (n = 120) were less likely to have intellectual disability and more likely to be female. Sensitivity and specificity were best balanced with DSM-5 ASD criteria (0.95 and 0.78, respectively). Conclusions The DSM-5 definition of ASD maximizes diagnostic sensitivity and specificity in the SEED2 sample. These findings support the DSM-5 conceptualization of ASD in preschool children.

Integrity signals

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Crossref · 10.1007/s00127-019-01674-1

Cites

40 of 40 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

5 of 7 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Kappa agreement between SEED2 final classification status and clinical judgment was 0.71.

    “Moreover, kappa agreement between SEED2 final classification status and clinical judgment was 0.71, reflecting substantial agreement.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [29] Wiggins LD, Reynolds A, Rice C, Moody EJ, Bernal P, Blaskey L et al (2015) Using standardized diagnostic instruments to classify children with autism in the Study to Explore Early Development. J Aut Dev Disord 45:1271–1280 source

      The Methods (Statistical Analyses) compare SEED ASD classification with clinical judgment using sensitivity and specificity, and the Results report those measures. Searches for “SEED2,” “kappa,” and “0.71” found no passage reporting the claimed kappa agreement; this paper’s discussion of SEED classification does not verify that SEED2 figure. Page numbers were not available in our copy. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.
  • Premisecitation

    Previous SEED analyses showed that children termed 'DD with ASD symptoms' had a phenotypic profile more similar to children with ASD than to children with other developmental disorders.

    “Previous SEED analyses have shown that children termed “DD with ASD symptoms” and used in these analyses have a phenotypic profile more similar to children with ASD than children with other DD [32].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [32] Wiggins LD, Levy SE, Daniels J, Schieve L, Croen LA, DiGuiseppi C et al (2015) Symptoms of autism spectrum disorder among children enrolled in the Study to Explore Early Development. J Aut Dev Disord 45:3183–3194 source
  • Premisecitation

    Among females and males with similar ASD traits, females with more behavior problems or intellectual disability, or both, are more likely to be recognized and diagnosed.

    “Among females and males with similar ASD traits, females with more behavior problems or ID, or both, are more likely to be recognized and diagnosed [34, 35].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [34] Dworzynski K, Ronald A, Bolton R, Happe F (2012) How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders? J Am Acad Chil Adoles Psychiatry 51:788–797 source

      The Discussion (page not supplied) reports that lower cognitive ability and/or additional behavior problems distinguished diagnosed from undiagnosed girls with similarly high ASD traits, but not boys. It suggests that girls may be missed in diagnosis, while also offering better adaptation as an alternative explanation; it does not establish that the additional problems make girls more likely to be recognized. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [35] Frazier TW, Georgiades S, Bishop SL, Hardan AY (2014) Behavioral and cognitive characteristics of females and males with autism in the Simons Simplex Collection. J Am Acad Chil Adoles Psychiatry 53:329–340 source

      The Discussion (page not provided) reports lower cognitive ability and more externalizing problems among diagnosed females with ASD, and raises the possibility that higher-IQ females are underidentified. It does not establish that, among females and males with similar ASD traits, behavior problems or intellectual disability make females more likely to be recognized and diagnosed; underidentification is presented as a possibility. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Findingown data

    The DSM-IV-TR autistic disorder and PDD-NOS(1) and PDD-NOS(2) definitions had an adequate balance of sensitivity and specificity.

    “DSM-IV-TR definitions of autistic disorder and PDD-NOS(1) and PDD-NOS(2) had an adequate balance of sensitivity and specificity.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.
  • Findingown data

    Nine children met the DSM-5 ASD definition but not the DSM-IV-TR autistic disorder definition.

    “Of note, there were 9 children who met DSM-5 ASD but not DSM-IV-TR autistic disorder, and 120 children who met DSM-5 ASD, but not PDD-NOS(1) or PDD-NOS(2).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.
  • Classified as probably not a substantial claim. 11
  • May combine two claims. 14
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous analyses found that the SEED final classification criteria had a good balance of sensitivity and specificity compared with clinical judgment of ASD versus another developmental disorder.

    “Previous analyses found that SEED final classification criteria had a good balance of sensitivity and specificity when compared to clinical judgment of whether the child had ASD or another DD, and support the use of these instruments when defining ASD case status in SEED [29].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [29] Wiggins LD, Reynolds A, Rice C, Moody EJ, Bernal P, Blaskey L et al (2015) Using standardized diagnostic instruments to classify children with autism in the Study to Explore Early Development. J Aut Dev Disord 45:1271–1280 source
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

  • May combine two claims.

    Findingown data

    Females who met the DSM-IV-TR autistic disorder definition were as likely as males to meet the DSM-5 ASD definition, but females were more likely than males to shift between a DSM-IV-TR PDD-NOS definition and the DSM-5 ASD definition.

    “Results of this study add to this dialogue by providing evidence that females who meet DSM-IV-TR autistic disorder are as likely as males to meet DSM-5 ASD; however, they are more likely than males to shift between DSM-IV-TR PDD-NOS and DSM-5 ASD.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among the 1061 children with ASD or DD with ASD symptoms, 802 met the DSM-5 ASD definition, 864 met the DSM-IV-TR autistic disorder definition, 744 met PDD-NOS(1), and 736 met PDD-NOS(2).

    “Of the 1061 ASD and DD with ASD symptoms children in the sample, 802 met DSM-5 ASD, 864 met DSM-IV-TR autistic disorder, 744 met PDD-NOS(1) and 736 met PDD-NOS(2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In the SEED2 sample, 773 children satisfied the study's ASD criteria and 288 satisfied criteria for a different developmental disorder after comprehensive evaluation.

    “773 children met SEED2 criteria for ASD and 288 met criteria for another developmental disorder (DD).”
    • Also stated in: § Results · plain
      “A total of 773 children met SEED2 criteria for ASD and 288 met criteria for another DD after a comprehensive evaluation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Children who met the DSM-5 ASD definition but not PDD-NOS(1) or PDD-NOS(2) were less likely to have intellectual disability, more likely to be female, and more likely to have mild ASD symptoms.

    “Children who met DSM-5 ASD but not PDD-NOS(1) or PDD-NOS(2) were less likely to have intellectual disability (χ2 = 28.1, p < 0.01) and more likely to be female (χ2 = 8.5, p = 0.01) and have mild ASD symptoms (χ2 = 65.4, p < 0.01).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The sensitivity and specificity of the DSM-5 ASD definition were 0.95 and 0.78, respectively.

    “Sensitivity and specificity were best balanced with DSM-5 ASD criteria (0.95 and 0.78, respectively).”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

  • May combine two claims.

    Findingown data

    Children who met a PDD-NOS definition but not the DSM-5 ASD definition, or the reverse, were less likely to have intellectual disability and more likely to be female.

    “Children who met PDD-NOS but not DSM-5 ASD (n = 66), or vice versa (n = 120) were less likely to have intellectual disability and more likely to be female.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

  • May combine two claims.

    Interpretationreasoning

    Higher-functioning females and females without intellectual disability may be missed by current diagnostic systems.

    “These results imply that higher-functioning females and those without ID may be missed by current diagnostic systems.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The ADOS and ADI-R are considered gold-standard instruments for distinguishing ASD from other developmental disorders.

    “The ADOS and ADI-R are considered gold-standard diagnostic instruments used to differentiate children with ASD from children with other DD [25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Gray K, Tonge B, Sweeney D (2008) Using the autism diagnostic interview-revised and the autism diagnostic observation schedule with young children with developmental delay: evaluating diagnostic validity. J Aut Dev Disord 38:657–667 source

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Clinicians who administered the ADOS and ADI-R had at least a Master's degree and were monitored for administration fidelity and coding reliability.

    “Clinicians who administered the ADOS and ADI-R had at least a Master’s degree in psychology or related field and were deemed field ready once they established administration fidelity and research reliability with a supervising clinician at their site. These clinicians were monitored by the supervising clinician for administration fidelity at least once per year and for coding reliability at least”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The closest definition of Social Communication Disorder in this study is PDD-NOS(1), which had an adequate balance of sensitivity and specificity for ASD classification.

    “The closest definition of SCD in this study is PDD-NOS(1), which had an adequate balance of sensitivity and specificity for ASD classification.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    First-pass coding reliability for field clinicians was 92% for the ADOS and 97% for the ADI-R.

    “First-pass coding reliability for field clinicians was 92% for the ADOS and 97% for the ADI-R.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The sample was limited to children aged 2 to 5 years who completed a comprehensive evaluation because of ASD risk noted on the SCQ.

    “Fourth, the sample was limited to children 2–5 years of age who competed a comprehensive evaluation because of ASD risk noted on the SCQ.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The process of using ADOS and ADI-R information in the diagnostic checklist reflects clinical practice and may generalize to real-world clinic settings.

    “Nonetheless, this process reflects clinical practice and, therefore, may generalize to real-world clinic settings.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The study findings are strikingly similar to an analysis of 439 children and adolescents in the Autism Treatment Network.

    “These findings are strikingly similar to an analysis of 439 children and adolescents enrolled in the Autism Treatment Network [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Mazurek MO, Lu F, Symecko H, Butter E, Bing NM, Hundley RJ et al (2017) A prospective study of the concordance of DSM-IV and DSM-5 diagnostic criteria of autism spectrum disorder. J Aut Dev Disord 47:2783–2794 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Supervising clinicians had a doctorate, established research reliability with certified trainers, were monitored for fidelity and reliability, and had first-pass coding reliability of 92% for the ADOS and 97% for the ADI-R.

    “Supervising clinicians had a doctorate degree in psychology, medicine, or related field and established research reliability with a certified ADOS and ADI-R trainer.”
    • Also stated in: § Data collection procedures · plain
      “First-pass coding reliability for supervising clinicians also was 92% for the ADOS and 97% for the ADI-R.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    SEED2 did not systematically collect criteria for Social Communication Disorder.

    “Third, SEED2 did not systematically collect criteria for Social Communication Disorder (SCD), which was introduced in DSM-5 and thought to capture some children formerly defined as PDD-NOS.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The sample was large and was ascertained from clinic and non-clinic sources in multiple geographic areas across the United States.

    “The sample was large and ascertained from clinic and non-clinic sources in multiple geographic areas throughout the United States.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The results are best generalized to samples with a similar age and developmental profile and may differ in younger or older children or those with few social and communication concerns.

    “In sum, these results are best generalized to samples with a similar age and developmental profile and may look different in sample of younger or older children or those with few social and communication concerns.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.
19 of 19

  • The paper relies on this without support.

    No prior study has examined concurrent coding of DSM-IV-TR and DSM-5 criteria by a clinician evaluating preschool children at the age when symptoms are first recognized.

    “To our knowledge, no study has examined concurrent coding of DSM-IV-TR and DSM-5 criteria for ASD by a clinician who evaluated the child at a developmental period when symptoms may be first recognized by a parent or healthcare professional.”

  • The paper relies on this without support.

    The ADOS and ADI-R scores are both sensitive and specific in detecting ASD when used in combination.

    “However, scores from the ADI-R and ADOS are both sensitive and specific in detecting children with ASD when used in combination, and offer several advantages to classify children with ASD in large epidemiologic studies.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • PDD-NOS(3) appears in the analysis plan but is never defined

    Minor

    The statistical methods list PDD-NOS(3) among the definitions assessed, but the definitions section says only two PDD-NOS definitions were created. The reported results also discuss only PDD-NOS(1) and PDD-NOS(2).

  • Analysis lists an undefined third PDD-NOS definition

    Minor

    The methods say that two PDD-NOS definitions were created, but the statistical methods list PDD-NOS(3) among the definitions assessed. The text provides no definition for PDD-NOS(3).

2 of 2

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Authors
Wiggins, L. D., Rice, C. E., Barger, B., Soke, G. N., Lee, L.-C., Moody, E., Edmondson-Pretzel, R., & Levy, S. E.
Affiliations
  • Centers for Disease Control and Prevention (US)
  • Emory University (US)
  • Georgia State University (US)
  • Johns Hopkins University (US)
  • University of Colorado Anschutz (US)
  • Children's Hospital of Philadelphia (US)
Corresponding author
Wiggins, Lisa D.
ORCID
Venue
Social Psychiatry and Psychiatric Epidemiology
Publisher
Springer Science and Business Media LLC
Published
2019-03-08
Volume
54
Issue
6
Pages
693-701
ISSN
  • 0933-7954 (ISSN-L)
  • 1433-9285
DOI
10.1007/s00127-019-01674-1
PMC
PMC6713264
OpenAlex
W2921046787
Cited by
95
References
39
Citations by year
2026: 11 · 2025: 11 · 2024: 13 · 2023: 20 · 2022: 15 · 2021: 11 · 2020: 11 · 2019: 3
FWCI
5.81
Type
journal article
Language
en
Open access
Licence
Locations
  • Social Psychiatry and Psychiatric Epidemiology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
Centers for Disease Control and Prevention (U10DD000180, U10DD000181, U10DD000182, U10DD000183, U10DD000184, U10DD000498)
Topics
  • Life Sciences › Neuroscience › Cognitive Neuroscience › Autism Spectrum Disorder Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Child Nutrition and Feeding Issues
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
Keywords
autism spectrum disorder, DSM-5 diagnostic criteria, DSM-IV-TR, sensitivity and specificity, preschool children, autistic disorder, pervasive developmental disorder not otherwise specified, intellectual disability, sex differences
MeSH terms
Autism Spectrum Disorder, Child, Preschool, Female, Humans, Male, Intellectual Disability, Sensitivity and Specificity, Diagnostic and Statistical Manual of Mental Disorders, Checklist

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