“The diagnostic literature on autism describes autistic people who are frequently devastated by accidentally breaking social rules they were trying hard to follow.”

Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).

DSM-5 can improve sample characterization and provide opportunities for researchers to identify possible subtypes within ASD.

The ICD-11 underscores that an ASD diagnosis is still appropriate in such cases because the clinical presentation may eventually occur in terms of accompanying decompensation symptoms such as depression, anxiety, and emotion dysregulation when social demands overwhelm the capacity to compensate. According to ICD-11, this propensity particularly applies to adolescent girls, which is consistent with research indicating a diagnostic bias based on gender-specific adaptation skills that allow female patients to hide their social difficulties.

Typically, children with ASD are slower and/or less able to adapt to new experiences and circumstances. Strong reactions (often one of acute anxiety, distress and/or anger) can be evoked by changes to a familiar environment that, to non-autistic people, seem trivial, or in response to unanticipated events. Characteristic of the response to such unwelcome change and uncertainty is extreme discomfort which manifests in childhood as acute distress.

For the domain of restrictive and repetitive behaviors comprises 16 possible features of which several show questionable empirical evidence of specificity for ASD, such as excessive adherence to rules (e.g., when playing games).

Autism spectrum disorder (ASD) is often associated with emotional distress and psychiatric comorbidities. Atypical emotion regulation (ER) may underlie some of these difficulties. In a cross-sectional sequential analysis, they further demonstrated that less cognitive appraisal was associated with higher levels of negative emotion, which in turn was related to more maladaptive behavior in ASD.

Impairment in social communication and social interaction. 1. Deficits in social-emotional reciprocity; ranging from abnormal social approach.

Two new childhood mental disorders were added in the DSM-5: social communication disorder (or SCD) and disruptive mood dysregulation disorder (or DMDD).

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text revision (DSM-IV-TR) and the International Classification of Diseases, Tenth edition (ICD-10), autism spectrum disorders (ASD) are characterized by severe and pervasive abnormalities in reciprocal social interaction and communication skills, and the presence of stereotyped behaviors, interests and activities which lead to life-long impairments.

Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). Excessive adherence to routines and restricted patterns of behavior may be manifest in resistance to change (e.g., distress at apparently small changes, such as in packaging of a favorite food; insistence on adherence to rules; rigidity of thinking).

We believe that some influential accounts of autism rest on a questionable assumption that many of its behavioral characteristics indicate a lack of social interest – an assumption that is flatly contradicted by the testimony of many autistic people themselves.

Social communication evidence includes difficulties with social-emotional reciprocity, such as reduced initiation of social interaction or atypical response to social overtures. Nonverbal communication impairments manifest as limited eye contact, restricted facial expression, or difficulty interpreting gestures. Relationship challenges appear as problems developing peer relationships appropriate to developmental level or reduced interest in sharing experiences with others.

KNOWLEDGE_BASE: ICD-11 describes autism spectrum disorder (6A02) with persistent deficits in social communication and interaction, and restricted repetitive behaviors. It notes manifestations may include limited social-emotional reciprocity, difficulties responding to social cues, and rigidity or insistence on sameness, but does not explicitly describe devastation from accidentally breaking social rules.

Specifically, it is important to understand whether trauma is being assessed both during the initial diagnostic evaluation for children suspected of ASD and directly experiencing the event, witnessing the event, learning the event occurred to a close family member or friend, or experiencing repeated or extreme exposure to aversive details of the event.

Persistent deficits in initiating and sustaining social communication and reciprocal social interactions that are outside the expected range of typical functioning given the individual’s age and level of intellectual development. Persistent restricted, repetitive and inflexible patterns of behaviour, interests or activities that are clearly atypical or excessive for the individual’s age, gender and sociocultural context plus lifelong excessive and persistent hypersensitivity or hyposensitivity to sensory stimuli.

Resistance to demands is a characteristic experienced by and observed in some autistic people. It is sometimes labelled as Pathological Demand Avoidance. This can manifest as distress or avoidance when faced with everyday demands, potentially linked to social rule-breaking anxiety.

Qualitative impairment in social interaction, as manifested by at least two of the following: a. 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. Lack of social or emotional reciprocity.

ICD-11's ASD has incorporated into its spectrum the earlier ICD-10 diagnosis (F84) of Asperger syndrome, indicative of autism in individuals with average or above-average intelligence. Social communication deficits persist, but no specific mention of distress from breaking social rules.

Insistence on sameness and inflexible adherence to routines describes distress when routines are disrupted, rigid thinking patterns, the need to take the same route or follow the same sequence, and difficulty with transitions.

Difficulties adjusting behavior to suit social contexts. Does not notice another person’s lack of interest in an activity. Lack of response to contextual cues (e.g. social cues from others indicating a change in behavior is implicitly requested). Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest.

The DSM-5 diagnostic criteria for autism spectrum disorder (ASD) emphasize “persistent deficits in social communication and social interaction. Autistic people are often misunderstood, misinterpreted, misrepresented, and mistreated by allistic (non-autistic) peers, researchers, and clinicians.

Many autistic adults engage in forms of self-regulation, sometimes called stimming. These behaviours can help regulate sensory input, manage anxiety, support focus, or process emotions.

The DSM-5 criteria for ASD include under Criterion B2: 'Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).' This describes distress from disruptions to routines or rules, which can include social rules like greeting rituals.

The DSM-5 also introduced Social (Pragmatic) Communication Disorder (SPCD) which was meant to capture people with pervasive social communication problems without the restricted and repetitive behaviours required for ASD. Clinical psychologists warn that rising autism diagnoses “overlap suspiciously” with presentations of borderline or avoidant personality disorder and complex trauma.