Five years after the publication of DSM-5 in 2013, three widely used diagnostic instruments have published algorithms designed to represent its (sub-)criteria for Autism Spectrum Disorder (ASD) in children and adolescents. This study aimed to: (1) establish the content validity of these three DSM-5-adapted algorithms, and (2) identify problems with the operationalization of DSM-5 diagnostic criteria in measurable and observable behaviors. Algorithm items of the Autism Diagnostic Observation Schedule—Second Edition (ADOS-2), Developmental, Dimensional and Diagnostic Interview (3di) and Diagnostic Interview for Social and Communication Disorders—11th edition (DISCO-11) were mapped onto DSM-5 sub-criteria. The development and decision-making rules integrated in their algorithms were then compared with DSM-5. Results demonstrated significant variability in the number and nature of sub-criteria covered by the ADOS-2, 3di and DISCO-11. In addition to differences in the development of algorithms and cut-off scores, instruments also differed in the extent to which they follow DSM-5 decision-making rules for diagnostic classification. We conclude that such differences in interpretation of DSM-5 criteria provide a challenge for symptom operationalization which will be most effectively overcome by consensus, testing and reformulation.
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The authors thank Wouter De la Marche (child psychiatrist at OPZ Geel, Belgium) and Annelies de Bildt (research psychologist at Accare, the Netherlands) for their contribution to the coding process as members of the expert panel.
This study was funded by a postdoctoral fellowship from the Fund for Scientific Research Flanders awarded to KE (12L6916N) and by the KU Leuven (Leuvens Universiteitsfonds ‘Opening the Future’).
Conflict of interest
Some of the authors (SL, SC, JM, IN) contributed to the development of the DSM-5 algorithm of the DISCO-11, and some of them are also involved in the DISCO-11 training for researchers (SL, SC, JM, IN, KE).
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Evers, K., Maljaars, J., Carrington, S.J. et al. How well are DSM-5 diagnostic criteria for ASD represented in standardized diagnostic instruments?. Eur Child Adolesc Psychiatry 30, 75–87 (2021). https://doi.org/10.1007/s00787-020-01481-z
- Autism spectrum disorder
- Content validity
- Diagnostic outcome