Why Autism Has Two Different Relationship Criteria

The basketball analogy that completely changed the way I think about the DSM criteria

I’m the type of person who loves to dive deep. If something doesn’t make sense to my brain, I can’t just accept it and move on. I need to understand why. I want to know how the pieces fit together. All of the pieces.

That’s especially true when I’m involved in something as important as diagnosis. I take this stuff really seriously because I know how life-changing it can truly be.

Over the past few years I’ve spent hundreds of hours conducting autism assessments. I’ve read the DSM criteria more times than I can count. I’m the first to admit that I still have it open every single time I write an assessment because my brain refuses to memorize it. Somehow I can remember the lyrics to songs I haven’t heard in twenty years but not the exact wording of Criterion A. Brains are funny like that.

Even after reading the DSM hundreds of times one section kept making me stop and think. If you’ve ever looked at the DSM-5-TR criteria for autism you may have had the same reaction I did.

The DSM separates social communication into two different criteria.

One is social-emotional reciprocity (Criterion A1) and the other is developing, maintaining and understanding relationships (Criterion A3).

My first thought?“…But isn’t that the same damn thing?” Both involve people, relationships and social communication.

As someone who spends a lot of time translating the DSM into everyday language I couldn’t shake the feeling that I was missing something. Surely there had to be a reason these were separated into two different criteria.

Now I’ll be the first to admit that you might be reading this thinking, “I’ve never once considered this nuance, Jena, you nerd.” If that’s you I’m genuinely happy for you. But for those of us whose brains refuse to move on until every piece clicks into place come along for a little ride through the DSM with me.

The answer to the distinction came from asking a different type of question. Instead of asking, “What’s the difference between these criteria?” I started asking, “What are they actually trying to measure?”

Oddly enough the analogy that finally made it click had nothing to do with psychology.

It had to do with basketball.

One thing you might not know about me is that when I was in the 3rd grade, I decided I was going to be a professional basketball player. Those who know me are probably laughing really hard right now because I’m barely even 5 feet tall and I have the athletic prowess of a blowfish. But stick with me for a few minutes here:

Imagine you’ve never watched a basketball game before. You walk into a gym and see ten people running around a court. They’re passing a ball, pointing at one another, shouting things that somehow make perfect sense to everyone else and constantly moving in ways that seem almost instinctive. If you’ve watched basketball your whole life this all feels perfectly normal. If you’ve never learned the game it looks like complete chaos.

Now imagine I ask you a simple question.

Do you know how to play basketball?

Most people would answer by thinking about the skills involved in actually playing the game. Can you dribble? Can you pass? Can you shoot? Can you recognize when a teammate is open? Can you react quickly enough to what’s happening around you?

Those skills all happen while you’re actively playing. They require you to process information, make decisions and respond in real time. You don’t get to pause the game for five minutes while you decide whether to pass the ball. You have to make that decision almost instantly.

But then I ask you a different question.

Do you understand how basketball works?

Suddenly we’re talking about something completely different.

Now we’re thinking about positions, team dynamics, coaching strategies, trust between teammates, why certain plays work and how people learn to function as a team over an entire season. None of those things have anything to do with dribbling a basketball. They’re about understanding the larger system the game exists within.

That’s when it hit me. The DSM isn’t asking the same question twice. It’s asking two entirely different questions about social interaction.

One question is about what happens during the interaction.

The other is about understanding the larger system of relationships that interaction exists within.

Once I saw it that way the distinction between Criterion A1 and Criterion A3 stopped feeling redundant and became one of my most favorite, nuanced part of my assessments.

Let’s take that basketball analogy one step further..because WHY NOT? I love a theme.

Imagine you’re standing on the court during a game. Everything is happening at once. A teammate is calling your name, another player is cutting toward the basket, the defense is shifting, the crowd is loud and the shot clock is winding down. Your brain has to take in all of that information, decide what’s important, ignore what isn’t, predict what everyone else is about to do and respond in less than a second.

Playing basketball isn’t just about knowing how to dribble or pass. It’s about coordinating dozens of tiny decisions in real time. Conversation works much the same way.

While you’re talking with another person your brain isn’t just producing words. It’s tracking facial expressions, interpreting tone of voice, deciding whether it’s your turn to speak, remembering what the other person just said, planning your response, considering whether that response fits the moment and trying to determine whether the conversation feels balanced. It is quite a feat!

For many autistic people much of this processing is conscious rather than automatic. The conversation may look effortless from the outside while requiring an incredible amount of mental effort on the inside.

That’s what Criterion A1 is actually trying to measure.

It isn’t asking whether someone enjoys people, whether they’re empathetic or whether they want relationships. It’s asking about the process of social interaction itself. How much effort does it take to coordinate the back-and-forth exchange of conversation? How much conscious thought goes into something many people experience as intuitive?

Now…

Imagine the game is over and someone asks you to explain basketball to a person who’s never watched it before. Suddenly the conversation isn’t about dribbling or passing anymore. It’s about understanding the game itself. Why does each player have a different position? What makes someone a good teammate? How does a team build trust? Why do certain plays work? What separates a casual player from someone who truly understands the game?

Relationships have an invisible structure in much the same way.

Most of us are never explicitly taught when someone becomes a friend, how often we’re supposed to reach out, why one relationship feels effortless while another doesn’t or how social groups develop their own unwritten expectations. Many people seem to absorb these patterns naturally over time.

Many autistic people don’t.

Instead they often describe observing, analyzing and consciously learning these patterns almost like studying a game whose rules were never fully explained.

That’s what Criterion A3 is measuring (it's also what makes us GREAT at being therapists).

It’s not asking whether someone has relationships or even whether they want them. It’s asking how they understand the larger social system relationships exist within.

The focus shifts away from the mechanics of conversation and toward the unwritten rules that shape friendships, families, workplaces and communities over time.

When I finally saw the criteria through this lens everything clicked.

The DSM wasn’t repeating itself. It was looking at social interaction from two different distances.

Criterion A1 zooms all the way in and asks what happens during an interaction.

Criterion A3 zooms all the way out and asks how someone understands the broader landscape of relationships.

Together they paint a much richer picture of social processing than either criterion could on its own.

So, why does any of this matter? Because if we misunderstand what these criteria are measuring we risk misunderstanding autistic people.

Criterion A1 isn’t measuring whether someone is friendly, interested in other people or capable of having meaningful conversations. Criterion A3 isn’t measuring whether someone has friends or wants relationships. They’re measuring the mental processes underneath those experiences.

When we recognize the distinction between these two, we stop looking at behavior as the whole story and start becoming curious about the processing underneath it. The person who doesn’t jump into a conversation may not be disinterested. They may still be organizing everything that’s happening around them.

The person who asks, “Are we actually friends?” after spending months together may not lack social interest. They may simply be trying to understand rules that other people absorbed without realizing it.

The person who appears socially confident may still leave every interaction mentally exhausted because so much of that process required conscious effort.

This is why I love autism assessments.

Yes, my job is to determine whether someone meets diagnostic criteria. But diagnosis has never felt like the finish line to me. It’s the beginning of understanding.

Every criterion in the DSM tells us something about how a person’s brain experiences the world. If we stop reading those criteria as a checklist of deficits and start reading them as descriptions of processing the conversation changes.

Instead of asking, “What’s wrong?”

We start asking, “What is this person’s brain working so hard to do?”

And once we know that we can ask an even better question.

“What would make it easier?”

Maybe it’s more processing time, clearer communication or relationships where authenticity is valued more than performance. Maybe it’s environments where social interaction doesn’t constantly feel like playing in the championship game.

To me that’s the real magic hidden inside the DSM.

Most people read it looking for differences. I read it looking for needs.

And that’s exactly what the Assessment Fairy™ is all about. I'll be sharing more about this in upcoming weeks, but just know that a little fairy dust doesn’t change the criteria. It simply helps us see the person underneath them.

So, if you’re looking to start to understand the criteria in a deeper, more enriching way, follow along for a little magic!