There is no such thing as “Level 2 Autism.”

Dr. Alice Ann Holland

Sep 20

4 min read

Have you been told that your child’s diagnosis is “level one” autism, or has someone suggested your child might have “level two” autism? Neither of these exists. It is a common misconception that the severity of an autism diagnosis can be classified by an overall level.

What is level 2 autism?

"Level 2 autism" is not a diagnosis. Level 2 is one of three severity ratings described in the DSM-5, and it applies to a symptom category — not to a child's autism diagnosis as a whole.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the criteria for an autism diagnosis. The DSM-5 also describes three "levels" of autism symptom severity:

Level 1: Requiring support
Level 2: Requiring substantial support
Level 3: Requiring very substantial support

So, yes, these levels exist, but many clinicians and educators use them incorrectly.

The DSM-5 requires that levels be applied to symptoms, not the overall diagnosis.

The diagnosis of Autism Spectrum Disorder (ASD) is primarily based on two symptom categories:

Category A involves persistent deficits in social communication and social interaction.
Category B includes restricted, repetitive patterns of behavior, interests, or activities.

Each symptom category gets its own severity rating or "level." The DSM-5 specifically states:

“Severity of social communication difficulties and restricted, repetitive behaviors should be separately rated.” DSM-5-TR

Thus, applying a single "level" to an overall autism diagnosis is a misuse of the concept. There is good reason for this. Every child on the autism spectrum has a diverse array of strengths and weaknesses. Using a single, overall level can be overly reductive.

A young girl attempts to talk to a young boy who is anxious and withdrawn.

Some children on the autism spectrum need support primarily due to Category A symptoms. For example, a child might “require substantial support” (level 2) in knowing how to respond when peers come up to him and say hello or ask him to play, while his hand flapping and fixated interests only occur occasionally and require minimal support in terms of his daily functioning (level 1). For other children on the autism spectrum, Category B symptoms drive nearly all of the support required — such as a child who manages relatively well socially but requires “very substantial support” with behavioral meltdowns triggered by minor changes to the daily routine.

"Level 2" is a severity rating applied to one symptom category — not a type of autism, and not an overall diagnosis. Here's a visual example:

Severity level	Social communication CATEGORY A	Restricted, repetitive behaviors CATEGORY B
Level 1 REQUIRING SUPPORT	—	✓ THIS CHILD
Level 2 REQUIRING SUBSTANTIAL SUPPORT	✓ THIS CHILD	—
Level 3 REQUIRING VERY SUBSTANTIAL SUPPORT	—	—

A complete DSM-5 severity specification for one hypothetical child. Two ratings, in two categories, which frequently land in different rows.

Attempting to describe the broad spectrum of ASD symptoms with a single number can be detrimental to support/intervention efforts. What a teacher or therapist needs to know about a child is precisely what a single overall level throws away. This is why the DSM-5 dictates that any severity specification associated with an autism diagnosis should be two ratings, not one.

Levels describe the present, and the present can change.

An autism diagnosis is generally stable across development, but support needs are not. A four-year-old who requires very substantial support to manage transitions may, after a couple of years of targeted intervention, require considerably less. The diagnosis has not changed, but the “level” has. This is why the DSM-5 levels are specific to current severity:

“The severity specifiers (see Table 2) may be used to describe succinctly the current symptomatology (which might fall below level 1), with the recognition that severity may vary by context and fluctuate over time.” DSM-5-TR

A severity level describes a period in a child's life, not a permanent feature of the child. Unfortunately, when written in a report, symptom "levels" can follow a child even if those numbers are no longer accurate. This is why I typically do not document autism symptom "levels" in my reports. Levels can change, but reports do not.

If your child has been assigned a single, overall “level” of autism:

IN THE CONTEXT OF AN EVALUATION

— Either request that severity levels not be documented in the report, or ask the evaluator to classify each diagnostic category with a separate level, per DSM-5 guidelines.

— Ask which symptoms have the potential to change with intervention, and what implications this may have for the assigned severity levels.

— Ask the evaluator to discuss the pros and cons of explicitly documenting autism severity levels within the report.

IN THE CONTEXT OF THERAPY/INTERVENTION

— Ask about the rationale for assigning severity levels. If levels are being used to decide what services your child receives, you may point out that the DSM-5 states that severity levels should not be used to determine eligibility for and provision of services.

— Ask about the basis for assigning any severity levels, especially if a formal evaluation has not been conducted.

— Ask which symptoms have the potential to change with intervention, and what implications this may have for the assigned severity levels. How often will severity levels be reassessed, and how will documentation be handled if severity levels change?

— Ask that each diagnostic category be classified with a separate level, per DSM-5 guidelines.

None of this means that autism severity levels are useless. If used as specified by the DSM-5, the two levels quickly summarize a child’s current need for support with respect to each symptom category. Unfortunately, your child’s evaluation report can follow them for years, and since the concept of autism severity levels is commonly misunderstood, there is a real risk of your child also being misunderstood. To minimize this risk, either ask that levels not be explicitly documented — which does not prevent the clinician from narratively describing your child’s symptom profile — or insist that levels be documented according to DSM-5 guidelines, with one level per diagnostic symptom category, rather than an overall level.

Sources

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Arlington, VA: American Psychiatric Association Publishing, 2022.