autism spectrum disorders ( asd ) are lifelong conditions severely impairing social skills and autonomy . according to the fifth edition of the diagnostic and statistical manual of mental disorders ( dsm-5 ) ,
asd core features are : persisting deficits of social communication and interaction ; restricted and repetitive behaviors , interests , activities . compared to the previous edition ( dsm - iv - text revision ) , dsm-5 introduced significant changes . in the diagnostic criteria , language abilities not employed in social communication have been de - emphasized .
further , the diagnostic subcategories , that is , autistic disorder , asperger disorder , rett disorder , childhood disintegrative disorder , and pervasive developmental disorder ( pdd ) not otherwise specified , have been abolished .
dsm-5 describes three levels of increasing severity of asd , from ( 1 ) (  requiring support  ) to ( 2 ) (  requiring substantial support  ) , finally to ( 3 ) (  requiring very substantial support  ) .
we report two explanatory cases affected by asd with the same severity level , according to dsm-5 , but with remarkable differences regarding the neuropsychological and neurobehavioral profile .
the maternal grandfather was a very skilled electronics technician , but he lacked empathy and had difficulties relating to others ; as a child , he self - taught himself four languages
. the boy was born at full term ; pregnancy and delivery were uncomplicated , psychomotor development was normal . since 18 months of age he appeared isolated , wanted things to be placed in a certain order , played along with water and looked at books for hours .
he showed great ability to design projects , e.g. , a new home or railway line and was frustrated by not being able to get the highest grade in maths . applied behavior analysis ( aba ) intervention
wechsler intelligence scale for children - iii edition ( wisc - iii ) showed a full intelligence quotient ( iq ) = 102 , with a significant discrepancy ( p < 0.01 ) between verbal iq ( = 115 ) and performance iq ( = 89 ) . comparing the 10 wisc - iii subtests among them [ table 1 ] ,
the score in vocabulary , involving lexical knowledge , prevailed significantly ( p < 0.01 ) , while the scores in block design ( visuoperceptual abilities , visuomotor coordination ) and in object assembly ( visual analysis , construction of objects ) were significantly lower ( p < 0.01 ) .
copy of rey  osterrieth complex figure , involving visuoconstructional and visuospatial abilities , was unrecognizable .
autism diagnostic observation schedule ( ados ) ( module 3 ) showed a score above the cut - off for autism spectrum in language and communication and above the cut - off for autism in reciprocal social interaction ; the overall result was above the cut - off for autism .
childhood autism rating scale second edition - high functioning ( cars2-hf ) showed the presence of mild to moderate asd symptoms .
krug asperger 's disorder index ( kadi ) appeared compatible with a highly probable asperger 's disorder diagnosis ; among the findings from this questionnaire the following should be noted : demanding a lot from himself and from others ; too serious appearance ; fluent language and adequate vocabulary before 5 years of age ; tendency to say embarrassing things to others ; unusual way to enact or talk about fantasies or thoughts .
the first five from the left are the verbal subtests , the other five are the performance subtests according to dsm-5 criteria , this case had an asd diagnosis with severity level 1 .
family history was positive for : learning disorder in the older sister , asd in the younger brother . during pregnancy ,
psychomotor development was normal except for language as the child began to speak sentences with a slight delay .
social - emotional reciprocity was lacking : he often followed the course of his thoughts and conversational exchanges remained limited .
comprehension of verbal messages tended to be literal , leading to difficulties in understanding the meaning of metaphors , jokes , and slang expressions .
first speech therapy and psychomotricity were conducted , then aba intervention . at school , he had the special needs teacher .
wisc - iii showed a full iq = 95 , with a verbal iq = 88 and a performance iq = 104 : this difference was significant at 0.05 level , very near to 0.01 level . comparing the 10 wisc - iii subtests among them [ table 1 ] ,
the score in comprehension , involving social and practical judgment , was significantly lower ( p < 0.05 ) , while the score in picture completion , involving visual analysis and attention to detail , was almost significantly higher ( p = 0.05 ) .
ados ( module 3 ) showed a result above the cut - off for autism both in language and communication , and in reciprocal social interaction ; consequently also the overall result was above the cut - off for autism .
kadi was compatible with an extremely low probability of asperger 's disorder diagnosis . according to dsm-5 criteria ,
the maternal grandfather was a very skilled electronics technician , but he lacked empathy and had difficulties relating to others ; as a child , he self - taught himself four languages
. the boy was born at full term ; pregnancy and delivery were uncomplicated , psychomotor development was normal . since 18 months of age he appeared isolated , wanted things to be placed in a certain order , played along with water and looked at books for hours .
he showed great ability to design projects , e.g. , a new home or railway line and was frustrated by not being able to get the highest grade in maths . applied behavior analysis ( aba ) intervention
wechsler intelligence scale for children - iii edition ( wisc - iii ) showed a full intelligence quotient ( iq ) = 102 , with a significant discrepancy ( p < 0.01 ) between verbal iq ( = 115 ) and performance iq ( = 89 ) . comparing the 10 wisc - iii subtests among them [ table 1 ] ,
the score in vocabulary , involving lexical knowledge , prevailed significantly ( p < 0.01 ) , while the scores in block design ( visuoperceptual abilities , visuomotor coordination ) and in object assembly ( visual analysis , construction of objects ) were significantly lower ( p < 0.01 ) .
copy of rey  osterrieth complex figure , involving visuoconstructional and visuospatial abilities , was unrecognizable .
bvn 511  ( italian battery of neuropsychological assessment for children and adolescents ) . autism diagnostic observation schedule ( ados ) ( module 3 ) showed a score above the cut - off for autism spectrum in language and communication and above the cut - off for autism in reciprocal social interaction ; the overall result was above the cut - off for autism .
childhood autism rating scale second edition - high functioning ( cars2-hf ) showed the presence of mild to moderate asd symptoms .
krug asperger 's disorder index ( kadi ) appeared compatible with a highly probable asperger 's disorder diagnosis ; among the findings from this questionnaire the following should be noted : demanding a lot from himself and from others ; too serious appearance ; fluent language and adequate vocabulary before 5 years of age ; tendency to say embarrassing things to others ; unusual way to enact or talk about fantasies or thoughts .
the first five from the left are the verbal subtests , the other five are the performance subtests according to dsm-5 criteria , this case had an asd diagnosis with severity level 1 .
family history was positive for : learning disorder in the older sister , asd in the younger brother . during pregnancy ,
psychomotor development was normal except for language as the child began to speak sentences with a slight delay .
social - emotional reciprocity was lacking : he often followed the course of his thoughts and conversational exchanges remained limited .
comprehension of verbal messages tended to be literal , leading to difficulties in understanding the meaning of metaphors , jokes , and slang expressions .
first speech therapy and psychomotricity were conducted , then aba intervention . at school , he had the special needs teacher .
wisc - iii showed a full iq = 95 , with a verbal iq = 88 and a performance iq = 104 : this difference was significant at 0.05 level , very near to 0.01 level . comparing the 10 wisc - iii subtests among them [ table 1 ] ,
the score in comprehension , involving social and practical judgment , was significantly lower ( p < 0.05 ) , while the score in picture completion , involving visual analysis and attention to detail , was almost significantly higher ( p = 0.05 ) .
ados ( module 3 ) showed a result above the cut - off for autism both in language and communication , and in reciprocal social interaction ; consequently also the overall result was above the cut - off for autism .
kadi was compatible with an extremely low probability of asperger 's disorder diagnosis . according to dsm-5 criteria ,
the description of these two explanatory cases underlines some critical points of the current setting of dsm-5 classification for asd . according to dsm-5 criteria ,
both cases fall under asd , due to a significant impairment in social communication and interaction , and to restricted interests and activities . at the same time , both cases ( verbal boys , aged about 7 and a half years , without intellectual disability ) , based on dsm-5 description , fall into the lowest severity level of asd ( level 1 ) , which by definition requires support . however , their respective neuropsychological and neurobehavioral profiles were notably different .
while the first boy showed a prevalent impairment of visuoconstructional and visuoperceptual abilities , with language functions even overdeveloped in some respects , the second boy presented an almost specular profile characterized by a predominant involvement of verbal functions , with qualitative impairments in communication , and a preservation of nonverbal functions , some of which ( particularly visual analysis ) were the strength of his development .
admittedly , a detailed neuropsychological and neurobehavioral profile represents a basic prerequisite for the treatment of patients with asd . in the past years
, when the dsm - iv - text revision ( tr ) was being used , among the pdds , asperger disorder , together with autistic disorder , has been the most studied from the neuropsychological and neurobehavioral perspective .
basically , according to dsm - iv - tr criteria , the main distinguishing features that characterized asperger disorder compared with other pdds , were the absence of intellectual disability and the presence of structured language .
further , we could observe a cognitive profile characterized by strengths in verbal skills ( e.g. , vocabulary ) and weakness in nonverbal skills ( e.g. , visuospatial and visuomotor abilities ) .
, several papers highlighted the differences between neuropsychological profiles of asperger disorder and  high - functioning 
autistic disorder , but over the years the opinion of the authors that devalue these differences has prevailed . according to dsm - iv - tr criteria ,
both cases fall into pdds ; nevertheless , while the first boy would receive a diagnosis of asperger disorder , the second one , due to his qualitative impairments in communication , would rather receive a diagnosis of autistic disorder , to be considered  high - functioning  .
one of dsm-5 assumptions is the lack of data supporting the distinction between these two entities , but , unfortunately , the current dsm approach ( three severity levels ) does not allow the division of patients with autism into sufficiently homogeneous groups .
our report is not meant to suggest a return to the past , but rather to give a cue to improve the current dsm classification .
we believe that a further step forward in asd definition and classification is necessary in order to meet the needs of affected individuals from the rehabilitation perspective . in our view
it is important to take into account not only the intensity of symptoms , but also their quality , in order to formulate a reliable prognosis , plan an individualized treatment , and monitor the clinical course over time .
in addition , description of detailed behavioral phenotypes , allowing the creation of homogeneous subgroups of patients with asd , may be useful also for genetic research .
 the fifth edition of the diagnostic and statistical manual of mental disorders ( dsm-5 ) introduced significant changes in the classification of autism spectrum disorders ( asd ) , including the abolition of the diagnostic subcategories proposed by dsm - iv - text revision . 
 dsm-5 describes three levels of increasing severity of asd . 
 the authors report two explanatory cases with asd ( verbal boys , aged about 7 and a half years , without intellectual disability ) . according to dsm-5 
 , both cases fall into the lowest severity level of asd . however , their neuropsychological and neurobehavioral profile varies significantly . 
 while the first boy showed a prevalent impairment of visuoconstructional and visuoperceptual abilities , the second one presented a predominant involvement of verbal functions , with qualitative impairments in communication . a further step forward in the definition and classification of asd , taking into account both intensity and quality of symptoms , is recommended in order to formulate a reliable prognosis , plan an individualized treatment and monitor the clinical course over time . 
Introduction
Case Reports
Case 1
Neuropsychological and neurobehavioral assessment
Case 2
Neuropsychological and neurobehavioral assessment
Discussion