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As its name implies, Autism Spectrum Disorder falls on a continuum, meaning the associated characteristics fall underneath the overarching domain difficulties but may manifest differently in individuals based on any number of factors. For children, who have more subtle characteristics, diagnosis may be delayed. This may be due to many factors including high intelligence, social motivation, lack of subjective distress or impaired functioning, and assigning symptoms as being part of another condition as there are some shared overlap in symptoms (i.e., ADHD, OCD, Sensory Processing Disorder, anxiety, social anxiety, depression) with symptom overlap. However, as we age, particularly from childhood to preadolescence, there is an increasing reliance on social communication often bringing social difficulties and executive functioning challenges to the forefront. Therefore, difficulties may not be detected until the demands exceed what the individual can tolerate and or execute.
WHY pursue an evaluation?
Families/individuals often pursue an evaluation for a few reasons…
Understanding- Understanding alone can be a game changer regardless of the diagnosis. For families, it can provide a foundation that provides a lens of understanding to view their loved one’s strengths and needs. For individuals, it may lead to greater self-awareness and increased confidence.
Diagnostic clarity- Accurate diagnosis is important because it drives treatment.
Access to services/resources- Diagnosis may be required to access support services through the state, county, school district, or workplace.
Educational/service planning- Evaluation and recommendations can prove an individual with the foundation from which to access 504 Accommodations or Individualized Education Plans (IEPs).
WHO? Finding the Right Practitioner
Psychologists, developmental pediatricians, psychiatrists, and neuropsychologists are trained in diagnosing Autism. At times, there are teams of practitioners. But as with any practitioner, it is important to choose a professional who has extensive experience in diagnosing individuals with ASD and other conditions which may appear similar to ASD at first glance. Seek a knowledgeable and experienced practitioner who engages in a differential diagnostic process.
Don’t be afraid to interview potential practitioners. You can often find much of this information online, but some of it you likely will not. Most will be happy to answer questions. Here are some questions that may be helpful when selecting the right provider.
Can you describe your assessment process?
What areas do you assess if the referral concern includes characteristics associated with Autism?
What is your experience with assessing neurodiversity?
How do you communicate the results?
When do you communicate the results?
Will there be recommendations/referrals?
How long will the testing take?
When and how will I receive the results?
WHAT is an evaluation?
An evaluation is a means by which a practitioner trained in diagnosing developmental challenges gathers information through a variety of means regarding the individuals functioning. These may include:
Structured interviews- information about one’s development is gathered via questionnaire and/or direct interview with the parent and individual (if appropriate). Autism specific tools are designed to elicit specific information that may have been forgotten, overlooked, or misattributed to another condition or personality idiosyncrasies. Oftentimes, parents will have information that the individual may not recall, and the individual also has information about their own internal and environmental experiences that are imperative to the evaluation process.
Questionnaires- These come in a variety of formats but are designed to elicit developmental and basic information about the individual. They often ask the respondent to provide current and developmental functioning in a variety of areas. The information provided is at the informant’s discretion.
Rating scales- These are structured assessments that require the respondent to rating the individual’s behavior, functioning, personality, etc. Frequently there are statements, and the informant can indicate the extent to which it matches the individual. This is presented in True/False or more distinct quantifiers such as Never, Sometimes, Often, Almost Always.
Structured and unstructured Observation- The Autism Diagnostic Observation Schedule (ADOS) is a tool that has the examiner present the individual with certain tasks, activities, and questions to assess the quality of their responses. It consists of different modules based on the individual’s age and function.
Standardized Assessments are developed based on research and rigorous analysis. A person’s score is an indication of how well they did in comparison to a large group of same aged peers. Furthermore, administered in a predetermined manner. This means that the questions, conditions of administration, scoring, and interpretation of responses are consistent from one occasion to another.
WHAT areas are being examined?
Intelligence -An intelligence battery should be administered if one has not been completed recently. The rationale is to assess for co-occurring cognitive disability and/or assess cognitive processing facilities that may indicate the need for school or workplace accommodations.
Pragmatic language- This refers to social communication which involves verbal and nonverbal communication and the ability to accurately identify, respond, and adjust to the audience, context, or conversational content. This can be assessed using feedback from those close to the individual, rating scales, observations, and direct testing. I often find that individuals with characteristic similar to what was known as Asperger’s; respond perfectly to questions when asked to respond to scenarios (i.e., What would you do in this situation?) Where I have seen individuals struggle most, is within the spontaneity or fluidity of social engagement. This is one of the areas where it is extremely important to gather information from a variety of tools.
Social, emotional, and behavioral functioning- Assessment in this area involves interview, observation, rating scales. It is important to assess for frequently co-occurring conditions such as depression, anxiety, inattention, executive dysfunction, etc.
Sensory processing- Neurodiverse individuals frequently have difficulty modulating sensory input. This means they may overreact or under-react to what one would typically expect. Frequently, this information is gathered from the individual (which is age contingent) or an individual with close personal knowledge (i.e., a parent).
Adaptive behavior- Adaptive behavior is assessed to determine the level of functioning in particular domains. This is particularly important in determining the impact of the individual’s concerns on a daily functioning basis.
Structured/semi structured observation tools- The most well-known is the Autism Diagnostic Observation Schedule (ADOS) is a tool that has the examiner presents the individual with certain tasks, activities, and questions to assess the quality of their responses. It consists of different modules based on the individual’s age and function.
Concluding Comments
Any psychological tool is only as good as the practitioner using it. Assessment tools offer guidance to the practitioner. Furthermore, no one tool should be used to singularly assess any condition. Some tools may not be sensitive enough to detect the wide nuances and subtle presentations of many neurodiverse individuals. Also, administration does not include developmental history which is imperative to the diagnosis. This is another important reason to find a well-seasoned practitioner trained in the administration of these tools well versed in their utility, validity, reliability, and limitations.
For more information about evaluations or to learn more about Dr. Renee Lake's evaluation process and availability, please go to Carolina Anchor Psychological & Educational Consulting or contact her at lake@carolinaanchor.com.