Evidence-based assessment/Autism spectrum disorder (assessment portfolio)

What is a "portfolio"?
For background information on what assessment portfolios are, click the link in the heading above.

Want even 'more' information about this topic? There's an extended version of this page here.

Diagnostic criteria for autism spectrum disorder
ICD-11 Diagnostic Criteria:

Autism spectrum disorder is characterized by persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication, and by a range of restricted, repetitive, and inflexible patterns of behaviour and interests. The onset of the disorder occurs during the developmental period, typically in early childhood, but symptoms may not become fully manifest until later, when social demands exceed limited capacities. Deficits are sufficiently severe to cause impairment in personal, family, social, educational, occupational or other important areas of functioning and are usually a pervasive feature of the individual’s functioning observable in all settings, although they may vary according to social, educational, or other context. Individuals along the spectrum exhibit a full range of intellectual functioning and language abilities.

Note: The ICD-11 contains seven subcategories of ASD that can be found in the ICD-11, here.

ASD encompasses these previous DSM-IV diagnoses:


 * Autistic disorder (autism)
 * Asperger’s disorder
 * Childhood disintegrative disorder
 * Pervasive developmental disorder not otherwise specified

 ASD is characterized by:  Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.
 * 1) deficits in social communication and social interaction and
 * 2) restricted repetitive behaviors, interests, and activities (RRBs).

 Changes in DSM-5 Criteria 


 * The diagnostic criteria for ASD changed from DSM-IV to DSM-5. Summaries are available here and here.

Base rates of ASD in children and adolescents in different populations and clinical settings
As noted above, the base rate of autism diagnosis is greater in males compared to females. However, research indicates that this sex difference could be due to a number of factors, perhaps leading to the under-identification of females with autism. Indeed, there is evidence that differential item functioning exists for some diagnostic screening tools for males and females with autism. Care must be taken to ensure that the manner in which autism symptoms are identified and assessed are not unduly influenced by sex, further perpetuating sex differences in the rate of diagnosis.

Psychometric properties of screening instruments for autism spectrum disorder
The following section contains a list of screening and diagnostic instruments for autism. The section includes administration information, psychometric data, and PDFs or links to the screenings.
 * Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.


 * For a list of more broadly reaching screening instruments, click here.

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

In light of the COVID-19 pandemic, efforts have been made to develop autism screening tools that can be administered remotely. One such tool is the Brief Observation of Symptoms of Autism (BOSA), to be used by ADOS-trained clinicians and researchers. ROC analyses suggest high sensitivity and specificity, as well as high convergent validity with the ADOS.

Interpreting autism screening measure scores

 * For information on interpreting screening measure scores, click here.

Gold standard diagnostic interviews

 * For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for autism spectrum disorder
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings. A. Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) -- The ADOS-2 is a semi-structured, play-based assessment of social and communicative behaviors indicative of autism. There are several different modules that can be used based off of the individual’s speech/communication level. Training is necessary to conduct the ADOS-2.

B. Autism Diagnostic Interview, Revised (ADI-R) -- The ADI-R is a caregiver interview that helps to provide a developmental history (ages 4-5) and current functioning level of restricted and repetitive behaviors and social impairment. Training is necessary to conduct the ADI-R. Due to the homogeneity of the population, there are many other process measures that can be used in autism assessments. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility, motor functioning, comorbidity). The two measures provided below are commonly used to assess adaptive behaviors (including communication and socialization, core deficits in ASD) and may provide important information regarding levels of daily functioning of individuals with ASD..

C. Vineland Adaptive Behavior Scales-Second edition (VABS-II) – Parent report recommended with careful attention paid to the Daily Living domain. More commonly used with children.

D. Adaptive Behavior Assessment System, Second Edition (ABAS-II) – Parent report recommended with special attention to the Global Adaptive Composite (GAC). More commonly used with adults.

Process phase
The following section contains a brief overview of treatment options for autism and list of process and outcome measures for autism. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Process measures
The following section contains a list of process and outcome measures for autism. The section includes benchmarks based on published norms and on those on the spectrum samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

There are many processes that may be considered important when evaluating a child or an adolescent with ASD; however, due to the diversity of the population and symptom expression, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The two measures provided below are commonly used to assess adaptive behaviors (including communication and socialization, core deficits in ASD) and may provide important information regarding levels of daily functioning of individuals with ASD.

Outcome and severity measures
This table includes clinically significant benchmarks for autism specific outcome measures
 * Information on how to interpret this table can be found here.
 * Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
 *  For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks,  see here.

Treatment

 * Please refer to the page on Autism Spectrum Disorder for more information on available treatment or go to Effective Child Therapy for a curated resource on effective treatments for ASD.

Behavior and Communication Approaches


 * 1) Applied Behavior Analysis (ABA)20
 * 2) *Method of teaching appropriate behaviors by breaking tasks down into small discrete steps and training in a systematic and precise way called discrete trial training (DTT).
 * 3) *Based on the context that children with ASD have significant difficulties with learning, learning through imitation and listening as typical peer
 * 4) Early Intensive Behavioral Intervention (EIBI)20
 * 5) *Focuses on remediation of deficient language, imitation, pre-academics, self-help and social interaction skills broken down into discrete components, taught on a one-to-one basis in school and/or at home.
 * 6) *Typically using discrete trial teaching, reinforcement, backward chaining, shaping, extinction, prompting and prompt fading. Parent involvement is essential.
 * 7) Pivotal Response Training (PRT)23
 * 8) *Derived from ABA, an approach that teaches the learner to seek out and respond to naturally occurring learning opportunities.
 * 9) *Goals include the development of communication, language and positive social behaviors and relief from disruptive self-stimulatory behavior.
 * 10) Early start Denver Model (ESDM)21
 * 11) * A comprehensive early behavioral intervention for infants (as young as 12 months) to preschool- aged children with ASD, integrating applied behavior analysis (ABA) approaches with developmental and relationship-based approaches.
 * 12) Developmental, Individual Differences, Relationship-Based Approach (DIR or “Floortime”)22
 * 13) *Objectives are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors.
 * 14) Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)24
 * 15) *Statewide, community based intervention program that emphasizes environmental organization and visual supports, individualization of goals, and the teaching of independence and developmental skills.
 * 16) *Teaching strategies are taught within the natural environment and within context. Includes early intervention services through adulthood.
 * 17) Program for the Education and Enrichment of Relational Skills (PEERS)
 * 18) *Evidence-based social skills intervention designed to help neurodiverse individuals develop and maintain friendships.
 * 19) Others (Treatments tackling symptoms not exclusive to ASD)
 * 20) * Cognitive Behavioral Therapy (CBT)
 * 21) *Occupational Therapy
 * 22) *Sensory Integration Therapy
 * 23) *Speech Therapy
 * 24) *Picture Exchange Communication System (PECS).

Medication
 * The data on other relevant diagnoses indicate that children and youth are frequently treated with medication under an ASD diagnosis, despite the fact that the target symptoms may be commonly associated with other mental disorders (ADHD, Anxiety, Depression, etc.).
 * Approximately 70% of children with ASD ages 8 and up receive some form of psychoactive medication. Before recommending medication as a form of treatment, consult a supervisor and a medical doctor.26,27

External Resources

 * 1) ICD-10 diagnostic criteria
 * 2) Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
 * 3) NIMH (information about schizophrenia)
 * 4) https://www.autismspeaks.org/what-autism/diagnosis/mchat Free online autism screen for toddlers
 * 5) OMIM (Online Mendelian Inheritance in Man)
 * 6) 209850
 * 7) Effective Child Therapy information on Autism Spectrum Disorder
 * 8) Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.