How to Evaluate Autism Spectrum Disorder

Picture this?

  • A 6 year old boy who is nonverbal, flaps his hands frequently, struggles to make eye contact, walks on tiptoes, loves lining his toy cars in a row, and gets upset at loud noises.
  • A 22 year old woman who has trouble making friends and forgets to speak to others, struggles with social anxiety, avoids certain food textures, has trouble understanding sarcasm and emotions, and speaks in a flat, monotonous manner.

Which one sounds like Autism? 

Well (obviously) that was a trick question.  While there are specific diagnostic criteria for Autism Spectrum Disorder, each person on the spectrum has their own unique presentation of behaviors, which can make it super challenging to assess, even more so in “higher functioning” people.

What is Autism?

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder that affects the way a person experiences and interacts with the world.  It is marked by two kinds of behavior:

  1. Deficits in communication and social skills including forming and maintaining relationships, nonverbal communication like eye contact and tone of voice, and the social “back and forth” of conversation.
  2. Restricted Interests and Repetitive behaviors, which includes repetitive movements, highly specific interests, trouble with changes in routine or cognitive/behavioral rigidity, and sensory sensitivities.

ASD can affect individuals in different ways and can range from very mild (“high functioning” - previously called Asperger’s Syndrome) to severe.

About 1 in 44 children has been identified with ASD.  While boys are 4x more likely to be diagnosed with ASD than girls,  1 in 116 girls identified with ASD.  Those assigned female at birth (AFAB) are often overlooked, misdiagnosed, or diagnosed later in life, as their symptoms are frequently misinterpreted, masked, or compensated for, or they exhibit less (obvious) restrictive interests and repetitive behaviors than boys.  The woman I mentioned in the above example? She was diagnosed at age 22.  Also, minority groups tend to be diagnosed later and less often.

How do we diagnose Autism?

To diagnose ASD, we have to assess the 2 kinds of behavior I previously mentioned (deficits in social communication and restricted interests and repetitive behaviors.  Common signs and symptoms include:

  • Delayed or lack of speech development
  • Trouble making eye contact
  • Problems starting and/or holding conversations
  • Trouble making and/or keeping friends
  • “All or nothing” or “black and white” thinking
  • Trouble adapting to changes
  • Very narrow and limited interests that are hard for them to transition away from
  • Sensory sensitivities to noise, touch, and textures

Other complex signs and symptoms that can also denote ASD are:

  • Preferring to be or play alone
  • Trouble understanding others’ perspectives
  • Social anxiety or finding social interaction tiring or stressful
  • Feeling “weird” or out of place
  • “Revolving door” friendships
  • Having anxiety from making eye contact even though they are able to
  • Hard time understanding emotions

Trouble with emotion regulation is also a common problem amongst those with ASD.

Based on the criteria in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), ASD symptom presentation must have been present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).  

Symptoms must also cause significant impairment in social, occupational, or other important areas of life.

What’s included in an Autism Evaluation?

It is best to be evaluated by a psychologist, neuropsychologist, or qualified professional who has been specifically trained in assessing ASD and understanding the general diagnostic criteria as well as the subtle variations of symptom presentation.

Since social impairment is a primary feature of ASD, much of the evaluation focuses on understanding how clients initiate and maintain social communication and friendships, how they may struggle with social context, if and how they use nonverbal communication, and review of interests and repetitive behaviors.

Hallmarks of a thorough evaluation include:

  1. A clinical interview that explores general background details such as home and school life but also focuses on social history and functioning such as how many friends a client might have, how they relate to peers and authority, etc.
  2. A review of relevant supporting documents and collateral information sources  to establish childhood symptoms and impairment and general daily functioning.  These documents may include previous evaluation and screening reports, notes from other service providers, and report cards.  Collateral sources may include parents, spouses, and close friends.
  3. Observations from the psychologist overall behavior during the assessment, with particular focus on social interaction, social presence, and rapport building.
  4. Standardized assessments of areas such as cognitive ability, social language and behavior, adaptive functioning, and emotional/behavioral functioning.  Most often, ASD evaluations utilize the Autism Diagnostic Observation Schedule - 2nd Edition (ADOS-2) or the Autism Diagnostic Interview - Revised (ADI-R). 
  • Many clinicians are shifting to the Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition (MIGDAS-2), as it has shown more specificity in detecting ASD in high functioning adolescents, those assigned female at birth (AFAB), and adults in general.

Upon completion of these assessment areas, you meet with the psychologist to discuss your results, which includes an explanation of the assessments, outcomes, diagnoses, if applicable, and recommendations for resources to support success.

Early intervention affords the best opportunity to support healthy development and deliver benefits across the lifespan.  The sooner you have an evaluation, the better.

If you want to learn more about our ASD  evaluations at Magnolia Wellness & Psychology, check out our information and frequently asked questions on our website!