How Do We Assess a Child for Autism Spectrum Disorder?
Clinician’s who diagnose autism spectrum disorder (ASD) can only come to that conclusion if they believe that their observations of the child and the input from other adults who frequently interact with that child match the criteria for ASD; which is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
The DSM 5 is the manual used by clinicians to check diagnostic criteria for a variety of mental or behavioral health conditions.
There is no exact test (medical or otherwise) to diagnose autism spectrum disorder.
Symptoms of ASD are described later in this article, but if you would like to see the exact DSM-5 criteria for autism, see this Autism Interactive Symptom Checklist.
There are many symptoms of ASD. Some people present with just a few while others present with many. Each of these symptoms can range from mild to severe. This is why autistic tendencies are referred to as falling along a spectrum.
Usually, more severe cases of ASD have the most trouble with independence and self-care (e.g., relationships, school, work, hygiene, independent community travel, etc).
Why Is ASD A Challenge to Diagnose Sometimes?
One reason that ASD can be difficult to diagnose is that no two people will exhibit the same symptoms, and as previously discussed, the intensity of symptoms varies tremendously.
Another reason that it may be difficult to diagnose ASD is that students with other conditions (e.g., ADHD, dyspraxia, anxiety, Oppositional Defiant Disorder) sometimes display similar behaviors to those of students on the autism spectrum (e.g., focusing challenges, frequently fidgeting/moving, refusal to complete school work, peer relationship difficulties, etc.).
Symptoms Must Significantly Impact Life Functioning
One primary question a clinician attempting to make a diagnosis of ASD has to ask is whether the symptoms the patient presents with are at such a level that they significantly impair the person’s life.
There are certainly people who have one or more of the symptoms associated with ASD who do not have their life significantly impacted. This is why interviews, questionnaires, and observations are so important.
It is the combination of this information that allows clinicians to determine if and how symptoms impact functioning and in what areas (i.e., cognitive, academic, physical, social, behavioral).
The Symptoms of Autism Spectrum Disorder Can Mostly Be Grouped into Two Broad Categories
1. Communication and Social Interactions Differences.
For instance, a person on the autism spectrum may not make eye contact in a conversation and may have trouble interpreting facial expressions and body language. People on the spectrum may not always catch the humor in a joke or may struggle with picking up on social cues that their peers pick up on easily.
As an example, they may unknowingly overstay their welcome or carry on about topics, without realizing that others may uncomfortable, bored, or disinterested. These social differences could potentially lead to challenges with making or keeping friends.
In some cases, individuals may struggle to express their thoughts or basic needs and/or to process language.
2. Restricted and or Repetitive Behaviors, Interests, or Activities.
These restricted or repetitive tendencies can manifest themselves in many ways. For example, a person on the spectrum may be much more rigid about scheduling changes. They may prefer a specific routine or method when completing certain tasks or activities. They can be hypersensitive to environmental stimuli such as noise, bright light, temperature changes, or the way a fabric feels against their skin. Sometimes these stimuli (as well as eye contact) can be uncomfortable or painful.
People on the spectrum may also become intensively interested in a particular object or subject to the point that they talk about it obsessively or become an expert on the topic.
Some people on the spectrum will exhibit “stimming” behavior where they repeat a simple activity like shake their foot, flap their hands, or rock. Stimming may help relieve anxiety. It can also be a way to express excitement. Some peope think it should be discouraged but many experts and individuals in the autism community see the benefits of stimming and advise against trying stop it.
You have to put boundaries in place in particular situations if being quiet is absolutely required, but hopefully there won’t be too many of these occasions.
Should the occasion arise where silence is required, offering and teaching quieter stimming or other engaging alternatives can be tried? If this is not successful you may have to switch to a different environment in order to meet the needs of your child.
How Does the Assessment Process for ASD Work?
In order to determine a person’s symptoms and whether then need support because their symptoms impact daily functioning, the child needs an evaluation.
Those who can complete autism evaluations include school psychologists (ask your child’s school about this), or community professionals such as child psychologists, pediatric neurologists, developmental pediatricians, psychiatric nurse practitioners, psychiatrists or other similar support staff.
In addition to interviews, observations, review of developmental history, and sometimes IQ and academic assessments, clinicians utilize specific autism tools (see examples below) to help them determine if students are meeting the DSM-V criteria for autism spectrum disorder.
Examples of Autism Assessment Tools
Questionnaires (referred to as rating scales) are a common tool used to measure the number and severity of autism symptoms.
Rating Scales often use a Likert Scale to collect answers from parents and teachers. See an example of a Likert Scale below:
As an example of a rating scale, an assessment tool, like the Social Responsiveness Scale, Second Edition SRS-2, is a questionnaire for parents and teachers that can help differentiate between Autism Spectrum Disorder and other mental health and physical conditions that can have some similar symptoms (i.e., Attention Deficit Hyperactivity Disorder (ADHD), anxiety, depression, schizophrenia, hearing difficulties, language articulation issues, and learning disabilities.
The SRS-2 is a questionnaire that gives parents and teachers questons to answer about their child’s/students behavior, in order to determine how closely their behaviors relate to autism spectrum disorder. This scale is designed for ages 2.5 to 18. Young adults 19 and up can complete a self scale or ask a familiar adult to complete a scale based on what they’ve observed.
Autism Diagnostic Assessment Schedule, Second Edition (ADOS-2)
Another well-recognized reliable autism assessment tool, is the Autism Diagnostic Assessment Schedule, Second Edition (ADOS-2) – the most advanced autism assessment currently available.
The ADOS-2 can help make the determination of ASD easier when rating scale scores between parent and teacher are strikingly different or when scores are borderline in the overall presentation of symptoms. When rating scales are not enough, ADOS-2 is the next step up.
The ADOS-2 is a semi-structured, standardized assessment, that includes a number of play-based activities designed to provide information on the child’s interactions.
Using the materials in the ADOS-2 kit, the examiner assesses the child’s communication, reciprocal social interactions, and restricted and repetitive behaviors associated with a diagnosis of ASD.
Not All Schools, Agencies, or Clinics Have Access to the ADOS-2
If you are looking for an ADOS-2 and your child’s school does not offer it, try a google search in your area for an autism assessment, or go through your insurance provider (or ask your child’s doctor for a referral), and then call and ask the clinician if they offer the ADOS-2.
We Need to Consider Gender
Studies show that symptoms of autism in girls may be less noticeable than symptoms in boys, especially if the girl does not have learning or behavior problems.
However, a good assessment tool, like ADOS-2, can help a clinician pick up on the more subtle autistic traits that may be found in girls and also in boys who may have milder symptoms.
How Young Can We Diagnose Autism Spectrum Disorder?
The Centers for Disease Control and Prevention (CDC) reports that ASD can sometimes be detected at 18 months or younger. By age 2, a diagnosis by an experienced professional is considered reliable. However, many children do not receive an autism diagnosis until much older. Some people are not diagnosed until they are adolescents or adults.
However, if symptoms of autism spectrum disorder were not present prior to age three, it is unlikely that a person would be diagnosed with autism because autism is a developmental disability in which symptoms are observed before age three.
Get a Second Opinion if Unsure
If feeling uncertain about a diagnosis or lack of diagnosis, parents can always take their child for a second opinion. If you are working with your child’s school and want a second opinion after the evaluation is complete, talk to the principal, school counselor, or special education director. You can ask about the options available to you and your child.
You can also pay out-of-pocket or with insurance for a private evaluation in your area with a child psychologist, developmental pediatrician, etc., and then share your findings with the school. That will be helpful to the school team when completing their own evaluation to determine if your child needs any supports or accommodations, and it will give you another opinion.
An evaluation from a source outside the school could also help you obtain community support for your child (e.g., therapy, social group, etc.).
Share Your Concerns When They Arise
Research shows that early intervention for a child on the spectrum can improve their skillset and quality of life tremendously. That’s why it’s important to share the concerns you have with your child’s school and/or doctor around the same time that you observe them. This also helps keep everyone involved on the same page.
Teachers can also voice their concerns. They generally go to the parents first, but if more support is needed it’s appropriate to inform the school team (e.g., principal, school counselor, school psychologist, etc.) and develop a plan to support the student. Parents should be informed when the school is making changes to their child’s curriculum or educational day if the change is specific just to that student because of learning or behavioral challenges.
It Is Never Too Late to Get a Diagnosis or Supports and Services in Your Community.
If you suspect that autism is interfering with life functioning at any age (for you or your child), it’s appropriate to request an evaluation.
Adults on the spectrum who have gone un-diagnosed throughout their life often have struggles that they don’t quite understand (e.g., why don’t I feel like I fit in, why is it hard to keep conversations going, why do I hate the feel of jeans, etc.).
Getting a diagnosis of Autism Spectrum Disorder, even later in life, can help an adult put things in perspective and heal from emotional scars.
When you don’t know why you feel different growing up, or why something seems off, that can be hurtful and confusing. It can be relieving for some to know there is a reason.
I’ve actually known some people personally who described this very feeling. For instance, a good friend said:
“I always knew something was off but I just thought something was wrong with me. When I learned more about autism at 27 in a counseling session and spoke with others who had similar social challenges, fascinations about space, and sensory needs, I didn’t feel so alone anymore.”
If one gets a diagnosis of Autism Spectrum Disorder as an adult, they can educate themselves as much as they want to on the subject of autism and on what they may need moving forward. Parents and teachers of children on the spectrum can also educate themselves so they know how to provide the best support.
Find Out All You Can
Reading research, talking to people in the behavioral health field and autism community (students/clients, parents), and watching professional development videos are all great methods to educate yourself. Here is a head start…check out this video on ASD below:
Access Community Supports If You Feel Your Child Needs Additional Services
Both children and adults on the spectrum can access community supports (e.g., behavioral health support/counseling, social skills groups, speech therapy, etc.) and seek out additional social opportunities (e.g, social groups or clubs for those on the spectrum, groups geared towards their hobbies or interests, etc.).
All in all, Autism Spectrum Disorder is not easy to diagnose due to varying symptoms and severity, and other similar conditions. A major factor is whether symptoms impact daily functioning. Although the situation isn’t black and white (a lot of grey area here), reliable autism assessment tools like the SRS-2 and the ADOS-2 can aide in proper diagnosis.
Additionally, with supportive parents, teachers, and therapists taking the time to educate themselves about what children (or adults) with ASD need, people on the spectrum can spend a little more time in their comfort-zone.
Hopefully accommodations and supports will lessen some of the pressure many people with ASD carry on their shoulders everyday, as they try to navigate around this predominantly neuro-typical world.
- 12 Ways Schools Can Support Students on the Autism Spectrum
- Academic Strategies to Teach Students on the Autism Spectrum
- 15 Behavior Strategies for Children on the Autism Spectrum
- What is a Certified Autism Specialist? How Do You Become One?
Side Note: The purpose for interventions is not to cure autism spectrum disorder. There is no need to. We need to allow for accommodations and modifications to make educational and community facilities feel supportive, fair and safe for people on the spectrum.
Students on the spectrum need teachers who:
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