The ASD Evaluation from the Psychological Perspective

Kathrin Hartmann, Ph.D.Clinical Psychologist / Associate Professor

Department of Psychiatry Eastern Virginia Medical School

Difficulty in Early Identification [Landa, R. & Garrett-Mayer, E. (2006). Development in infants with autism specturm disorders: A prospective stuey.

Journal of Child Psychology and Psychiatry 47 (6), 629-638.]

• Overlap with other developmental disabilities (e.g. speech and language delay)

• Presence of clearly abnormal behaviors is easier to detect than absences of behaviors

• Variability of child behaviors as seen in the home by family

• Each family has a unique interpretation of their child’s development

ASD Clinical Database – Participants and Procedures

Retrospective clinical chart review (2005-2008) • Demographic data• Pregnancy and birth complications• Maternal/infant characteristics• Family History of psychiatric disorders and

stressors• Developmental history and educational information• Behavioral observations by the clinician• Parent report of ASD characteristics• Standardized test scores for intellectual,

behavioral, and adaptive functioning• Referral and recommendation information

ASD Database – Preliminary Data Analysis

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% Boys % Girls

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Proportion of males to females (4:1) matched national prevalence data (CDC, 2010)

Figure 1. Gender Distribution of Participants

ASD Database – Preliminary Data Analysis

Most participants were preschool-aged children. CDC (2010) reports that the median age of diagnosis is 4.5 to 5.5 years old.

Figure 2. Age Distribution of Participants.

ASD Database – Preliminary Data Analysis

Figure 3. Distribution of Participant IQ Scores

Full-Scale IQ was assessed for 48 of the participants using either the WISC-IV or the WPSSI-III. Only 21% had an IQ of 70 or below, as compared to the national prevalence estimate of 30-51% possessing an Intellectual Disability (CDC, 2009).

ASD Database – Preliminary Data Analysis

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% PDD Primary Dx % PDD Rule-Out Dx

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ADHD was the most common primary diagnosis for ASD rule-out participants.

Figure 4. Percentage of Primary vs. Rule-Out PDD Diagnoses

ASD Database – Preliminary Data Analysis

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% EatingDifficulties

% SleepingDifficulties

% History ofST/OT

% DevmtDelays

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Eating and sleeping difficulties were reported in approximately half of the participants. Developmental delays and a history of speech-language and/or occupational therapy were present the majority of participants.

Figure 6. Developmental Variables

ASD Database Qualitative Observations

• Birth of a sibling frequently reported as a significant family stressor.

• Feeding problems (most notably reflux), frequent ear infections, and sleep apnea most commonly reported health problems in infancy.

• Asthma, eczema, environmental allergies, and seizures most commonly reported ongoing health problems.

• Use of prescribed stimulants (e.g., Adderall, Concerta, Ritalin) frequently reported.

• Developmental delays present in large majority of cases.

• Social difficulties and speech irregularities present in large majority of cases.

• First relationship in infancy between primary care-giver and child reported as “good” or “great” in majority of cases.

Screening versus Testing versus Assessment

• Screening: Use of initial clinical questions about a problem, either in an interview format or with screening measures that include questions and/or direct observations

• Testing: Use of one or more psychological tests by the clinician to assess specific or global areas of functioning (e.g. administration of an IQ test)

• Assessment: Sophisticated integration of information derived from a flexible multimethod assessment battery

Purpose of Psychological Assessment

• Answers the referral question

• Provides a frame of reference for the individual child, e.g. their strengths and weaknesses

• Helps narrow down diagnostic possibilities

• Provides a basis for what treatment strategies should be used

• Documentation of functioning may provide access to further services as needed

ASD EvaluationASD Evaluation: Part of an : Part of an Interdisciplinary Interdisciplinary ApproachApproach

• Parents/Caregivers/Family/Friends • Pediatricians, pediatric specialties, and other

health care providers• Speech and language therapists• Occupational therapists • Physical therapists• Special education professionals and guidance

counselors and other school professionals

Essential Elements of the ASD Evaluation

• Diagnostic work-up (health, behavioral, educational, and intervention history; current symptoms and behaviors, family vulnerability)

• Developmental or intellectual assessment

• Adaptive functioning assessment

• Speech, language, and communication assessment

• Fine and gross motor assessment

• Additional assessment (e.g. clinical genetics; neurological status, and sensory/motor functioning)

ASD Cognitive and

Social-Adaptive Testing [Klin, A., Saulnier, C., Tsatsabusm, J. & Volkmar, F.R. (2005). Clinical evaluation in autism spectrum disorders:

Psychological assessment within a trandisciplinary framework. In: F.R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (3rd Ed., pp. 772-798). New Yorlk: Wiley.]

• Examples• Bayley Scales of Infant Development (2003)• Mullen Scales of Early Learning (1995)• Wechsler Primary and Preschool Scale of

Intelligence - Third Edition (2002)• Vineland Adaptive Behavior Scales - Second

Edition (2005) and many others

ASD Specific Screening MeasuresCompleted by Professional

AAP Clinical Report on Children With Autism Spectrum Disorders (ASD)[Plauché Johnson, C., Myers, S.M, and the Council on Children with Disabilities (2007). Identification and Evaluation of Children

with Autism Spectrum Disorder. Pediatrics, 120 (5), 1183-1215.]

• Checklist for Autism in Toddlers (CHAT); 18 m+ Interview and Interaction

• Childhood Autism Rating Scale (CARS); 2 y+• Gilliam Autism Rating Scale (GARS); 3-22 y • Screening for Autism in 2- Year-Olds (STAT);

24-36m• Autism Behavior Checklist (ABC);18 months+

ASD Specific Screening Measures Completed by Parents/Caregivers

AAP Clinical Report on Children With Autism Spectrum Disorders (ASD)[Plauché Johnson, C., Myers, S.M, and the Council on Children with Disabilities (2007). Identification and Evaluation of Children

with Autism Spectrum Disorder. Pediatrics, 120 (5), 1183-1215.]

• Modified Checklist for Autism in Toddlers

(M-CHAT); 18 m +

• Pervasive Developmental Disorders Screening Test (PDDST); 18-48 m

• Autism Screening Questionnaire/Social Communication Questionnaire (ASQ/SCQ); 4 y +

ASD-Specific Diagnostic Measurescompleted by Clinician

1. Autism Diagnostic Interview - Revised (ADI-R)

2. Autism Diagnostic Observation Schedule (ADOS)

ADI-R and ADOS are effective ways of qualifying subjects and superior to screening instruments

ADOS with young children (below 6 years) includes the parents in the assessment process

Autism Diagnostic Observation Schedule (ADOS)

Catherine Lord, Ph.D., Michael Rutter, M.D., FRS, Pamela C. DiLavore, Ph.D., and Susan Risi, Ph.D.

• Social Behavior

• Use of Vocalizations and Speech and Gesture in Social Situations

• Play and Interests

For more ADOS information see: http://www.wpspublish.com

ADOS Triggers for Language and Communication

• Greeting and small talk• Tell me about your school/job• Tell me about your friends• What makes you feel ….• Tell a story from a wordless picture book• Describe the action in a comic strip• Tell me about your ideas for your future

Scoring Language and Communication

• Frequency of Vocalizations Directed at Others• Stereotyped or Idiosyncratic Use of Words or

Phrases• Use of Others’ Body to Communicate• Pointing • Gestures• Reporting of Events• Conversation

ADOS Triggers forReciprocal Social Interaction

• Providing inviting activities that typically pull for enjoyment (e.g. bubble or balloon play)

• Providing play materials that lend themselves to sharing or showing

• Activities the participants do on their own to provide for ample observation time

• Engaging the participant in conversations about the nature of social relationships and their current experiences

Scoring Reciprocal Social Interactions

• Unusual Eye Contact

• Facial Expressions Directed to Others

• Sharing Enjoyment in Interaction

• Showing Objects to Others

• Spontaneous Initiation of Joint Attention

• Response to Joint Attention

• Quality of Social Overtures

• Insight

• Amount of Reciprocal Social Communication

ADOS Triggers for Restricted and Repetitive Behaviors

• Inviting the participant to engage in an open-ended conversation for social purpose only to elicit further observations of participant’s interests in topics or objects or behaviors

• Time/Space for general observations of participant’s unusual sensory interests or compulsions or rituals or hand and finger or other mannerisms or self-injurious behaviors

Scoring Restricted & Repetitive Behaviors

• Intonation of Vocalizations of Verbalizations

• Stereotyped/Idiosyncratic Use of Words or Phrases

• Unusual Sensory Interest in Play Material/Person

• Hand and Finger and Other Complex Mannerism

• Unusually Repetitive Interests or Stereotyped Behaviors

• Excessive Interest in or Reference to Highly Specific Topics

ADOS Summary Algorithm - What Does the ADOS Score Mean?

• Originally based on 2 Domains:

• Communication• Reciprocal Social Interactions

• Now based on 3 Domains:

• Communication• Reciprocal Social Interactions• Restricted and Repetitive Behaviors

• Provides Cut-Offs for Autism and Autism Spectrum

Need for the Testing Feedback Session with the Parents/Caregivers

Eisman, E.J. et al. (2000). Problems and limitations in using psychological assessment in the contemporary health care delivery system. Professional Psychology: Research and Practice, 31, ( 2), 131-140.

• Feedback is necessary overall for the sucessful treatment process (Finn & Tonsager, 1992, 1997; Newman & Greenway, 1997; Pollak, 1988).

• Increases hope • Decreases parental distress• Helps the family understand their child’s

functioning • Alleviates symptomatic distress • Affects the course of treatment• Educates about treatment options and resources• May open access to services

After the ASD Identification: Essential Elements of

Successful Intervention Methods (Dawson & Osterling, 1997; Lord & McGee, 2001]

• Intervention begins early and is intensive in hours

• Families are active participants in their child’s intervention

• Staff are well-trained and knowledgeable about autism

• There is objective evaluation of the child’s progress

• The curricula is highly structured with predictable routine and focus on developing communication and other skills

• Teaching procedures emphasize generalization and maintenance of skills

• Transitions to school and between schools are carefully planned and well supported

Testing and Assessment Websites

• American Academy of Pediatrics, see specific Policies and Guidelines: http://www.aap.org

• General Psychological Testing: American Psychological Association http://www.apa.org/science/faq-findtests.html

• Test Reviews: Tests in Print. The Buros Institute for Mental Measurements www.unl.edu/buros

• Test Locator for Internet Searches http://ericae.net; http://buros.unl.edu/buros/jsp/search.jsp; http://www.ets.org/testcoll

• Specific Test see Test Publishers, e.g. Western Psychological Services Publishers and Distributors www.wpspublish.com or Pro-Ed www.proedinc.com or PsychCorp/HarcourtAssessmentwww.harcourtassessment.com