Monday, September 8, 2014

Best Practice Guide to Assessment for Autism Spectrum Disorder

Assessment and diagnosis are only of value when they provide access to the delivery of appropriate intervention and educational services. The primary goals of conducting an autism spectrum assessment are to determine the presence and severity of an autism spectrum disorder (ASD), develop interventions for intervention/treatment planning, and collect data that will help with progress monitoring. Professionals must also determine whether an ASD has been overlooked or misclassified, describe coexisting (comorbid) disorders, or identify an alternative classification. Interviews and observation schedules, together with an interdisciplinary assessment of social behavior, language and communication, adaptive behavior, motor skills, sensory issues, atypical behaviors, and cognitive functioning are recommended best practice procedures.
There are several important considerations that should inform the assessment process. First, a developmental perspective is critically important. While the core symptoms of are present during early childhood, ASD is a lifelong disability that affects the individual’s adaptive functioning from childhood through adulthood. Utilizing a developmental assessment framework provides a yardstick for understanding the severity and quality of delays or atypicality. Because ASD affects multiple developmental domains, the use of an interdisciplinary team constitutes best practice for assessment and diagnosis of ASD. A team approach is essential for establishing a developmental and psychosocial profile of the child in order to guide intervention planning. The following principles should guide the assessment process.
  • Children who screen positive for ASD should be referred for a comprehensive assessment.  Although screening tools have utility in broadly identifying children who are at-risk for an autism spectrum condition, they are not recommended as stand alone diagnostic instruments or as a substitute for a more inclusive assessment.
  • Assessment should involve careful attention to the signs and symptoms consistent with ASD as well as other coexisting childhood disorders.
  • When a student is suspected of having an ASD, a review of his or her developmental history in areas such as speech, communication, social and play skills is an important first step in the assessment process.
  • A family medical history and review of psychosocial factors that may play a role in the child’s development is a significant component of the assessment process. 
  • The integration of information from multiple sources will strengthen the reliability of the assessment results.
  • Evaluation of academic achievement should be included in assessment and intervention planning to address learning and behavioral concerns in the child’s overall school functioning.
  • Assessment procedures should be designed to assist in the development of  instructional objectives and intervention strategies based on the student’s unique pattern of strengths and weaknesses.
  • Because impairment in communication and social reciprocity are core features of ASD, a comprehensive developmental assessment should include both domains. 
A comprehensive developmental assessment approach requires the use of multiple measures including, but not limited to, verbal reports, direct observation, direct interaction and evaluation, and third-party reports. Assessment is a continuous process, rather than a series of separate actions, and procedures may overlap and take place in tandem. While specific activities of the assessment process will vary and depend on the child’s age, history, referral questions, and any previous evaluations and assessments, the following components should be included in a best practice assessment and evaluation of ASD in school-age children.
  •  Record review
  •  Developmental and medical history
  •  Medical screening and/or evaluation
  • Parent/caregiver interview
  • Parent/teacher ratings of social competence
  • Direct child observation
  • Cognitive assessment
  • Academic assessment
  • Adaptive behavior assessment
  • Communication and language assessment  
Children with ASD often demonstrate additional problems beyond those associated with the core domains. Therefore, other areas should be included in the assessment battery depending on the referral question, history, and core evaluation results. These may include:
  • Sensory processing
  • Executive function and attention
  •  Motor skills
  • Family system 
  • Coexisting behavioral/emotional problems   
The above referenced principles and procedures for the assessment of school-age children with ASD are reflected in recommendations of the American Academy of Neurology, the American Academy of Child and Adolescent PsychiatryAmerican Academy of Pediatrics, and a consensus panel with representation from multiple professional societies. A detailed description of the comprehensive developmental assessment model and specific assessment tools recommended for each domain can be found in A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools.
© Lee A. Wilkinson, PhD

1 comment:

Annelise Spees, MD said...

Dr. Wilkinson,
I very much appreciate your excellent outline of the many facets of a comprehensive assessment of a child, teen, or adult for an Autism Spectrum Disorder. I am a Board-Certified specialist in Developmental-Behavioral Pediatrics. My primary concern is making it possible for families to access the evaluation process as quickly as possible. With my staff, we are trying to see children within one to two months of the first call to our office. I gather information prior to the visit. I use two visit times to make observations, perform a physical exam including neurological findings, review school records and family background with the caregivers, and come to a working diagnosis. I then refer children to OT, PT, Speech Therapy, and ABA/specific autism therapy as appropriate for the diagnosis. I also order any lab studies including genetic testing if that is suggested by the medical exam and review. If I find that a child/teen is "on the autism spectrum", I begin the explanation process and direct the family to resources online, in books, and in the community to help them on the new learning curve of understanding their child and the new diagnosis. I create letters with the diagnosis label listed to request an IEP at school as well.
My approach is "outside the box" for the typical evaluation timing. Most large university centers have a waiting period of about six months until a child can have an evaluation appointment. My goal is to get the process started much sooner so children can start appropriate therapy as soon as possible if needed. I believe this has been successful so far. I hope that other Developmental-Behavioral Pediatricians can work toward this model to improve access to care for families with Autism. Sincerely, Annelise Spees, MD

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