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

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EBA Implementation
Assessment phases
Steps 1-2: Preparation phase

Preparation phase

Steps 3-5: Prediction phase

Prediction phase

Steps 6-9: Prescription phase

Prescription phase

Steps 10-12: Process/progress/outcome phase

Process phase

What is a "portfolio"?

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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.

Preparation phase

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Diagnostic criteria for autism spectrum disorder

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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:

  1. deficits in social communication and social interaction and
  2. restricted repetitive behaviors, interests, and activities (RRBs).

Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.

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

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Demography Setting (Reference) Base Rate Diagnostic Method
11 ADDM sites Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) - 8 year olds *** 1.5% (1 per 68) Diagnosis by doctor based on DSM-IV-TR criteria
Epidemiological: 43,283 household surveys National Health Statistics Report (NHIS; 2014), 3-17 year olds[1] 2.2% (1 per 45) DSM-IV-TR
11 ADDM sites: Male/Female Ratio The Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) – 8 year olds 1 in 42 boys (2.4%), 1 in 189 girls (.05%) DSM-IV-TR
Came from family registry for those who had children under 18 years old in United States Interactive Autism Network (IAN): Individual Sibling Recurrence[2] ASD status occurred in an additional child in 10.9% of families DSM-IV-TR
11 ADDM sites (Race/ethnicity study) The Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) – 8 year olds

Race/Ethnicity:

  • Non-Hispanic White
  • Non-Hispanic Black
  • Hispanic
  • Asian
  • Non-Hispanic White: 1 in 63 (1.6%)
  • Non-Hispanic Black: 1 in 81 (1.2%)
  • Hispanic: 1 in 91 (1.1%)
  • Asian: 1 in 81 (1.2%)
 DSM-IV-TR
Male/Female Ratio Epidemiological study: Review of 43 studies[3] 4.2% (4.2 male:1 female) DSM-IV/Rating Scales/Clinical

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.[4][5] 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.

Prediction phase

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Psychometric properties of screening instruments for autism spectrum disorder

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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.
Measure (Wikipedia Link) Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Modified Checklist for Autism in Toddlers (M-CHAT) Questionnaire (Parent report) 16-30 months 5-10 minutes / 20 questions
Autism Spectrum Quotient (AQ) Questionnaire 16 years and up 10-15 minutes
Childhood Autism Rating Scale (CARS) Observation 2 years-adult 5-10 minutes Not free

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)[6], 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

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

Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.
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Diagnostic instruments for ASD
Measure Age Range Administration/

Completion Time

Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) 12 months- 30 months 40-60 minutes
Autism Diagnostic Interview, Revised (ADI-R) 18 months- adult 90-150 minutes
Adaptive Behavior Assessment System, Second Edition (ABAS-II) Birth- 89 years 20-30 minutes

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

More information on the above interviews

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

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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

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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

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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.
Clinically significant change benchmarks for ASD outcome measures
Benchmarks Based on Published Norms
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
CBCL T-scores
(2001 Norms) 		Total 49 70 58 5 4 2.4
Autism Diagnostic Observation Schedule
- Generic (ADOS-G)6,12 		Module 1 Social Affect Total 8.1 12.5 10.2 2.3 1.9 1.1
Module 1 RR Total 0.4 4.4 2.7 1.1 0.9 0.5
Module 2 Social Affect Total 7.7 10.4 9.1 2.0 1.7 1.0
Module 2 RR Total 1.2 4.9 3.2 1.1 0.9 0.6
Module 3 Social Affect Total 3.7 9.8 7.1 2.1 1.8 1.1
Module 3 RR Total -0.4* 3.3 1.9 0.9 0.8 0.5
Childhood Autism Rating Scale (CARS)[7][8] Parent Total 23.0 18.0 18.6 1.6 1.4 0.8
Social Responsiveness Scale (SRS)[8]
Caregiver Report (Appendix B) 		Total 72.7 62.8 66.8 11.3 9.5 5.8

Treatment

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More information on ASD treatment

Behavior and Communication Approaches

  1. Applied Behavior Analysis (ABA)20
    • 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).
    • Based on the context that children with ASD have significant difficulties with learning, learning through imitation and listening as typical peer
  2. Early Intensive Behavioral Intervention (EIBI)20
    • 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.
    • Typically using discrete trial teaching, reinforcement, backward chaining, shaping, extinction, prompting and prompt fading. Parent involvement is essential.[9]
  3. Pivotal Response Training (PRT)23
    • Derived from ABA, an approach that teaches the learner to seek out and respond to naturally occurring learning opportunities.
    • Goals include the development of communication, language and positive social behaviors and relief from disruptive self-stimulatory behavior.[10]
  4. Early start Denver Model (ESDM)21
    • 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.[11]
  5. Developmental, Individual Differences, Relationship-Based Approach (DIR or “Floortime”)22
    • Objectives are to build healthy foundations for social, emotional, and intellectual capacities rather than focusing on skills and isolated behaviors.
  6. Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH)24
    • Statewide, community based intervention program that emphasizes environmental organization and visual supports, individualization of goals, and the teaching of independence and developmental skills.
    • Teaching strategies are taught within the natural environment and within context. Includes early intervention services through adulthood.[12]
  7. Program for the Education and Enrichment of Relational Skills (PEERS)
    • Evidence-based social skills intervention designed to help neurodiverse individuals develop and maintain friendships.
  8. Others (Treatments tackling symptoms not exclusive to ASD)
    • Cognitive Behavioral Therapy (CBT)[13]
    • Occupational Therapy
    • Sensory Integration Therapy
    • Speech Therapy
    • Picture Exchange Communication System (PECS).[14]

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[15][16]

External Resources

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  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)
    1. 209850
  6. Effective Child Therapy information on Autism Spectrum Disorder
    1. 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.

References

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Click here for references
  1. ↑ Zablotsky, B; Black, LI; Maenner, MJ; Schieve, LA; Blumberg, SJ (13 November 2015). "Estimated Prevalence of Autism and Other Developmental Disabilities Following Questionnaire Changes in the 2014 National Health Interview Survey.". National health statistics reports (87): 1-20. PMID 26632847. 
  2. ↑ Constantino, JN; Zhang, Y; Frazier, T; Abbacchi, AM; Law, P (November 2010). "Sibling recurrence and the genetic epidemiology of autism.". The American journal of psychiatry 167 (11): 1349-56. PMID 20889652. 
  3. ↑ Kogan, M. D.; Blumberg, S. J.; Schieve, L. A.; Boyle, C. A.; Perrin, J. M.; Ghandour, R. M.; Singh, G. K.; Strickland, B. B. et al. (2009-11-01). "Prevalence of Parent-Reported Diagnosis of Autism Spectrum Disorder Among Children in the US, 2007". PEDIATRICS 124 (5): 1395–1403. doi:10.1542/peds.2009-1522. ISSN 0031-4005. http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2009-1522. 
  4. ↑ Murray, Aja Louise; Allison, Carrie; Smith, Paula L.; Baron-Cohen, Simon; Booth, Tom; Auyeung, Bonnie (2017-05). "Investigating diagnostic bias in autism spectrum conditions: An item response theory analysis of sex bias in the AQ-10". Autism Research: Official Journal of the International Society for Autism Research 10 (5): 790–800. doi:10.1002/aur.1724. ISSN 1939-3806. PMID 27891820. https://pubmed.ncbi.nlm.nih.gov/27891820/. 
  5. ↑ Kalb, Luther G.; Singh, Vini; Hong, Ji Su; Holingue, Calliope; Ludwig, Natasha N.; Pfeiffer, Danika; Reetzke, Rachel; Gross, Alden L. et al. (2022-04-01). "Analysis of Race and Sex Bias in the Autism Diagnostic Observation Schedule (ADOS-2)". JAMA network open 5 (4): e229498. doi:10.1001/jamanetworkopen.2022.9498. ISSN 2574-3805. PMID 35471566. PMC 9044110. https://pubmed.ncbi.nlm.nih.gov/35471566/. 
  6. ↑ Dow, Deanna; Holbrook, Alison; Toolan, Christina; McDonald, Nicole; Sterrett, Kyle; Rosen, Nicole; Kim, So Hyun; Lord, Catherine (2022). "The Brief Observation of Symptoms of Autism (BOSA): Development of a New Adapted Assessment Measure for Remote Telehealth Administration Through COVID-19 and Beyond". Journal of Autism and Developmental Disorders 52 (12): 5383–5394. doi:10.1007/s10803-021-05395-w. ISSN 0162-3257. PMID 34914016. PMC 8674519. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674519/. 
  7. ↑ Coplan, J; Jawad, AF (July 2005). "Modeling clinical outcome of children with autistic spectrum disorders.". Pediatrics 116 (1): 117-22. PMID 15995041. 
  8. ↑ 8.0 8.1 Chlebowski, C; Green, JA; Barton, ML; Fein, D (July 2010). "Using the childhood autism rating scale to diagnose autism spectrum disorders.". Journal of autism and developmental disorders 40 (7): 787-99. PMID 20054630. 
  9. ↑ Peters-Scheffer, N; Didden, R; Korzilius, H; Sturmey, P (2011). "A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders". Research in Autism Spectrum Disorders 5 (1): 60-69. 
  10. ↑ Odom, Samuel L.; Collet-Klingenberg, Lana; Rogers, Sally J.; Hatton, Deborah D. (19 May 2010). "Evidence-Based Practices in Interventions for Children and Youth with Autism Spectrum Disorders". Preventing School Failure: Alternative Education for Children and Youth 54 (4): 275–282. doi:10.1080/10459881003785506. 
  11. ↑ Dawson, G; Rogers, S; Munson, J; Smith, M; Winter, J; Greenson, J; Donaldson, A; Varley, J (January 2010). "Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model.". Pediatrics 125 (1): e17-23. PMID 19948568. 
  12. ↑ Dawson, G; Osterling, J (1997). "Early Intervention in Autism". The Effectiveness of Early Intervention: 307-326. 
  13. ↑ Kasari, C; Lawton, K (April 2010). "New directions in behavioral treatment of autism spectrum disorders.". Current opinion in neurology 23 (2): 137-43. PMID 20160648. 
  14. ↑ al.], Lynn Cannon ... [et (2011). Unstuck and on target! : an executive function curriculum to improve flexibility for children with autism spectrum disorders (Research ed.). Baltimore: Paul H. Brookes Pub. Co.. ISBN 9781598572032. 
  15. ↑ Mandell, DS; Morales, KH; Marcus, SC; Stahmer, AC; Doshi, J; Polsky, DE (March 2008). "Psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders.". Pediatrics 121 (3): e441-8. PMID 18310165. 
  16. ↑ Oswald, DP; Sonenklar, NA (June 2007). "Medication use among children with autism spectrum disorders.". Journal of child and adolescent psychopharmacology 17 (3): 348-55. PMID 17630868. 
  1. Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008. Morbidity and Mortality Weekly Report, 61 (3), 1–19.
  2. Pedersen, A., Pettygrove, S., Meaney, F. J., Mancilla, K., Gotschall, K., Kessler, D. B., ... & Cunniff, C. (2012). Prevalence of autism spectrum disorders in Hispanic and non-Hispanic white children. Pediatrics, 129(3), e629-e635.
  3. Charman, T., Baird, G., Simonoff, E., Loucas, T., Chandler, S., Meldrum, D., & Pickles, A. (2007). Efficacy of three screening instruments in the identification of autistic-spectrum disorders. The British Journal of Psychiatry, 191(6), 554-559.
  4. Constantino, J.N., Davis, S.A., Todd, R.D., Schindler, M.K., Gross, M.M., Brophy, S.L., et al. Validation of a brief quantitative measure of autistic traits: comparison of the social responsiveness scale with the autism diagnostic interview-revised. J Autism Dev Disord. 2003 Aug;33(4):427-33.
  5. Gotham, K., Pickles, A., & Lord, C. (2009). Standardizing ADOS scores for a measure of severity in autism spectrum disorders. Journal of autism and developmental disorders, 39(5), 693-705.
  6. Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The Modified Checklist for Autism in Toddlers: an initial study investigating the early detection of autism and pervasive developmental disorders. Journal of autism and developmental disorders, 31(2), 131-144.
  7. Fombonne, E. (2009). Epidemiology of pervasive developmental disorders.Pediatric research, 65(6), 591-598.
  8. Constantino, J. N., Zhang, Y., Frazier, T., Abbacchi, A. M., & Law, P. (2010). Sibling recurrence and the genetic epidemiology of autism. The American journal of psychiatry, 167(11), 1349.
  9. Durkin, M. S., Maenner, M. J., Meaney, F. J., Levy, S. E., DiGuiseppi, C., Nicholas, J. S., ... & Schieve, L. A. (2010). Socioeconomic inequality in the prevalence of autism spectrum disorder: evidence from a US cross-sectional study. PLoS One, 5(7), e11551.
  10. Humphreys, B. P. (2010). Infants and Toddlers with Autism Spectrum Disorders: Early Identification and Early Intervention. Journal of Early Intervention, 32(75), 75-98.
  11. Bastiaansen, J. A., Meffert, H. Hein, S. Huizinga, P. Ketelaars, C. Pijnenborg, M. ,... de Bildt, A. 2011). Diagnosing autism spectrum disorders in adults: The use of Autism Diagnostic Observation Schedule (ADOS) Module 4 Journal of Autism and Developmental Disorders, 41, 1256–1266
  12. Kamp-Becker, I., Ghahreman, M., Heinzel-Gutenbrunner, M., Peters, M., Remschmidt, H., & Becker, K. (2013). Evaluation of the revised algorithm of Autism Diagnostic Observation Schedule (ADOS) in the diagnostic investigation of high-functioning children and adolescents with autism spectrum disorders. Autism, 17(1), 87-102.
  13. Hus, V., & Lord, C. (2013). Effects of child characteristics on the Autism Diagnostic Interview-Revised: Implications for use of scores as a measure of ASD severity. Journal of autism and developmental disorders, 43(2), 371-381.
  14. Coplan, J., & Jawad, A. F. (2005). Modeling clinical outcome of children with autistic spectrum disorders. Pediatrics, 116(1), 117-122.
  15. Chlebowski, C., Green, J. A., Barton, M. L., & Fein, D. (2010). Using the childhood autism rating scale to diagnose autism spectrum disorders. Journal of autism and developmental disorders, 40(7), 787-799.
  16. Saulnier, C. A., & Klin, A. (2007). Brief report: social and communication abilities and disabilities in higher functioning individuals with autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 37(4), 788-793
  17. Fenton, G., D’ardia, C., Valente, D., Del Vecchio, I., Fabrizi, A., & Bernabei, P. (2003). Vineland adaptive behavior profiles in children with autism and moderate to severe developmental delay. Autism, 7(3), 269-287.
  18. Oakland, T., & Harrison, P. L. (Eds.). (2011). Adaptive behavior assessment system-ii: clinical use and interpretation. Academic Press.
  19. Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders. Research in Autism Spectrum Disorders, 5(1), 60-69.
  20. Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., ... & Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics, 125(1), e17-e23.
  21. Wieder, S., & Greenspan, S. I. (2003). Climbing the symbolic ladder in the DIR model through floor time/interactive play. Autism, 7(4), 425-435.
  22. Odom, S. L., Collet-Klingenberg, L., Rogers, S. J., & Hatton, D. D. (2010). Evidence-based practices in interventions for children and youth with autism spectrum disorders. Preventing school failure: Alternative education for children and youth, 54(4), 275-282
  23. Dawson, G., & Osterling, J. (1997). Early intervention in autism. The effectiveness of early intervention, 307-326.
  24. Kasari, C., & Lawton, K. (2010). New directions in behavioral treatment of autism spectrum disorders. Current Opinion in Neurology, 23(2), 137-143.
  25. Mandell, D. S., Morales, K. H., Marcus, S. C., Stahmer, A. C., Doshi, J., & Polsky, D. E. (2008). Psychotropic medication use among Medicaid-enrolled children with autism spectrum disorders. Pediatrics, 121(3), e441-e448.
  26. Oswald, D. P., & Sonenklar, N. A. (2007). Medication use among children with autism spectrum disorders. Journal of child and adolescent psychopharmacology, 17(3), 348-355.
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