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

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

What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above.

Does this page feel like too much information? Click here for the condensed version.

Preparation phase

Diagnostic criteria for autism spectrum disorder

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

Year	Country	Sponsor of Study	Demography	Base Rate Type	Setting (Reference)	Base Rate	Diagnostic Method	Base Rate Estimation Procedure	Best Recommended For
	USA		11 ADDM sites	Population Prevalence	Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) - 8 year olds ***	1.5% (1 per 68)	DSM-IV-TR		***This is considered a respected current estimate of the rate in the general population
	USA		Epidemiological: 43,283 household surveys	Population Prevalence	National Health Statistics Report (NHIS; 2014), 3-17 year olds	2.2% (1 per 45)	DSM-IV-TR	Phone interviews (caregiver report) from 43,283 parents with children ages 3-17 yrs-- checklist of diagnoses was based off of DSM-IV-TR language
	USA		11 ADDM sites: Male/Female Ratio	Population Prevalence	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
2010	USA	ADS	Came from family registry for those who had children under 18 years old in United States	Family Reoccurrence	Interactive Autism Network (IAN): Individual Sibling Recurrence	ASD status occurred in an additional child in 10.9% of families	DSM-IV-TR	2,920 children from 1,235 families participating in a national volunteer register, with at least one child clinically affected by ASD and at least one full biological sibling
	USA		11 ADDM sites (Race/ethnicity study)	Population Prevalence	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
	USA			Family Reoccurrence	The Autism and Developmental Disabilities Monitoring (ADDM) Network (2010) – 8 year olds Race/Ethnicity - Non-Hispanic White - Non-Hispanic Black - Hispanic - Asian - Other	60.3% 15.7% 17.2% 3.3% 3.5%	DSM-IV-TR
	USA		Male/Female Ratio	Population Prevalence	Epidemiological study: Review of 43 studies	4.2% (4.2 male:1 female)	DSM-IV/Rating Scales/Clinical

Prediction phase

Psychometric properties of screening instruments for autism spectrum disorder

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	Inter-rater reliability	Test-retest reliability	Construct validity	Content validity	Highly recommended	Free and Accessible Measures
Modified Checklist for Autism in Toddlers (M-CHAT)	Questionnaire (Parent report)	18-30 months	5-10 minutes						Free printable PDF MCHAT Free Online MCHAT
Autism Spectrum Quotient (AQ)	Questionnaire	16 years and up	10-15 minutes						Online version with scoring AQ free printable PDF Printable scoring guide
Parent Interview for Autism (PIA)	Questionnaire (Parent report)	2-6 years	15-20 minutes						PIA-CV printable version
Social Communication Questionnaire (SCQ)	Questionnaire (Parent report)	4 years-adult	10 minutes						Not free
Pervasive Developmental Disorders Behavior Inventory (PDDBI)	Questionnaire (Parent report)	1-17 years	10-15 minutes						Not free
Autism Diagnostic Observation Schedule (ADOS)	Direct Testing	2 years-adult	30-50 minutes						Not free
Autism Diagnostic Interview-Revised (ADI-R)	Questionnaire	18 months-adult	90-150 minutes						Not free
Childhood Autism Rating Scale (CARS)	Observation	2 years-adult	5-10 minutes						Not free
Mullen Scale of Early Learning (MSEL)	Direct testing	Birth-68 months	15-60 minutes						Not free
Differential Ability Scales (DAS)	Direct testing	2.5-17 years	25-65 minutes						Not free
Wechsler Intelligence Scale for Children-IV (WISC-IV)	Direct testing	6-16 years	50-70 minutes						Not free
Stanford-Binet Intelligence Scales V	Direct testing	2-85 years	45-75 minutes						Not free
Leiter- Revised	Direct testing	2-20 years	25-90 minutes						Not free
Clinical Evaluation of Language Fundamentals (CELF)	Direct testing	3-21 years	30-45 minutes						Not free
Peabody Picture Vocabulary Test (PPVT)	Direct testing	2.5-90+ years	10-15 minutes						Not free
Expressive One-Word Picture Vocabulary Test-2000 (EOWPVT-2000)	Direct testing	2-18 years	10-15 minutes						Not free
Test of Language Competence (TLC)	Direct testing	5-18 years	<60 minutes						Not free
Children's Communication Checklist (CCC)	Questionnaire	5-17 years	10-15 minutes						Not free

Likelihood ratios and AUCs of screening measures for ASD

• For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

Screening Measure (Primary Reference)	AUC (sample size)	DLR+ (score)	DLR- (score)	Clinical Generalizability
Modified Checklist for Autism in Toddlers (M-CHAT)
Autism Spectrum Quotient (AQ)
Parent Interview for Autism (PIA)
Social Communication Questionnaire (SCQ)
Pervasive Developmental Disorders Behavior Inventory (PDDBI)
Autism Diagnostic Observation Schedule (ADOS)
Childhood Autism Rating Scale (CARS)
Mullen Scale of Early Learning (MSEL)
Differential Ability Scales (DAS)
Wechsler Intelligence Scale for Children-V (WISC-V)
Stanford-Binet Intelligence Scales V
Leiter- Revised
Clinical Evaluation of Language Fundamentals (CELF)
Peabody Picture Vocabulary Test (PPVT)
Expressive One-Word Picture Vocabulary Test-2000 (EOWPVT-2000)
Test of Language Competence (TLC)
Children's Communication Checklist (CCC)

Interpreting autism screening measure scores

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

Prescription phase

Gold standard diagnostic interviews

• For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for autism spectrum disorder

Diagnostic instruments for ASD
Measure	Age Range	Administration/ Completion Time	Interrater Reliability	Test-Retest Reliability	Construct Validity	Content Validity	Highly Recommended	Free and Accessible Measures
Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)
Autism Diagnostic Interview, Revised (ADI-R)	18 months-adult	90-150 hours
Vineland Adaptive Behavior Scales-Second edition (VABS-II)	Birth-18 years	20-60 minutes
Adaptive Behavior Assessment System, Second Edition (ABAS-II)

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Click here for 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

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

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

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)	Parent Total	23.0	18.0	18.6	1.6	1.4	0.8
Social Responsiveness Scale (SRS) Caregiver Report (Appendix B)	Total	72.7	62.8	66.8	11.3	9.5	5.8

Treatment

• Please refer to the page on Autism Spectrum Disorder for more information on available treatment or go to Effective Child Therapy for a curated resource on effective treatments for ASD.

Click here for more information on ASD treatment

Behavior and Communication Approaches 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 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. 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. 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. 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. 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. Others (Treatments tackling symptoms not exclusive to ASD) Cognitive Behavioral Therapy (CBT) Occupational Therapy Sensory Integration Therapy Speech Therapy Picture Exchange Communication System (PECS). 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

External Resources

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

Click here for references

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. 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. 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. 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. 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. 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. Fombonne, E. (2009). Epidemiology of pervasive developmental disorders.Pediatric research, 65(6), 591-598. 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. 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. Humphreys, B. P. (2010). Infants and Toddlers with Autism Spectrum Disorders: Early Identification and Early Intervention. Journal of Early Intervention, 32(75), 75-98. 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 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. 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. Coplan, J., & Jawad, A. F. (2005). Modeling clinical outcome of children with autistic spectrum disorders. Pediatrics, 116(1), 117-122. 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. 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 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. Oakland, T., & Harrison, P. L. (Eds.). (2011). Adaptive behavior assessment system-ii: clinical use and interpretation. Academic Press. 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. 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. Wieder, S., & Greenspan, S. I. (2003). Climbing the symbolic ladder in the DIR model through floor time/interactive play. Autism, 7(4), 425-435. 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 Dawson, G., & Osterling, J. (1997). Early intervention in autism. The effectiveness of early intervention, 307-326. Kasari, C., & Lawton, K. (2010). New directions in behavioral treatment of autism spectrum disorders. Current Opinion in Neurology, 23(2), 137-143. 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. 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.