Autism Spectrum Disorders Assessment and Evaluation

1. Autism Spectrum DisordersAssessment and Evaluation Kathrin Hartmann, Ph.D.; RPT-S Clinical Psychologist / Associate Professor Department of Psychiatry Eastern Virginia Medical School

2. Psychological Evaluation: Part of an Interdisciplinary Approach Part of a interdisciplinary team approach that involves parents and professionals with different areas of expertise: • Speech and language therapists • Occupational therapists • Physical therapists • Pediatricians, pediatric specialties, and other health care providers • Special education professionals • Parents/Caregivers/Family/Friends

3. Typical Process of the Psychological Evaluation • More than one “testing” appointment • Use of several sources of data/observations (home, clinic, school…) • Results are interpreted on the basis of patterns emerging from different tests with common underlying factors and multiple observations of typical behaviors • Parent feedback with an interactive and therapeutic emphasis

4. Essential Elements of the Psychological 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 • Additional assessment (e.g. clinical genetics; neurological status, and sensory/motor functioning)

5. Purpose of Psychological Assessment • Provides a frame of reference for the individual child, their strengths and weaknesses • Helps narrow down diagnostic possibilities • Provides a basis for what teaching strategies may be used • Documentation of functioning may provide access to services

6. Optimal and AdjustedPsychological Assessment Standardized administration with adaptations may be necessary for child’s cooperation and optimal performance Utilization of instruments that require less language mediation and imitative skills may be better Use of instruments that are more dependent on visual than auditory skills may be better Observations during the testing can provide extremely valuable additional information

7. Psychological Assessment • Standardized administration with adaptations may be necessary for child’s cooperation and optimal performance • Utilization of instruments that require less language mediation and imitative skills may be better • Use of instruments that are more dependent on visual than auditory skills may be better • Observations during the testing can provide extremely valuable additional information

8. Recommended Instruments(adapted from Klin et al. 2005)

9. Additional Screening Measures Beery Buctenica Developmental Test of Visual-Motor Integration (VMI) to screen grapho-motor skills, perceptual accuracy, and hand-eye coordination Projective Drawings (DAP, KFD) for further verbal accounts of social relationships Child Behavior Checklist (CBCL, parent and teacher/caregiver versions) for general emotional and behavioral screening Conners’ Rating Scales (parent and teacher versions) to screen for ADHD Children’s Depression Inventory (CDI) to screen for co-morbid depression Play Observations to screen ability of pretend play, self-understanding, capacity for taking the perspective of others, etc.

10. Screening Instrumentsfor Autism Spectrum Disorders • Checklist for Autism in Toddlers (CHAT) 18 months Interview and interactive; 18 months+ • Childhood Autism Rating Scale (CARS); age not specified • Gilliam Autism Rating Scale (GARS); 3-22 years • Screening for Autism in 2- Year-Olds (STAT); 24-36 months • Autism Behavior Checklist (ABC);18 months+

11. Parent Questionnairesfor Autistic Spectrum Disorders Modified Checklist for Autism in Toddlers (M-CHAT); 18 months up Pervasive Developmental Disorders Screening Test 1- Stage 1 and 2 (PDDST Stage 1 and Stage 2) Autism Screening Questionnaire/Social Communication Questionnaire (ASQ/SCQ); 4 years up

12. Clinical InterviewsFree-form versus Structured Example of a typical free-form interview with child and parent: Standard care Example of a structured interview with Parent: Autism Diagnostic Interview - Revised (ADI-R) • Early developmental domain • Communication domain • Social development and play domain • Restricted interests and behaviors domain

13. Clinical Observations(informal versus formal) • Behavioral observations during intellectual and academic testing • Play Observations • Classroom Observations • ASD Specific Tests: Autism Diagnostic Observation Schedule (ADOS) Checklist for Autism in Toddlers (CHAT)

14. Social Behavior Use of Vocalizations and Speech and Gesture in Social Situations Play and Interests ADOSCatherine Lord, Ph.D., Michael Rutter, M.D., FRS, Pamela C. DiLavore, Ph.D., and Susan Risi, Ph.D. http://www.wpspublish.com

15. Comparing ASD-Specific Diagnostic Measures • Both the ADI and ADOS are effective ways of qualifying subjects • Tools are fairly comparable; ADOS slightly better • ADOS has not been standardized on children with developmental levels younger than 18 months

16. ADOS-TAutism Diagnostic Observation Schedule - Toddler module • Modified version of the ADOS for use in very young children • Presented at the 7th Annual International Meeting for Autism Research R. Luyster, W. Guthrie, K. Gotham, S. Risi, P. DiLavore, & C. Lord (2008). The Autism Diagnostic Observation Schedule – Toddler module: Preliminary findings using a modified version of the ADOS. • Available in the near future at Western Psychological Services www.wpspublish.com

17. Choosing the Right Module! • You get what you look for: The social and language demands placed on the participant have an effect on the extent the participant will show impairment • First obtain a Language Sample • Administration of the ADOS should be only part of a more Comprehensive Evaluation

18. Free Play Response to Name Response to Joint Attention Bubble Play Anticipation of a Routine with Objects Responsive Social Smile Anticipation of Social Routine Functional and Symbolic Imitation Birthday Party Snack ADOS Module 1Pre-Verbal / Single Words

19. Construction Task Response to Name Make Believe Play Joint Interactive Play Conversation Response to Joint Attention Demonstration Task Description of a Picture Telling a Story from a Book Free Play Birthday Party Snack Anticipation of a Routine with Objects Bubble Play ADOS Module 2Phrase Speech

20. Construction Task Make-Believe Play Joint Interaction Play Demonstration Task Description of a Picture Telling a Story from a Book Cartoons Conversation & Reporting Socioemotional questions: Emotions Socioemotional questions: Social Difficulties/Annoyance Break Socioemotional questions: Friends & Marriage Socioemotional questions: Loneliness Creating a Story ADOS Module 3Fluent Speech(Child/Adolescent)

21. Construction Task* Telling a Story from a Book Description of a Picture* Conversation & Reporting Socioemotional questions: Current Work or School* Socioemotional questions: Social Difficulties/Annoyance Socioemotional questions: Emotions *denotes optional Demonstration Task Cartoons* Break Daily Living* Socioemotional questions: Friends & Marriage Socioemotional questions: Loneliness Plans & Hopes Creating a Story ADOS Module 4Fluent Speech(Adolescent/Adult)

22. ADOS Triggers for Language and Communication • Greeting and small talk • Tell me about your school/job • Tell me about your friends • What makes you happy?afraid?angry? annoyed? proud? • Tell a story from a wordless picture book • Describe action in a comic strip • What would you do if you won a million dollars?

23. 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

24. 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

25. Scoring Reciprocal Social Interactions • Unusual Eye Contact • Facial Expressions Directed to Others • Sharing Enjoyment in Interaction • Showing • Spontaneous Initiation of Joint Attention • Response to Joint Attention • Quality of Social Overtures • Insight • Amount of Reciprocal Social Communication

26. ADOS Triggers for Restricted and Repetitive Behaviors Inviting the participant to engage in an open-ended conversation for social purpose only for further observations of participants 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

27. 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

28. ADOS Summary Algorithm • 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

29. Using the ADOS for Programming/Education • Breaking down social behaviors • Social overtures and responses • Reciprocity • Basic Aspects of social behavior (eye contact, facial expressions, vocalization, gesture, use of objects)

30. Test Patterns of Children with ASD Atypical patterns of strengths and weaknesses: often + in visual perceptual tasks and - in conceptual and reasoning tasks Often a drop in standard scores over time Presence of clearly observable repetitive behaviors is easier to detect than pragmatic speech delays or deficiencies - Participants with mild autism or very high functioning autism may be overlooked for symptom presence

31. ASD ComorbiditiesMatson & Nebel-Schwalm (2008) • Depression is probably the most frequent form of comorbid psychopathology with ADS (2%). Children with Asperger’s syndrome have comorbidity with depression as high as 30%. • Overlap with Anxieties, OCD, and Psychosis • Waxing and waning of symptoms is a central distinguishing feature between ASDs and most forms of childhood psychopathology. • Future need for differential diagnosis studies

32. Pragmatic Language Difficulties Poor Theory of Mind Poor Eye Contact Restricted Interests Poor/Delayed Pretend Play Fascination with letters/ written words Appears uninterested in friends Nonverbal IQ < Verbal IQ Strengths in verbal/auditory skills Learns by Rote Problems with visual-spatial organization Poor Executive Functioning Poor Abstract Understanding Poor Social Skills ASD versus NVLD

33. ASD versus SLILeyfer et al. (2008) • Overall significant differences between groups: On the ADOS, Children with autism scored significantly higher on the social and communication algorithm scores than the children in the SLI group • Nonetheless, 25% of the children in the SLI sample met the ADOS cut-off for ASD on the communication domain. • 11% of the SLI sample met the autism spectrum cut-off on the reciprocal social interaction domain

34. How to Give the News: Using the Testing Feedback for Understanding and Referrals • Interpretative session maximizes the probability of a beneficial effect on the family and opens the way to successful interventions in the future • Families vary in reactions that the feedback provides; hopefully from an initial sense of denial or shock to a sense of relief and reassurance • Helps the family with a shift in perspective and understanding and may open ways to better cope. • With the diagnosis, access to services becomes possible that the family otherwise may not be entitled to or aware of. • Helps the child to obtain a range of therapies and approaches for interventions to better learn and progress.

35. Reactions to Psychological Testing ResultsAdapted from Siegel, B. (1997)

36. Professional Websites for Autism Testing and Assessment • University of Michigan Autism and Communication Disorders Center, Director: Catherine Lord, Ph.D. www.umaccweb.com • Western Psychological Services Publishers and Distributors www.wpspublish.com • Finding Information about Psychological Tests: http://www.apa.org/science/faq-findtests.html • Test Reviews online: The Buros Center for Testing www.unl.edu/buros • Test Locator for Internet Searches http://ericae.net; http://buros.unl.edu/buros/jsp/search.jsp , and http://www.ets.org/testcoll