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ASSESSMENTS AND EVALUATIONS
Interdisciplinary Evaluation for an ASD
Autism Spectrum Disorders impact all aspects of development, including learning, social skills, language and behavior, leaving children and families to face enormous challenges.
Autism Spectrum Disorders, which include Autistic Disorder, Pervasive Developmental Disorder Not Otherwise Specified and Asperger’s Disorder, are a range of complex disorders with a wide degree of variation in presentation. Optimal care of the child with one of these disorders requires attention to medical, behavioral, cognitive and language problems. The Autism Treatment Network and the National Institutes of Mental Health advocate for a comprehensive and an interdisciplinary approach to both an initial diagnostic evaluation and on-going follow-up evaluations during the critical years of the child’s development. The goal is to understand and promote the highest level of functioning and participation possible for each individual.
Although there are some concerns about labeling a young child with an ASD, the earlier the diagnosis is made, the earlier important interventions can begin. Clinical and research evidence over the last 15 years indicates that early intensive intervention results in improved outcomes for most children with ASD.
Evaluations of school age and adolescent individuals should also include comprehensive interdisciplinary evaluations though the focus may be different. For the school age child, evaluation of cognitive development, language, social skills and behavior are important though the emphasis may be on assessing educational and treatment interventions and/or problem behaviors that are interfering with developmental progress. For the adolescent, the emphasis may be on adaptive behavior assessment and planning for the future. For children of any age, psychiatric evaluation should also be included to address possible problems with anxiety, depression or other mental health issues.
In evaluating a child of any age, professionals rely on behavioral characteristics to make a diagnosis. Some of the characteristic behaviors of ASD are apparent in the first two years of a child’s life, or they may appear at any time during the early years. For the diagnosis, problems in at least one of the areas of communication, socialization or restricted, stereotyped, repetitive patterns of behavior must be present before the age of 3. Diagnosis usually involves two stages. The first stage involves developmental screening during a pediatric check-up. The second stage involves a comprehensive evaluation by an interdisciplinary team.
The Comprehensive Diagnostic Evaluation
To ensure an accurate diagnosis of an ASD or other developmental problem, an initial comprehensive and interdisciplinary evaluation is necessary. The interdisciplinary team includes a child psychiatrist, child neurologist or developmental pediatrician, psychologist, speech therapist or other professionals with expertise in diagnosing children with ASD. Interdisciplinary also indicates that the professionals evaluating the child and family should work as a team providing a coordinated evaluation as well as coordinated treatment recommendations.
Because ASDs are complex disorders and may involve other neurological or genetic problems, a comprehensive evaluation should include neurologic and genetic testing, along with in-depth cognitive and language testing. In addition, valid diagnostic measures specific to ASDs, with adequate reliability are best to use as part of the evaluation. These measures include the Autism Diagnostic Interview-Revised (ADI-R), a semi-structured parent interview, and the Autism Diagnostic Observation Schedule (ADOS), an interactive child observation. The ADI-R is a structured interview that contains over 100 items and is conducted with the parents/caregiver. It is made up of four main domains, including the child’s communication, social interaction and restricted, repetitive, stereotyped patterns of behavior, as well as age of onset of symptoms. The ADOS is an interactive observational measure used to assess socio-communicative behaviors, which are usually delayed, abnormal or absent in children with ASD.
Formal audiologic hearing evaluation and a lead screening should also be completed in any child with a developmental delay. Hearing loss can co-occur with ASD, though frequently children who do not respond to their name are initially incorrectly thought to have a problem with hearing. Children with ear infections can experience transient hearing loss. Lead screening is essential, especially for children who put objects into their mouths.
An interdisciplinary team with expertise in diagnosing an ASD has the responsibility of providing a thorough evaluation of the child, assessing strengths and areas of difficulties, and determining a formal diagnosis. Members of the team should meet with the parents to review the complete findings, explain the meaning of the diagnosis, and discuss a plan of intervention. The intervention plan usually involves recommendations for an educational program. The team should be aware of both the needs of the child and the family and develop specific recommendations in discussion with the parents. In addition, the parents should be given the opportunity to ask questions and meet with someone from the evaluation team to provide further understanding of their child’s difficulties and also help in initiating interventions.
The Autism Treatment Network is currently developing best practice guidelines for the medical, metabolic, and genetic tests to include in an initial evaluation of a child with ASD. An electroencephalogram (EEG) is included as part of the medical work-up when there is suspicion of seizures or a child has experienced a regression. In children with ASD seizures occur to a higher degree than average. A brain imaging study is also being included as part of the initial medical work-up by more medical centers when a child presents with delays in multiple areas of development without obvious underlying cause. Brain imaging studies look for structural abnormalities to explain delays or developmental differences, as well as differences in white and grey matter to rule out a metabolic problem.
Children diagnosed with an ASD at a young age should be seen for yearly interdisciplinary follow-up evaluations to assess developmental progress and appropriateness of their treatment interventions.
Autism programs within medical centers or within a Children’s Hospital are frequently able to provide comprehensive interdisciplinary evaluations.
Courtesy Maureen McSwiggan-Hardin, NP-P and Molly Alergermissen, PhD
Columbia University Medical Center, 212-342-1600, www.newyorkautism.columbia.edu
hardinm@childpsych.columbia.edu, algermim@childpsych.columbia.edu
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