For a child of Scott’s age, the Mullen provides information about a child’s developmental level, and an assessment of critical skills in different domains. For an autism assessment, it is notable whether or not skills are average or advanced on tests that involve a lesser degree of social demand, such as the Visual Reception scale, but delays are seen in the Receptive or Expressive Language scales. Although, not diagnostic, many children with autism may have gross or fine motor delays, which can be assessed with this instrument. Of further interest for ASD evaluations, is the child’s approach to task. In this case example, Scott refused certain items and did not show the desire to please the examiners with his efforts. For some examiners, the child’s lack of effort on the Mullen can be disconcerting, in that the clinician may wonder if the child is capable of more than he demonstrates. However, this pure assessment of a child’s ability in a novel testing situation is valid, as it shows the examiner the skills a child can demonstrate independently. The Mullen is a critical tool for clinicians evaluating young children. It is generally recommended that two or more examiners administer the instrument in order to move through the items rapidly, manage the materials, and maintain the child’s attention to the tasks.

For a child Scott’s age, the ADOS-2: Toddler is the Gold Standard for assessing autism. This module includes toys targeting a toddler’s interest, such as a doll, balloons, bubbles, jack-in-the box, and a blanket. This module allows the examiner to play with the child and assess the interaction. Recall that autism is more about the negative symptoms; skills the child is expected to display that are absent or delayed, rather than positive symptoms, such as aggression or odd behaviors. During the ADOS-2: Toddler, examiners assess whether or not the child will make requests, for example, to blow up a balloon again. A typical child might point, gesture or say “again,” whereas a child with autism might grab the balloon away from the examiner or become frustrated. This assessment allows for the clinician to obtain a language sample, play behaviors, interactions with caregivers compared to examiners, response to joint attention and participation in a social routine.

Other Assessments Administered: Vineland Adaptive Behavior Scale—Parent/Caregiver Rating Form (VABS-II), Clinical Interview with Mr. and Mrs. Browne, Clinical Observations of Scott.

Scott shows delays on the Gross and Fine Motor assessment . On the Gross Motor scale, he obtained a T score of 22, which falls into the Very Low range and the 1st percentile. He is able to walk a straight line and jump with both feet. He can balance on one foot with one hand held but is not able to do so without support. He is able to run but tends to run stiffly and is not yet able to make a sharp turn while running. He struggled to walk five or six steps in a straight line. He can throw, catch, and kick a ball. His T score of 24 on Fine Motor falls into the 1st percentile and the 17 month age level. On fine motor tasks, Scott is able to put pennies in a slot, and to coordinate his movements from hand-to-hand. He could screw on a bolt and string beads. He was not interested in stacking blocks or drawing shapes. He is not yet able to fold, stack items, and build structures with blocks. Overall, Scott’s motor skills are delayed for his age. These delays in motor skills are not diagnostic but are often seen in children with autism. This is especially remarkable when it occurs in contrast with average or high cognitive abilities.

Scott showed significant delays in both Expressive and Receptive language . There was a 16-point discrepancy favoring Expressive Language Skills over Receptive. On the Expressive Language Scale, Scott’s T score of 36 falls just below the average range. Scott was able to say words like, “hi,” “bye,” “spoon,” “girl,” “milk,” and “doggie.” On the Receptive Language Scales, Scott displayed significant delays. His T score on the Receptive Language Scale of 20, falls into the Very Low range and 1st percentile. Scott has difficulty following directions. He is not yet able to look at a picture and discern, “where is baby eating” or “where is baby sleeping.” He does not demonstrate the ability to identify the purpose of objects. This profile of higher expressive language skills paired with lower receptive language skills is common in children with autism. This pattern is diagnostic in that children with other disabilities display the opposite pattern, tending to understand more than they can say. Further remarkable is that children with autism tend to use more advanced vocabulary than they understand and may be able to perform nonverbal cognitive tasks at a level that far exceeds their skills on receptive language tasks.

Scott shows the ability to utilize a social-smile during a peek-a-boo game. Scott makes intermittent eye-contact. He is able to show objects to others effectively at times, but tends not to sustain that interaction. His facial expressions are generally flat or only indicative of extremes of emotions. He tends to focus on the toys and objects more than people. When prompted, he did not request the balloon or the bubbles through gesture or verbalizations. Instead, he became frustrated with the tasks and would rest on the floor and suck his thumb to express his discontent. He shows a repetitive interest in toys; becoming focused on activating a toy bunny, blowing bubbles, or blowing up the balloon, such that the toy has to be removed from sight. He did not show the ability to use toys as an agent of action. He had difficulty imitating the sounds of animals and was not able to pretend one object could represent another object. He effectively pretended that he was washing a toy doll during “bath time.” He did not help dry or dress the doll and did not make bids for interaction. Scott was inconsistent in nonverbal communication such as limited or absent gesture use and lack of pointing to make requests. Generally, Scott’s ability to maintain an interaction with examiners is limited, affecting the quality of rapport. Scott has repetitive interests and does not display the ability to initiate and interact reciprocally with others. His symptoms are consistent with a diagnosis of Autism Spectrum Disorder (299.00).