, Marcy Willard1 and Helena Huckabee1
(1)
Emerge: Professionals in Autism, Behavior and Personal Growth, Glendale, CO, USA
Abstract
Contrary to alternative models using a fixed battery approach to neuropsychological assessment, these authors propose that clinicians choose the assessment battery based on the client’s data as testing progresses. This is consistent with the Nebraska—Luria model for neuropsychological assessment where the assessment evolves based on the needs of the client. To do so, this chapter provides the Dynamic Assessment Overview for ASD and Other Disorders. These authors propose that the first set of measures is based on the referral concern. The clinician must first use clinical judgment and careful analysis of all information presented during the intake interview to determine which areas must initially be assessed during the evaluation. If the initial concern is autism, the Core assessment Areas of: Cognitive, Language, Social, and Sensory must be evaluated. Once the client presents for testing, the examiner should consider the scope of the evaluation and referral questions as well as the data collected to determine whether or not to assess additional areas. The examiner may evaluate any number of Additional assessment Areas including: Visual Spatial, Motor, Attention, Executive Functions, Memory, Emotions/Behavior, and Adaptive. Then, the clinician or team of clinicians reviews these data from interviews, rating scales, observations, and a variety of direct measures to make a diagnosis. In the framework provided, that diagnosis may be ASD, ASD and comorbid condition (s), or Other Disorder (s). The process concludes with the feedback session, recommendations, and comprehensive report.
Keywords
Diagnostic framework for ASDDynamic assessment batteryClinical assessment process for ASDValid tests for autism assessmentRuling-out ASDAssessing disordered social interactions without autismShould I keep testing? ASD and other conditionsFour important areas in ASDCognitive and language in ASDSocial and sensory in ASDReferral
The “referral concern ” noted here is the clinician’s impressions formed during the initial consult, which may or may not be the same as the referral concern voiced by the client. For example, it has been the author’s experience that often a client may voice concerns about attention or ADHD, and then describe symptoms that appear to be more consistent with an autism spectrum disorder. The clinician should use clinical judgment to determine which areas must be assessed to address all of the symptoms discussed during the initial intake. When issues with social reciprocity are expressed during the initial consult, autism should be considered. In Fig. 7.1 a of the framework, the process begins with a referral for ASD. Any referral in consideration of autism necessitates that the following areas be assessed: Cognitive, Language, Social, and Sensory.
Fig. 7.1
Dynamic assessment framework for ASD and other disorders. (a) Dynamic assessment overview for ASD and other disorders. (b) Core areas. (c) Associated areas . (d) Diagnosing disordered examiner–client interactions in the absence of ASD
Assessing Core Areas
Cognitive
Cognitive assessment in consideration of ASD should include a careful look at overall cognitive ability compared to social understanding and comprehension. A bright child with adequate language skills, who cannot tell the examiner about simple relationship dynamics such as how a friend differs from any other classmate, is showing signs of autism. Clinicians may notice that a child on the Spectrum scores highest on nonverbal, untimed tests such as Matrix Reasoning. Often Block Design is a favorite subtest for individuals with ASD. Children with autism tend to score lowest on comprehension subtests. As stated in the previous chapter, approach to task should be considered with autism. Examiners should assess the child’s overall engagement, use of strategies and verbal mediation, the ability to accept feedback, flexibility in problem-solving approach, significant difficulties establishing rapport and connecting with a child can be observed during cognitive testing.
Language
When assessing language in consideration of ASD, clinicians should loo losely at pragmatic language. Does the conversation have a give-and-take, to-and-fro quality? Children who struggle to converse, share ideas, and show interest in the topics shared by others may be showing signs of autism. Next, clinicians should consider whether the child’s speech is overly formal; potentially comprises vocabulary that is beyond what is generally used in a child’s developmental vernacular. For example, the child who seems like a “little professor,” appearing to “talk at” the clinician, may be showing signs of autism. The clinician should take note of any monologue the individual may embark on, especially when centered around a restricted interest. Children with autism may use words they do not understand. Language testing may reveal a pattern where expressive language is especially high, relative to lower receptive language. All of these signs point to the notion that an ASD may be relevant.
Social
When assessing for social needs, clinicians utilize the ADOS-2, observations, clinical interview, and rating scales. Clinicians should look primarily at social reciprocity. Children with autism tend to lack empathy and perspective taking in their communication. When conversational bids are offered, such as, “oh, and then I broke my leg” a child with autism may not know how to respond. Children on the Spectrum may struggle with imaginative, reciprocal, and symbolic play. They may struggle with joint attention, and with following the pointing and eye-gaze of the examiner. Sometimes, a child on the Spectrum will simply walk away during a conversation with the examiner. Other times, the child may refuse tasks or throw tantrums during the evaluation. Any sense of rigidity or bossiness during the evaluation should be noted. Often, a child on the Spectrum fails to offer information and to provide narrative descriptions of events in his or her life. The overall rapport of the interaction is critical to assess as well. If the conversations or play feel awkward, flat, or stunted, the examiner should consider this as a sign autism may be relevant.
Sensory
Children with a previous diagnosis of “Sensory Processing Disorder” should be carefully evaluated for signs of ASD. Often, unfortunately, families have been misled to see that their child’s sensory symptoms occur in isolation; when in fact, they may occur in the context of an Autism Spectrum Disorder. Children with sensory sensitivities may show odd behaviors during the evaluation. They may visually inspect toys or objects. At times, children with ASD are observed playing with the wheels of the car or flipping the eyes of a toy doll, rather than playing with the toy in a functional manner. They may lick or eat non-food items. Sometimes, children with sensory problems walk on their toes, rigidly refuse eye contact, and fail to habituate to sounds, smells, and textures in the evaluation environment. Parents may report that the child is sensory seeking, sensory avoidant, or has sensory meltdowns. Sometimes, children with sensory defensiveness have feeding problems, avoiding a wide variety of foods due to problems with certain texture or smells. Sometimes, children with sensory problems avoid certain clothes, preferring to wear only elastic waistbands, collarless shirts, and refusing to wear socks or certain types of shoes. All of these sensitivities should be observed and considered, in concert with all of the evaluation data, as potential signs of autism.
Data Analysis
Clinicians reviewing Cognitive, Language, Social, and Sensory data from interviews, rating scales, observations, and rating scales are well equipped to make an autism diagnosis. Clinicians should consider data from all four areas together and certainly not use the ADOS-2 alone as the sole reason for making a diagnosis. When reviewing data in detail, readers are invited to the comprehensive sections in the next section (Part 3: Data Analysis). Chapter 8 is a comprehensive review of Cognitive and Language assessment data in an assessment for ASD. Chapter 9 provides a clear explanation of the data analysis process for the Social and Sensory areas. All of these data together should answer first, “does the child show impairments in social reciprocity?” Children with limited social reciprocity, poor communication skills (given adequate verbal skills), and restricted interests or behaviors meet the general criteria for an autism diagnosis (Fig. 7.2).
Fig. 7.2
Clinical judgment
Autism Alone or Comorbid?
Throughout the assessment and certainly toward the end of the first set of measures, clinicians should be able to decide whether to make a diagnosis of autism and to rule autism out. If the client has autism, the clinician must then begin to ask, is it autism alone or are there other concerns? For example, a clinician might observe that the client is clumsy or has poor posture, or handwriting, and consider running additional motor tests. The client might present with grandiosity and flight of ideas, and additional emotional and personality tests might be included in the assessment battery. Clients who present as disinhibited and unorganized might require attention or executive functioning measures. In this way, the clinician reviews the initial data collected in addition to the way the client presents as a way of determining what other assessments should be completed. When conducting the additional measures, clinicians are able to assess other potential diagnoses such as ADHD, Mood, Motor, and Behavior.
Assessing Additional Areas
If the clinician suspects the child may have additional concerns beyond autism, it may be necessary to do additional formal evaluation. Often, the clinician can screen for the above Associated Areas while looking at Core areas such as Cognitive and Language. The framework provided in Fig. 7.1c allows clinicians to consider all of the major Associated Areas: Visual Spatial, Motor, Attention, Executive Functions, Memory, Mood, Behavior, and Adaptive. Interested readers are again guided to the chapters in the next section (Part 3: Data Analysis) for a comprehensive overview of each area. Visual Spatial and Motor are covered in Chap. 10, Attention, Executive Functions, and Memory are covered in Chap. 11, and Emotions, Mood, Behavior, and Attachment are covered in Chap. 12. The next section here provides readers with a brief overview of each area in order to illuminate the process shown in the Diagnostic Overview framework.
Visual Spatial
Examiners should consider evaluating visual–spatial when clients present with poor visual planning skills. They may struggle with assembling visual puzzles or have trouble reading maps. They may have poor eye–hand coordination or problems with visual tracking. Sometimes, individuals with visual spatial problems may have trouble assessing their body’s position in the physical space, bumping into walls or door frames. Young children with visual spatial problems may not be able to navigate tunnels and other play equipment in the school-yard. If some of these symptoms appear while assessing the Core Areas, clinicians should evaluate Visual Spatial and may consider instruments such as the Motor-Free Visual Perception Test or the Beery Visual Motor Integration sequence or the Comprehensive Trail Making Test (CTMT) .
Motor
Children who present with poor coordination, poor posture, or poor drawing skills may require motor assessment. They may appear to have low muscle tone, and may struggle with climbing stairs, jumping, or riding a bike. Young children on the Mullen Scales may struggle with stringing beads, stacking blocks, or placing a penny in the bank. Parents might report that they cannot tie their shoes, struggle in sports, or are clumsy around the house. In this case, clinicians should consider tests like the Beery VMI, Grooved Peg Board, and scores on the Vineland Scales of Adaptive Behavior or Mullen Scales in the motor domains.
Attention
Individuals who present as disinhibited, impulsive, or disorganized may require testing for attention. People with attention problems may struggle with initiation of tasks or in shifting their attention between tasks. They may lack focus or only seem to be able to sustain attention for short periods. Sometimes during a cognitive assessment, an individual with attention problems will fatigue quickly during early items of the subtests. They may also show a pattern of getting one item right, missing one or two items, and then getting another couple items correct. Given that items generally increase in difficulty throughout cognitive subtests, this pattern is a red flag for attention problems. Clinicians with concerns about attention should consider administration of a continuous performance measure like the Test of Variable Attention (TOVA) , as well as response patterns during cognitive and language measures, executive functioning measures, joint attention skills on social tests, and working memory assessments.
Executive Functions
One important screener for executive functioning weaknesses is the Working Memory scales of cognitive or memory assessments. Working memory regulates attentional cognitive control processes to permit the simultaneous storage and processing of information while performing cognitive tasks. People with ASD struggle to manipulate stimuli compared to neurotypicals, while they can adequately store visual and verbal information. Individuals who present with poor planning and organization skills (common in ASD) may require executive functioning assessment. Children who struggle to initiate tasks, self-monitor their progress or their comprehension of assignments, and regulate their movements or emotions often have problems with executive functions. Examiners should consider results from the Tower of London, BRIEF, TOVA, and CTMT.
