Unfortunately, often when a parent has a concern , some well-meaning specialists from other disciplines may imply that a diagnosis is present or is unwarranted when they are not qualified to make diagnostic decisions. It is critical to be aware that when an individual is not qualified to diagnose an Autism Spectrum Disorder, he or she is also not qualified to rule out the diagnosis. At times, school professionals, counselors, occupational therapists, physical therapists, or other specialists without diagnostic training make comments such as, “He doesn’t seem to have autism to me.” Just as people who are not doctors cannot “rule out” cancer as the cause for certain symptoms, professionals who are untrained in ASD evaluations are not qualified to rule out autism. Well-meaning statements like “Don’t worry I think he’s just being a boy.” Or “His eye contact is excellent, it can’t be autism;” or (a comment made by a pediatrician to a mother) “He can talk so well; clearly it is not autism,” can be incredibly damaging to families. Unfortunately, some doctors tell parents for years to “wait and see,” often making families feel powerless to move forward with addressing their concerns. Bearing in mind that early intervention is critical, it is important that concerns are addressed by qualified professionals. Appropriate responses may include “It sounds like you have a few concerns about Johnny’s development. As a parent you know your child best. Consider a consultation with a psychologist or pediatrician to further discuss your concerns.” Or “I’m not qualified to diagnose but the following observations we’ve made in the classroom may be noteworthy. Why don’t you share this information with your doctor?”

Evaluations from qualified clinicians range from psychological or neuropsychological test batteries to parent consultation interviews that result in a diagnosis. Comprehensive evaluations may consist of comprehensive psychological or neuropsychological batteries including a wide range of standardized tests. Alternately, pediatricians or psychiatrists may provide a diagnosis based on a clinical consultation, potentially including rating scales or developmental screeners. Best practice comprehensive psychological evaluations for autism minimally include an initial consultation to prioritize areas of concern; an ADOS-2 and clinical interview; screening questionnaires; and formal assessment of cognitive, language, social, and sensory areas.

Often parents who pursue evaluations have clinically significant concerns that are causing great distress to the family and to their child. Referring individuals can support families in identifying an appropriate place for an evaluation. In doing so, referring parties should consider that an appropriate evaluation can occur only when the clinicians are highly qualified in diagnosing ASD, as well as understanding potential comorbidities and differential diagnoses. Understanding what autism is not is as just as important as understanding what autism is. Diagnostic clarification by highly trained clinicians helps guide treatment recommendations in accordance with best practice standards and ultimately can be of great benefit to the individual and the family.

Research varies about the precise components of a comprehensive evaluation but the common themes are that assessment should include multiple assessment modalities and look at a variety of domain areas. Most clinicians agree that a comprehensive evaluation should address cognitive, language, motor skills, emotions, and attention in addition to the social skills deficits associated with ASD. The Autism Diagnostic Observation Schedule, Second Edition (henceforth known as the ADOS-2) manual states that the ADOS-2 is only one part of an evaluation and that it is not appropriate to make a diagnosis considering a score on an ADOS-2 algorithm alone (Lord et al., 2012). Cognitive assessment, adaptive assessment, an ADI-R or caregiver interview, and a parent-report screening measure like the SCQ should be a part of the battery (Gotham, Bishop, & Lord 2011 for best practice guidelines for assessing ASD).

Diagnosticians who work with children and adolescents should have a thorough understanding of typical development in a variety of domains, and particularly in social communication. Often, autism symptoms are best identified by seeing whether or not the milestones typically achieved by a child of that age are indeed present. That is, many of the symptoms associated with autism are called “negative symptoms,” meaning essentially, that it is not necessarily what the child is doing, but what he or she is not doing that can be of concern. For example, a bright 7-year-old child, who does not play reciprocally or share enjoyment with others, may be showing important signs of ASD. Klin et al. in 1997 outlined a comprehensive developmental approach to Autism Assessment including assessment of multiple areas of functioning, adopting a developmental perspective. The approach emphasizes variability of skills, variability across settings, functional adjustment, and developmental delays. Kamphaus and Campbell (2006) discuss the use of this approach with assessment from clinicians in multiple disciplines in the book Psychodiagnostic Assessment of Children (Ed. Kamphaus & Campbell, 2006). These authors would argue that assessing multiple domains and incorporating various clinical perspectives are best practices. As shown in Chap. 7, there are four core areas that must be assessed for an ASD evaluation: cognitive, language, social, and sensory. There are seven associated areas that should be assessed if potential symptoms arise during the initial consultation or the evaluation of the core areas. The associated areas are visual–spatial, motor, attention, executive functioning, memory, emotional/behavioral, and adaptive. An evaluation that addresses (either formally or informally) all of these areas by way of screening instruments, interview, observations, and standardized testing is considered comprehensive.

Research shows that a multidisciplinary or “arena” evaluation is the best approach for assessing ASD. Multidisciplinary team evaluations may involve physicians, psychologists from various disciplines (clinical, neuropsychology, counseling, or school), speech therapists, occupational therapists, physical therapists, and educational specialists. It will involve, at minimum, a team of psychologists with consultation from other disciplines (i.e., referring doctor, OT, or SLP). An evaluation without a psychologist who is fully trained to administer the ADOS-2 cannot be considered comprehensive and does not meet the “gold standard” for autism assessment. A comprehensive literature review conducted in 2013 by Falkmer, Anderson, Falkmer, and Horlin indicated that while we refer to the ADOS and ADI-R as the “gold standard” a review of the literature supports this statement “…the true ‘gold standard’ classification and diagnosis of autism is still considered to be multi-disciplinary team clinical assessment, including use of the ADOS and ADI-R, as well as other assessments with consensus clinical judgment” (Falkmer et al., 2013). This study supports use of the CARS rating scale, while qualifying that it is used in combination with a developmental evaluation including the ADOS and ADI-R, as well as the M-CHAT parent-report questionnaire (often provided by pediatricians). It is important for referring professionals to know that the research indicates best practice for autism assessment is a comprehensive, multidisciplinary team assessment. When these various clinicians are not within the same practice, consultation can be helpful. Often, clinicians conducting evaluations will call the child’s therapist, teacher, psychiatrist, or medical doctor to obtain information and collaborate on the evaluation.

A referring clinician such as a speech therapist, pediatrician, or occupational therapist may reach out to the diagnostic team. The clinician may consult, write a letter, or provide screening data to the psychologist or team of professionals evaluating. A letter from a referring clinician can empower families as they pursue an evaluation. It may be the case that the family has cultural, language, or socioeconomic barriers, and the prospect of pursuing an evaluation for their child can be intimidating and daunting. A letter from a qualified professional who speaks the language of the evaluator, using clinical terminology to explain the referral concerns, can be a significant asset to families.

Comprehensive multidisciplinary evaluations are often provided by hospitals, outpatient clinics, and sometimes by private or group practices. Wait lists to receive these services can be long or there may not be such a provider in the area. Sometimes psychologists in independent private practice also provide evaluation services that are likely to cover fewer domains. While there are certainly drawbacks to a less comprehensive assessment, it is possible to rule out the presence of an Autism Spectrum Disorder if the necessary assessments are administered in the core areas of cognitive, language, social, and sensory. A quality referral from a clinician, doctor, teacher, or family member to a comprehensive, multidisciplinary evaluation can be the precise factor that turns the tides for families and allows a child to get critical treatment. When faced with a lengthy wait list (3 months to 1 year), clinicians recommend families make an effort to find comprehensive services that are more readily available. Especially with very young children, losing a year of potential treatment can be hugely detrimental.

To summarize, clinical psychologists, neuropsychologists, medical doctors, and specialists, such as child psychiatrists, may diagnose an Autism Spectrum Disorder. Training of these clinicians varies and if they do not have extensive training in autism assessment they should refer out. If a parent or referring clinician is having difficulty finding a provider, it may be helpful to contact a local chapter of the Autism Society. This organization should have a list of local providers. Families and referral sources might also contact the community centered board, insurance company, or Autism Speaks chapter for referrals.