A clinician or team of clinicians will begin the assessment process with a general idea of what measures may provide the most useful data as discussed in the previous chapter. Clinicians should have a completed checklist nearby during the assessment. As the assessment progresses and data are collected in domains including cognitive and autism symptoms, sometimes a battery will be adjusted as measures are added or removed to answer the referral question(s). The referral questions of most interest in this text are of course “Do I/Does my child have an Autism Spectrum Disorder? If so/if not, what other diagnoses are relevant?” And “Where do we go from here?”

As will be explained in Chap. 7, the selection of tests is dynamic and evolving throughout the assessment. The clinician may plan to administer a cognitive measure and an ADOS-2 on the first day of testing and then will constantly review data from that testing as a basis for understanding results from other tests. Provided here are some basic examples of the way in which a clinician may adjust the battery as needed. A child with presenting social skills deficits who does not meet criteria on the ADOS-2 for an Autism Spectrum Disorder may benefit from assessments that consider attention, anxiety, and attachment. A child who very clearly does meet criteria on the ADOS-2 and is very rigid and literal may not benefit from taking projective assessments but a rating scale for emotions and/or play observation may provide more useful data on emotion and behavior. If a cognitive measure reveals very low verbal skills, this may impact the language measures selected. If tasks of visual perception or fine motor demonstrate weaknesses, then additional measures in these areas (VMI sequence, Grooved Pegs, MVPT) may be added to a battery. These examples here were provided to illuminate how the selection of measures evolves throughout the testing sessions. Again, a more thorough description of this process is provided in Chap. 7.

It is essential to take very thorough behavior observations during the testing process. When assessing Autism Spectrum Disorders, it is necessary to pay close attention to eye contact, gestures, facial expressions, and the integration of these. Social interaction, play, and interests are also critical to observe. It is best practice to have behavior observations from multiple raters who are trained in autism assessment. Observations should be conducted by each clinician who works directly with the child and ideally by other clinicians who are observing the interaction. These observations answer questions like, “was the interaction comfortable or awkward?” “Was the child rigid or flexible in his or her problem-solving approach?” It can sometimes be helpful to consider first impressions of the client as compared to clinical impressions after a full diagnostic assessment. A careful look at the various perspectives of clinicians in different stages in the assessment process can provide rich data to be considered in diagnostic decisions. Below are the areas specifically addressed in the authors’ clinical practice in taking behavior observations. Each clinician who works with a client completes a behavior observation form and these forms are used as a piece of the data needed to formulate diagnostic impressions. Sometimes in practice clinicians may only note mood and behavior which is less comprehensive and limiting the valuable data comprehensive observations can provide. It is most helpful to be thorough in assessing each of the areas noted below.

Appearance is considered including dress, physical stature, facial features, and hygiene. It is important to note atypical features that may relate to genetics such as big ears, a wide nasal bridge, facial dysmorphologies or skin abnormalities, or an especially small or large head. Fashionable attire, grooming, and cleanliness should be considered. These can speak to the level of appropriate care and indicate sensory sensitivities or awareness of social norms. For example, it is important to recognize an individual who wears the same clothes on multiple days, dresses only in soft sweat pants, or is disheveled in appearance. These could reflect rigidity, sensory sensitivities, or a lack of appropriate social awareness. In some cases, a child’s dress may be overly formal or reflect restricted interests and rigidity. It should be noted when a child always wears neckties, vests, or hats. A child may dress in costumes, wear a cape, don shorts in the winter, or seem not to notice when his shoes are untied or shirt is unbuttoned. All of these atypical clothing preferences can indicate whether or not a child is aware of how he or she is perceived by peers or others in public. It can be helpful to notice if an individual wears excessive makeup, is overly accessorized, or dresses provocatively. Weight, height, and muscle tone can also provide useful information about diet and health.

Behavioral presentation is important to observe specifically looking at patterns of behavior and antecedents. For example, if behavior changes over the course of testing or if an individual presents differently on different days, it is helpful to take note and consider these shifts. For younger children, noting the response of the child to saying goodbye to or being without the caregiver and additionally noting the caregiver’s response to spending time away from the child is helpful. For example, a child with ASD may run into the testing room completely forgetting to say goodbye to mom or dad and without taking a moment to meet the examiner. He or she may also cry, hide behind a parent, or avoid the testing room. It is useful to note whether the individual greeted the examiner appropriately, avoided gaze and hid in the corner, or perhaps started out with a statement like “Do you know how many planets are in our solar system?” As testing progresses, it is helpful to note whether the individual warms to testing or becomes increasingly active and distracted. Misbehaviors or reactions that are out of the ordinary should also be recorded.

When making observations about language, include both receptive and expressive language skills. In children with ASDs, sometimes expressive language skills are better than receptive skills. In the receptive domain, it is important to note whether the client appears to listen, understand, and respond to others’ comments or directions. It is important to observe the length of utterance, prosody, and tone of voice and note any formal or stereotyped statements. Particular speech patterns can signal autism symptoms such as a “sing-song” voice, or a staccato or robotic tone. Children with a sing-song tone tend to exaggerate certain sounds and syllables in an odd fashion, even at a young age. Children with a robotic speech pattern, sound overly serious, often use formal, overly high level vocabulary, and tend to be monotone. The typical inflection and expression expected of a child that age may be absent or delayed. Sometimes, the child seems to be on a monologue and is unaware of whether the “audience” is following the conversation. Other times, the child constantly tells jokes or talks incessantly. Formal language may be very advanced or professorial in nature, often feeling as though the individual is giving a lecture or academic discourse, seeming unable to participate in an informal social context.

Stereotyped language may sound like a quote from a television show, movie, or quote from a parent. It is sometimes helpful to write these phrases down and keep track of how many times the child says them. Repetitive comments are also important to consider. Some children may echo the examiner or their parent but struggle to produce language that is not echoic. Other children may repeat the same phrase over and over. With older children, teens, and adults it is also important to consider stereotyped, formal, or repetitive utterances. At times, individuals with ASD will make a repetitive comment, be too formal, or quote a parent or TV program without fully understanding the concept or saying. For example, a repetitive comment may be reporting “I’m happy when my grandmother is happy!” And then when further questioned, “My grandmother is happy when I’m happy!” This can become repetitive and indicate that the individual is unaware of or unsure of how to describe his or her feelings. A formal response may be like in one case of an 8-year old in response to “Why do people get married?” answered “To perpetuate the human species.” Stereotyped language could include a comment like “Oh kids these days!” when asked about getting along with others at school. When taking language observations, we find it important to write down examples of these comments made by an individual because it can be very helpful when explaining differences in language skills to be able to provide parents or the individuals with examples of language differences that may be associated with ASD.

Other important behavior observations include the use of eye contact , gesture, and the integration of these with use of language. One common myth about Autism Spectrum is that an individual who makes eye contact cannot have Autism. While the quality of eye contact is important to note, an individual with appropriate eye contact may have Autism. Sometimes clinicians hear upon intake “I think my child may have an ASD but our pediatrician or classroom teacher says ‘no’ because my child has good eye contact.” Many individuals with Autism Spectrum Disorders do make eye contact. One important practice when taking behavior observations is to reflect on the quality of eye contact. Eye contact that is too intense or not well integrated with other components of communication is as important to take note of as avoiding gaze.

Often upon intake, parents ask how we might differentiate between a young child with language delays and a child with an ASD. Children with language delays or severe articulation difficulties are relatively easy to distinguish from individuals with Autism Spectrum Disorders by their use of other methods of communication. Even more than a typically developing child, a child with a language disorder will rely on means of nonverbal communication. This child will make eye contact and use gesture as a means of communicating play, intent, wants, and needs. Children with language delays but not autism often involve the examiner in their play, both show and share objects, and display a sense of shared enjoyment. Some children are inflexible and unable to take the perspective of another child even when talking about their own interests. As noted before, many individuals on the Spectrum make less coordinated eye contact and use gesture only when it is specifically requested of them. Often these individuals have difficulty integrating these modes of communication. Again, ASD is a spectrum, and so it is important not to rule it out or in with a single characteristic.

When observing a child’s play or interests, it is helpful to note whether they are age appropriate and flexible versus narrow and repetitive. An individual may love Legos, for example, but when a friend visits who does not have an interest in Legos; he or she can ride bikes, play board games, or complete arts and crafts activities all the while taking turns and playing cooperatively. It is when an interest is so narrow that a child would rather do this alone and let his or her playmate be entertained by parents or siblings than try a different game, that it can be a concern.

Individuals who are so bossy and controlling that they can only play with a very passive sibling or peer may have social difficulties worth noting. For example, a child may obsessively line up or organize toys, rather than playing with them. If another child or parent attempts to change the order of the toys, and the child has a meltdown, he or she may be showing signs of autism (although this could also be due to anxiety or other condition). It can also be important to consider the age-appropriateness of the play. It should be noticed as peculiar and restricted when a child who is 15 years old shows an obsessive interest in Disney princesses or Thomas the Train. Further, a teenage girl who seems to have no interest in the latest music, styles, or celebrities, although not diagnostic in itself, may be considered atypical. In the evaluation, it is helpful to determine whether an individual can have conversations about areas of interests and about other topics introduced. An individual who ignores the examiner or makes a shift like “Well the spiders in Minecraft … .” may have difficulty conversing reciprocally. Each time a new topic is introduced, an individual may have challenges taking the perspective of others or being flexible. It also should be noted when the child is overly directive in play with the examiner. For example, he may only allow certain toys to be used in a precise manner, or refuse to share certain objects with the examiner. It is of note when a child will not use an object symbolically and can only use it as intended. For example, if the examiner tries to pretend that a fire truck is an ambulance or wants to make an animal talk and this is disallowed by the child, this pattern may be indicative of limited imagination or rigidity.

Social reciprocity refers to an individual’s ability to respond appropriately to comments or play initiation from the examiner. Often as evaluators, we find ourselves making comments such as “Today is my birthday!” or “My favorite fish passed away yesterday” so that we can evaluate a client’s social and emotional reciprocity. We make note of the response and its relevance. Some children with ASD may ignore a comment completely or provide a very factual response like “What color fish?” They may offer their own perspective without taking the examiner’s saying “My fish didn’t die.” Or “I don’t even have a fish.” A response considering the examiner’s perspective might be “Oh no, what happened.” Or “poor fish!” In response to “it’s my birthday,” an appropriate answer may be “Oh! How old are you?” or “Happy birthday!” while a response that fails to take perspective may be “Huh” or no response at all. In play, an examiner may take interest in a toy or do something silly with a character and look to see if the child laughs or plays along versus ignores or tells the examiner he or she is wrong. An example of a child struggling with flexibility and reciprocity in play would be “No, no he didn’t slip on the banana he’s over there reading the book!” “That dinosaur is a plant eater, he can’t eat the hot dog.” or “My guy (play figure) doesn’t want to play that game.” These responses could indicate challenges in reciprocity and perspective taking.

It is helpful to make notes on attention, even though this is a domain very frequently evaluated with direct measures and parent/teacher questionnaires. First, it is necessary to consider differences in attention across settings; to note observations of attention, and to compare these to testing and rating scale data. An individual who starts out the evaluation without focus but improves quickly may have been anxious at the start but has “warmed up” to testing. An individual who can attend to certain tasks but not others may have intermittent challenges with attention or motivation. Finally, an individual who maintains attention initially but this quickly wanes over the course of 3–4 h in office may have significant challenges with sustained attention. It is helpful to know whether an individual appeared attentive but made errors related to inattention or appeared inattentive but responded correctly. At times, evaluations assess attention only with rating scales. These authors suggest that it is important to consider rating scales, behavior observations of attention, and performance on direct measures to be thorough in the assessment of this domain.

When observing gross and fine motor skills, it is helpful to consider gross motor movements like walking, jumping on the trampoline, running, and balancing. Fine motor skills are observed by watching pencil grip as well as grip on any utensils, considering the speed of writing, and noticing whether fine manipulative objects (beads, coins) are well managed or often dropped. Observe a child snacking and taking breaks to notice fine or gross motor challenges. Very active younger children may climb all over the testing room and it is noteworthy whether movements are clumsy or agile. Studying a child’s hands, arms, and core strength (i.e., does he have good muscle tone or is he very thin and weak) can be very helpful. A clinician should note posture and stamina to complete tasks. Again this is an area to assess via rating scales and direct measures but observations can also provide useful information.

Mood and affect should be observed for congruence and integration, as well as the level of fluctuation in mood throughout testing the session(s). Individuals with ASD often have restricted or incongruent affect. An individual with restricted affect does not show typical appropriate levels of emotion when sharing personal stories or relating to the emotions of the examiner. A child with incongruent affect may discuss times when he or she has felt sad or angry while wearing a big smile. Other individuals may report feeling happy but affect is flat, sad, or anxious. The other issue examiners should look for is how consistent or fluctuating the affect is. It is important to note cheerful or depressed mood or inappropriately labile mood. Euthymic mood with congruent affect would indicate that an individual feels fine, and mood may not be of concern. Sometimes individuals may be initially anxious during an evaluation but become more comfortable as testing continues. Taken together, examiners should carefully note any time the individual’s mood shifts suddenly or seems inappropriate to the situation or conversational content.

Taking observations outside of the office or assessment center may add credibility when providing diagnostic information to parents, families, or treatment teams. In some cases with complex presentation, it can be helpful diagnostically to observe an individual in more than one setting. Often rating scales from parents, teachers, tutors, or other familiar individuals provides useful and clear information about the individual’s presentation in multiple environments. At other times, even with rating scales and interview data, the clinician feels unclear and may need to consider a naturalistic observation. Sometimes diagnostic clarification is not needed, but it may be helpful to observe an individual at home, work, or school to consider environmental variables or relationship dynamics that are impacting them. This can provide more information from which to tailor specific recommendations for best supporting a child or adult with an ASD. Collaboration between school and clinical teams, when this is possible, is very helpful for diagnosis and treatment. In the chapters on school-based assessment, authors revisit the value of school observations and clinician–teacher consultation in meeting a child’s needs.

Now readers have been exposed to the primary areas required for observation during a comprehensive evaluation. These include: behavior, appearance, language, eye contact and gestures, play and interests, social reciprocity, attention, motor skills, mood and affect, and naturalistic. Sometimes, examiners mistakenly underutilize observation as a tool in assessment. Often the data obtained from watching the child complete the testing is every bit as important as the data obtained from the assessments. These authors suggest that observations should occur throughout testing, from the waiting room, to the time the individual goes home for the day.

Often, examiners conduct the cognitive evaluation first in the series of assessments administered. One reason for this is that cognitive testing provides a foundation from which each other assessment can be compared. The other potentially helpful reason to conduct cognitive testing first is to observe the child’s approach to attacking test items, persevering on challenging tasks, and problem solving. To that aim, examiners should consider “Facilitators/Inhibitors” as a guide for making observations during cognitive testing.