Autism Screen and Assessment
Autism Screen and Assessment
Autism Screen and Assessment
The process of evaluating for autism spectrum disorders is complex and cannot be reduced to a single
score from a single test. Freeman, Cronin, and Candela (2002) highlight that “rating scales were not
designed to be used in isolation to make a diagnosis. They are useful to the clinician, but are only one
source of qualitative information for a comprehensive clinical assessment” (p. 148). Accurate
identification of autism spectrum disorder requires analysis of both qualitative and quantitative data
from a number of sources. As such, a quality assessment is dependent on the clinician – the most
important component of any evaluation process.
This section discusses the importance of a thorough developmental history and reviews autism
screening and assessment tools.
• Autism spectrum disorders are not rare. They are more prevalent in children “than cancer,
diabetes, spina bifida, and Down syndrome” (Filipek et al., 1999, p. 440).
• A growing body of research suggests that autism can be accurately diagnosed by age 2
(Bishop et al., 2008; Charman & Baird, 2002).
• Diagnosis of autism at age 2 is accurate and stable over time (Charman et al., 2005; Eaves &
Ho, 2004; Lord et al., 2006; Turner et al., 2006).
Developmental History
Autism is classified as “Pervasive Developmental Disorders” by the Diagnostic and Statistical
Manual of Mental Disorders-4th Edition, Text Revision (American Psychiatric Association, 2000);
therefore, accurate assessment must include a thorough developmental history.
Developmental history is best collected through an in-person interview with the child’s
parents/caregivers. Indeed, Filipek et al. (1999) stress the importance of parent/caregiver input
to the diagnostic process.
Critical areas to include in a developmental history are summarized in the listing below. Several
autism screening and assessment tools incorporate components of a developmental history
questionnaire. These are denoted with an asterisk (*) on the assessment tool table.
• Birth History
• Family History (immediate and extended)
• Pervasive Developmental Disorders
• Genetic or Medical Disorders
• Learning Disorders
• Emotional/Behavioral Disorders
• Medical History
• Medical Conditions (e.g., seizures, allergies, asthma, head injury/trauma)
• Hospitalization
• Sensory Differences
• Medication
• Hearing/Vision
• Previous Evaluations/Other Diagnoses
• Developmental Milestones
• Language/Communication
• Social
• Motor
• History of Regression or Interruption of development
• History of Interventions
Overview of Instruments
A number of tools are available for screening and diagnosis/identification of autism spectrum
disorders. This section provides an overview of such instruments and the relevant research.
Efforts have been made in the following to distinguish between screening and diagnostic tools.
For example, Charak and Stella (2001-2002) state that, “Screening instruments are intended to
help clinicians identify children who present with developmental delays and/or atypical
behavior for whom a diagnosis in the autistic spectrum may be considered . . . [those] who
should be referred for a more intensive diagnostic evaluation” (p. 6). The term “diagnostic”
instrument is misleading because no single instrument constitutes a sufficient basis for a
diagnostic decision. In practice, there is no distinct line where screening ends and diagnostic
assessment begins. The information gathered during screening is incorporated in the
comprehensive assessment process.
This section will provide a brief review of measures designed to capture descriptive information
from parents/caregivers, staff, and the student.
The Asperger Syndrome Diagnostic Scale (ASDS; Myles, Bock, & Simpson, 2001) is a norm-
referenced measure consisting of 50 yes/no items. The ASDS yields scores in five areas:
cognitive, maladaptive, language, social, and sensorimotor, as well as an Asperger Syndrome
Quotient (ASQ). The five subtests provide information comparing the behaviors of the
individual to the behaviors of individuals diagnosed with Asperger Syndrome (AS). The ASQ
indicates the probability of Asperger Syndrome. Any individual who knows the child or
adolescent well may complete the ASDS.
The Autism Behavior Checklist (Krug, Arick, & Almond, 2008) is a 57-item questionnaire
completed by parents or teachers. It is one component of the Autism Screening Instrument for
Educational Planning-Third Edition (Krug et al., 2008). The ABC is divided into five subscales:
sensory behavior, social relating, body and object use, language and communication skills, and
social and adaptive skills.
The Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & LeCouteur, 1994) is the 1994
revision of the ADI. The interview is conducted with parents or caretakers who have knowledge
about the individual’s current behavior and developmental history. The questions address the
triad of symptoms related to autism spectrum disorders – Language/Communication;
Reciprocal Social Interactions; and Restricted, Repetitive, and Stereotyped Behaviors and
Interests. The measure consists of 93 yes/no questions followed by probe questions, which are
scored on a scale of 0 to 2. Using a scoring template, the scores are converted into diagnostic
criteria based on the International Classification of Diseases-10th Revision (ICD-10; World Health
Organization, 1993).
The ADOS/ADOS-G (Lord, Rutter, DiLavore, & Risi, 2001) is a semi-structured, standardized
observational assessment tool designed to assess autism spectrum disorders in children,
adolescents, and adults. The ADOS-G was developed from the original ADOS (Lord et al., 1989)
and the Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS; DiLavore, Lord, &
Rutter, 1995). The ADOS-G is now commonly referred to, and marketed by the publisher, as the
“ADOS.”
The new instrument consists of four modules that cover a broader age and developmental
range. Each module consists of a variety of activities that provide the examiner with the
opportunity to observe social and communication skills associated with autism spectrum
disorders. The examiner selects a module based on the individual’s expressive language skills
and chronological age. The module takes approximately 30-45 minutes to administer.
Observations are recorded and scored by the examiner. The ADOS provides cutoff scores to aid
in interpretation.
The Autism Observation Scale (AOSI; Bryson, McDermott, Rombough, Brian, & Zwaigenbaum,
2000) is a semi-structured, play-based measure designed to identify early signs of autism in
high-risk infants (those who have an older sibling with autism). The AOSI is intended for infants
6-18 months. Seven activities provide opportunities to observe behaviors in the following areas:
visual tracking, disengagement of attention, orientation to name, reciprocal social smiling,
differential response to facial emotion, social anticipation, and imitation. Currently, the AOSI is
used as a research instrument. It is unpublished and is not commercially available.
The ASIEP-3 (Krug, Arick, & Almond, 2008) was developed to evaluate autism spectrum
disorders and assist in developing and monitoring educational programs for individuals on the
spectrum. The ASIEP-3 consists of the following five standardized subtests:
The Autism Spectrum Screening Questionnaire (ASSQ; Ehlers, Gillberg, & Wing, 1999) is
designed to screen for symptoms related to AS and other high-functioning disorders (HFA)
along the autism spectrum. The checklist consists of 27 items that are rated on a 3-point scale.
The scale has been studied with individuals between the age of 6 and 17. Estimated cutoff
scores are provided.
The Checklist for Autism in Toddlers (CHAT; Baron-Cohen, Allen, & Gillberg, 1992; Baron-Cohen
et al., 1996) is a brief screening questionnaire that is completed by parents and a physician
during the child’s 18-month check-up. Five key items are indicative of the risk of developing
autism: pretend play, protodeclarative pointing (expressing interest), following a point,
pretending, and producing a point. If a child fails the initial administration of the CHAT, it is
recommended that the questionnaire be readministered one month later. Any child who fails a
second time should be referred for formal autism assessment.
The Childhood Asperger Syndrome Test (CAST; Scott, Baron-Cohen, Bolton, & Brayne, 2002) is a
parent questionnaire designed to screen for Asperger Syndrome and other social and
communication disorders. The test consists of a 37-item yes/no parent questionnaire and was
designed for children 4 to 11 years old.
The purpose of the Childhood Autism Rating Scale (CARS; Schopler, Reichler, & Renner, 1988) is
to identify the presence of autism in children. Fifteen domains are rated on a 7-point Likert
scale (assigned values range from 1 to 4 – 1, 1.5, 2, 2.5, 3, 3.5, 4): Relating to people; Imitative
behavior; Emotional response; Body use; Object use; Adaptation to change; Visual response;
Listening response; Perceptive response; Fear and anxiety; Verbal communication; Nonverbal
communication; Activity level; Level and consistency of intellective relations; and General
impressions. Ratings from within normal limits to severely abnormal are based on observation,
parent interview, and other records. The Total Score, generated from the 15 domains, provides
a rating in one of three categories – nonautistic, mild to moderately autistic, or severely
autistic.
The Developmental Checklist-Early Screen (DBC-ES; Gray & Tonge, 2005) is an autism screening
instrument derived from the Developmental Checklist Parent/Primary caregiver report (DBC-P).
The DBC-ES is comprised of 17 items from the original checklist and is intended for children 18
to 48 months.
The Diagnostic Interview for Social and Communication Disorders (DISCO; Wing, Leekam, Libby,
Gould, & Larcombe, 2002) is an assessment tool for the diagnosis of Autistic Disorder,
Asperger’s Disorder, psychiatric disorders, and other developmental disabilities. The DISCO also
assists in intervention planning. The DISCO is intended to be used as part of a multidisciplinary
assessment battery. Parents or other caregivers participate in an interview that takes
approximately three hours. The interviewer rates items based on the informant’s responses.
The Early Screening of Autistic Traits (ESAT; Swinkels et al., 2006) is a 14-item screening
checklist for parents/caregivers. The questionnaire is designed for 14-month-old infants. The
tool is designed to be administered by health practitioners at well-baby visits. Failure on three
or more items suggests the need for a diagnostic evaluation.
The Gilliam Asperger’s Disorder Scale (GADS; Gilliam, 2003) is a 32-item questionnaire designed
to identify individuals with Asperger’s Disorder. The tool is comprised of the following
subscales: Social Interaction, Restricted Patterns, Cognitive Patterns, and Pragmatic Skills. The
GADS can be completed by parents/caregivers or teachers. Respondents indicate the frequency
of behaviors from “never observed” to “frequently observed.” The GADS includes a parent
interview form that inquires about language and cognitive development, self-help skills,
adaptive behavior, and curiosity. There is also a section of “key questions” for
parents/caregivers to complete.
The Gilliam Autism Rating Scale-2 (GARS-2; Gilliam, 2006) is designed for screening and
diagnosis of autism in individuals aged 3 to 22. It was normed on a sample of 1,107 individuals
from 48 states in the United States. The GARS-2 can be completed by parents, teachers, or
other caregivers who are with the individual regularly. The GARS-2 consists of three subscales:
Stereotyped Behaviors, Communication, and Social Interaction. The 42 items are rated based
on frequency and can be completed in 5 to 10 minutes. The GARS-2 also includes a parent
interview and questions to consider during diagnostic decision-making.
The Krug Asperger’s Disorder Index (KADI; Krug & Arick, 2003) is a screening instrument for
Asperger Syndrome. It is also a useful tool for developing goals for intervention. Two forms,
elementary (6-12 years) and secondary (12-21 years), cover a wide age range. The KADI is
divided into two sections. Section 1 is a pre-screening tool. Section 2 consists of additional
items, which are completed only if results of the screening tool indicate need for further
assessment.
The Modified Checklist for Autism in Toddles (MCHAT; Robbins, Fein, Barton, & Green, 2001) is
a 23-item yes/no questionnaire for parents and caregivers. It is designed to screen for autism in
infants 16 to 30 months. The MCHAT was based on the CHAT (Baron-Cohen, Allen, & Gillberg,
1992; Baron-Cohen et al., 1996); however, it does not include items that require
observation/administration by a physician. The authors of the MCHAT indicate that the
instrument purposefully yields more false-positives. A follow-up questionnaire helps screen
those who require further evaluation.
The Monteiro Interview Guidelines for Diagnosing Asperger’s Syndrome (MIGDAS; Monteiro,
2008) is a qualitative assessment tool designed for use by school-based evaluation teams to
assess Asperger Syndrome in children and adolescents. The MIGDAS consists of three tools:
Pre-Interview Checklist, Parent and Teacher Interview, and Diagnostic Student Interview.
Together, these tools help teams to gather qualitative information to assist in the diagnostic
process. Teams first complete the Pre-Interview Checklist, a brief yes/no questionnaire, to help
determine the need for an evaluation. The remaining interviews (teacher, parent, and student)
are completed only when a need has been identified. After completion of the evaluation, teams
discuss their qualitative observations and interpret the results.
The Pervasive Developmental Disorders Screening Test-Second Edition (PDDST-II; Siegel, 2004)
is a questionnaire designed to screen for autism in young children from 12 to 48 months. Three
versions were developed for different settings, referred to as stages: Stage 1: Primary Care
Screener; Stage 2: Developmental Clinic Screener; and Stage 3: Autism Clinic Severity Screener.
Stage 1 is intended for primary care settings. Stage 2 is intended for children who are receiving
developmental services, and Stage 3 is designed to help differentiate autism from other
pervasive developmental disorders. The PDDST-II may be administered to parents/caregivers as
a questionnaire or given in an interview format. Results are interpreted by a clinician.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, Lord, & Berument, 2003) is an
instrument for screening for autism in individuals over the age of 4 with a mental age over 2
years. The SCQ contains 40 yes/no items, which can be completed in less than 10 minutes by a
parent or other caregiver. The SCQ has two forms – the Lifetime Form, which focuses on
behavior throughout development, and the Current Form, which focuses on behavior during
the most recent three months. The instrument yields a Total Score for comparison to defined
cutoff points.
The Social Responsiveness Scale (SRS; Constantino & Gruber, 2005) is a 65-item questionnaire
used to assist in screening and diagnosis of autism. The tool can be completed by
parents/caregivers or teachers who are familiar with the student. Questions are rated on a 4-
point Likert scale. The test provides an overall score and five treatment subscales that can be
used for program planning: Social Awareness, Social Cognition, Social Communication, Social
Motivation, and Autistic Mannerisms.
The Screening Tool for Autism in Two-Year-Olds (STAT; Stone, Coonrod, & Ousley, 2000) is an
instrument for screening for autism in children between the ages of 24 and 36 months. This
instrument consists of 12 interactive activities administered within the context of play.
Behaviors in four social-communicative domains – play, motor imitation, requesting and
directing attention – are assessed, and performance on each item is rated as Pass, Fail, or
Refuse, based on specified criteria. The STAT may be given by a wide range of professionals, but
training in administration and scoring is required. Administration time is approximately 20
minutes.
The Social Communication Questionnaire (SCQ; Rutter, Bailey, Lord, & Berument, 2003) is an
instrument for screening for autism in individuals over the age of 4 with a mental age over 2
years. The SCQ contains 40 yes/no items, which can be completed in less than 10 minutes by a
parent or other caregiver. The SCQ has two forms – the Lifetime Form, which focuses on
behavior throughout development, and the Current Form, which focuses on behavior during
the most recent three months. The instrument yields a Total Score for comparison to defined
cutoff points.
The Social Responsiveness Scale (SRS; Constantino & Gruber, 2005) is a 65-item questionnaire
used to assist in screening and diagnosis of autism. The tool can be completed by
parents/caregivers or teachers who are familiar with the student. Questions are rated on a 4-
point Likert scale. The test provides an overall score and five treatment subscales that can be
used for program planning: Social Awareness, Social Cognition, Social Communication, Social
Motivation, and Autistic Mannerisms.
The current versions of these tools are identified accordingly in the Screening/Diagnostic
column in the table. Instruments not included in Charak and Stella’s selective review are
identified as screening or diagnostic based on the authors’ description. Several autism
screening and diagnostic/identification tools incorporate components of a developmental
history questionnaire. These are denoted with an asterisk (*).
Note: All summary and research tables in the remainder of this section are from Grossman, B.
G., Aspy, R., & Myles, B. S. (2009). Interdisciplinary evaluation of autism spectrum disorders:
From diagnosis through program planning. Shawnee Mission, KS: Autism Asperger Publishing
Company. Used with permission.
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Scambler, Rogers, 2-3 44 Discriminative Original CHAT authors’ criteria:
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Specificity = 100%
Slightly altered criteria:
Sensitivity = 85%
Specificity = 100%
Misconceptions
Myth Reality
Autism is a medical diagnosis. Currently no medical tests can be used to diagnose an
autism spectrum disorder. The disorder is identified
behaviorally.
If a student can pass the state exam and Educational need extends beyond academics and
make passing grades, he/she does not includes communication, social, emotional, and adaptive
have an educational need for special skills.
education.
Asperger Syndrome means that an Individuals with Asperger Syndrome have a pervasive
individual is high functioning and, developmental disorder. It is impossible to have a
therefore, does not require special “pervasive” disorder and not be significantly impacted.
education support and services. While many of these individuals are highly intelligent and
articulate, they do have significant impairments and most
often require supports and services in order to make
educational progress.
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Texas Statewide Leadership for Autism Training | March 2009 44
TARGET: Texas Guide for Effective Teaching
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