Assessment Protocol

for
Autism Spectrum
Disorder
Dr Qurrat Ulain Hamdan
MBBS (NUST,PK) FCPS Psych (Gold Medal, CPSP) OJT
CAMHS (UK), Certified ADOS-2 Administrator (Sunfield,
US)
Assistant Professor
Head dept of Child Adolescent Mental Health
Institute of Psychiatry
Rawalpindi Medical University
Learning Objective

 At the end of this workshop the participants will be

able to
 Define Autism Spectrum Disorder
 Identify key symptoms of ASD in children under 11 years
with minimal to average speech
 Understand the utility of various tools available for
assessment of ASD
 Understand the holistic approach to assessing a child
with ASD
 1 in 59 people are in the Autism Spectrum ( 2:1)

The common misconception that autism ‘looks’ a particular,

Autism outwardly obvious way remains a significant barrier to
accessing and receiving an autism diagnosis.

Spectrum Only 30% of Autistic people have a co-occurring intellectual

disability.4
Disorder:
Epidemiology Autism is a lifelong neurodevelopmental “difference”

Many People with Autism are diagnosed later in life – esp

females 1
 Recognising early signs of Autism
 Active screening vs passive screening
 Assessment of gross motor, fine motor, Speech, cognition and social
development
Recognising early signs of Autism

Paediatricians and
Teachers are best
Recognising Surveilliance vs spot
placed to pick
parental concern screening
subtle differences
over time

Have a standard set Myths and messages

of questions when online – why natural
ever you see a child medicine is popular
– esp 18-24 mothers – they offer a cure
Examination

General examination – get the child accustomed to your

equipment such as otoscopes / auroscopes

Pay attention to the child and get down to their level when
communicating with them

Give them some activity e.g drawing can help you assess –
communication, social, and fine motor skills

Exclude co-occurring disorders (DSM-5): ID, ADHD, anxiety,

Depression, sleep disorders, seizure disorders ( <5% have none)
 Growth – Ht/wt/HC

Motor issues → injury

Medical Vision and hearing

evaluation Dental – grinding and lack of brushing due to sensory

issues

Nutritional deficiencies arising from a selective diet (

sensory or parent imposed ) → iron def, vit C def etc

Injury → bolting, drowning, going missing

Management

AUDIOLOGY EYE CHECK REFERRALS FOR REFERRAL TO ALLIED

ASSESSMENT SPECIALIST HEALTH FOR EARLY
ASSESSMENT INTERVENTION
 Specialist
Management
 Blood test to exclude
metabolic disorders and
chromosomal abnormalities:
 FBC, LFT, UEC, CMP, TFT, CK
 Iron studies, Vit B12, folic
acid, Vit D, Serum lead levels
 Fragile X syndrome7
 CGH Array – one of the most
heritable neurodevelopmental
disease and associated with
several dozens of molecular
abnormalities linked to it.
 Urine for metabolic screen
Developmental screening

Screening tools are designed to help to identify children who might

have developmental delay

Screening tools are specific to some disorder area or general

• Example; autism, cognitive development and pediatric practice and school system.

Screening tools do not provide ultimate evidence of developmental

delays.

Screening tools do not provide in-depth information about an area of

development
Selecting screening tools
 Domains the screening tool covers
 Psychometric properties
 Screening tool
 Characteristics of children
 The setting
 Age and stage questionnaire (ASQ)

Modified checklist for autism in toddlers

(MCHAT).
Types of
Communication and symbolic behavior scale
screening (CSBS)

tools Parents evaluation and developmental sacle

(PEDS)

Screening tool for autism in toddlers and

young children (STAT)
Ages and Stages Questionnaire (ASQ)

 Comprehensive developmental screening tool designed to assess children's

milestones in various domains
 From the age of one month to 5 ½ years.
 Completed by parents or caregivers, involving a series of age-specific
questions related to a child's skills and behaviors.
 Covers communication, gross motor, fine motor, problem-solving, and
personal-social skills.
 Widely used in healthcare settings, childcare centers, and by educators to
track developmental progress.
Modified Checklist for Autism in
Toddlers, Revised (M-CHAT-R)
 Screening tool designed to identify risk for Autism Spectrum Disorder (ASD) in
young children (16 to 30 months)
 Comprises a series of yes/no questions based on observed behaviors,
completed by the child's parent or caregiver.
 Targets key developmental domains such as socialization, communication, and
behavior.
 Includes a scoring algorithm to help categorize the level of risk for ASD
 Positive screens may require additional evaluation and follow-up assessments
by healthcare professionals.
Communication and Symbolic Behavior
Scales (CSBS)
 Assess the communication and social development of young children (6m to
6y)
 Involves both parent/caregiver input and direct professional observation for a
holistic assessment.
 Social, Speech, and Symbolic Composites, covering a range of communication
behaviors.
 Aims to identify communication delays or challenges early, allowing for timely
intervention.
 Administered by trained professionals in collaboration with parents,
commonly used in early intervention and special education settings.
Diagnostic tool
To assess ASD in young
children there are many
tools, but single tool
cannot be used as basis of
diagnosis. Diagnostic tools
rely on two vital elements
(Parents and Caregivers).
In some cases, caretakers Such specialists include
give advice to parents to
refer their child to a
specialist for diagnosis. Neurodevelopmental
pediatricians
Developmental-behavioral
pediatricians
Child neurologist
geneticists
Early intervention programs
that provide assessment
services.
 Childhood autism rating scale
(CARS).

Autism diagnostic interview Revied

Examples of (ADI-R)
diagnostic
Autism diagnostic observation
Tools schedule Ver 2 (ADOS-2).

Gilliam rating scale second edition

(GRS-2)
Childhood Autism Rating Scale (CARS)

 Designed to assist in diagnosing and classifying children with autism based on

observed behaviors.
 Focuses on specific behaviors related to autism spectrum characteristics
 Utilizes a 15-point scoring system to categorize the severity of autism
symptoms.
 Covers areas such as socialization, communication, and repetitive behaviors
 Typically administered by trained professionals, the CARS helps in
understanding and evaluating the presence and severity of autistic traits.
 It should be part of a comprehensive assessment alongside other tools.
Autism Diagnostic Interview-Revised
(ADI-R)
 A comprehensive, semi-structured interview for diagnosing Autism Spectrum
Disorder
 Conducted with a caregiver or parent and involves a series of standardized
questions about the individual's behavior.
 Focuses on three main domains: Social Interaction, Communication, and
Restricted and Repetitive Behaviors.
 Gathers information about the individual's developmental history, helping to
assess behaviors across different age ranges.
 Utilizes a scoring system to categorize responses and aid in the diagnosis
process.
 Administered by trained professionals
Autism Diagnostic Observation
Schedule, Second Edition (ADOS-2)
 ADOS-2 is a widely recognized tool in the field, contributing to a thorough and
accurate ASD diagnostic process.
 Administered to individuals across different age ranges to observe and
evaluate social and communicative behaviors associated with ASD
 Involves a series of structured and semi-structured activities to observe social
interaction, communication, and play.
 Utilizes different modules tailored to the individual's age and language
abilities.
 Focuses on assessing social communication skills and the presence of
repetitive behaviors.
 Employs a standardized scoring system to quantify observed behaviors.
 Administered by trained professionals
Benefits of early
intervention
 Early detection, diagnosis and
treatment of autism provides
the strong foundation needed to
develop the skills for affective
communication and social
interactions. This life long
process takes a kick start at
school. Given the various
mental health co-morbidities, it
is essential to build their
confidence and self esteem at
an early stage
References

1. https://www1.racgp.org.au/getattachment/a11ddcc9-2820-4889-b33b-cd268513168a/Autistic-or-
with-autism.aspx
2. https://www1.racgp.org.au/ajgp/2021/march/identifying-and-supporting-autistic-preschoolers
3. https://www.autismspeaks.org/screen-your-child
4. Baio J, Wiggins L, Christensen DL, et al. Prevalence of autism spectrum disorder among children
aged 8 years – Autism and developmental disabilities monitoring network, 11 sites, United States,
2014. MMWR Surveill Summ 2018;67(6):1–23. doi: 10.15585/mmwr.ss6706a1
5. https://www.cdc.gov/ncbddd/actearly/milestones/index.html
6. https://www.racgp.org.au/getattachment/21c724bc-9280-4262-814f-77366aa9e640/Appendix-
3A.pdf.aspx
7. https://www.ncbi.nlm.nih.gov/books/NBK562231/
8. https://www.racgp.org.au/racgp-digital-events-calendar/online-event-content/national-guideline-
for-the-assessment-and-diagnosi
9. Hyman SL, Levy SE, Myers SM, Kuo DZ, Apkon S, Davidson LF, Ellerbeck KA, Foster JE, Noritz GH,
Leppert MO, Saunders BS. Identification, evaluation, and management of children with autism
spectrum disorder. Pediatrics. 2020 Jan 1;145(1).
DSM 5 Criteria for ASD
Domain A - Social Communication and
Interaction Deficits (All)

1. Deficits in Social-Emotional Reciprocity:

1. Lack of initiation of social interactions.
2. Limited or atypical responses to social overtures from others.
2. Deficits in Nonverbal Communicative Behaviors:
1. Poorly integrated verbal and nonverbal communication.
2. Abnormalities in eye contact and body language.
3. Deficits in Developing and Maintaining Relationships:
1. Difficulties adjusting behavior to suit different social contexts.
2. Difficulties in sharing imaginative play or making friends.
Domain B - Restricted, Repetitive Patterns
of Behavior (atleast 2)

1. Stereotyped or Repetitive Motor Movements, Use of Objects, or Speech:

1. Simple motor stereotypes or repetitive use of objects.
2. Echolalia (repetition of speech) or idiosyncratic phrases.
2. Insistence on Sameness, Inflexible Adherence to Routines, or Ritualized
Patterns of Verbal or Nonverbal Behavior:
1. Extreme distress at small changes.
2. Inflexible adherence to routines or rituals.
3. Highly Restricted, Fixated Interests:
1. Intense and specific interests that are abnormal in intensity or focus.
4. Hyper- or Hypo-reactivity to Sensory Input:
1. Unusual responses to sensory stimuli, such as heightened sensitivity or lack of
responsiveness.
Additional Criteria and Conclusion

1. Symptoms Must Be Present in Early Developmental Period:

1. Symptoms must be present in the early developmental period but may not become
fully manifest until social demands exceed limited capacities.
2. Symptoms Cause Clinically Significant Impairment:
1. Symptoms must cause clinically significant impairment in social, occupational, or
other important areas of current functioning.