# Evidence-based assessment/Autism spectrum disorder (assessment portfolio)/extended version

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Evidence-based assessment/Autism spectrum disorder (assessment portfolio)/Sidebar

## What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above.
Does this page feel like too much information? Click here for the condensed version.

## Preparation phase
### Diagnostic criteria for autism spectrum disorder

   ICD-11 Diagnostic Criteria:
   Autism spectrum disorder is characterized by persistent deficits in the ability to initiate and to sustain reciprocal social interaction and social communication, and by a range of restricted, repetitive, and inflexible patterns of behaviour and interests. The onset of the disorder occurs during the developmental period, typically in early childhood, but symptoms may not become fully manifest until later, when social demands exceed limited capacities. Deficits are sufficiently severe to cause impairment in personal, family, social, educational, occupational or other important areas of functioning and are usually a pervasive feature of the individual’s functioning observable in all settings, although they may vary according to social, educational, or other context. Individuals along the spectrum exhibit a full range of intellectual functioning and language abilities.
   Note: The ICD-11 contains seven subcategories of ASD that can be found in the ICD-11, here.
   ASD encompasses these previous DSM-IV diagnoses:
   * Autistic disorder (autism)
   * Asperger’s disorder
   * Childhood disintegrative disorder
   * Pervasive developmental disorder not otherwise specified
   ASD is characterized by:
   * deficits in social communication and social interaction and
   * restricted repetitive behaviors, interests, and activities (RRBs).
   Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.
   Changes in DSM-5 Criteria
   * The diagnostic criteria for ASD changed from DSM-IV to DSM-5. Summaries are available here and here.

### Base rates of ASD in children and adolescents in different populations and clinical settings

| Year | Country | Sponsor of Study | Demography | Base Rate Type | Setting (Reference) | Base Rate | Diagnostic Method | Base Rate Estimation Procedure | Best Recommended For |
| | USA | | 11 ADDM sites | Population Prevalence | Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) - 8 year olds *** | 1.5% (1 per 68) | DSM-IV-TR | | ***This is considered a respected current estimate of the rate in the general population |
| | USA | | Epidemiological: 43,283 household surveys | Population Prevalence | National Health Statistics Report (NHIS; 2014), 3-17 year olds | 2.2% (1 per 45) | DSM-IV-TR | Phone interviews (caregiver report) from 43,283 parents with children ages 3-17 yrs-- checklist of diagnoses was based off of DSM-IV-TR language | |
| | USA | | 11 ADDM sites: Male/Female Ratio | Population Prevalence | The Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) – 8 year olds | 1 in 42 boys (2.4%), 1 in 189 girls (.05%) | DSM-IV-TR | | |
| 2010 | USA | ADS | Came from family registry for those who had children under 18 years old in United States | Family Reoccurrence | Interactive Autism Network (IAN): Individual Sibling Recurrence | ASD status occurred in an additional child in 10.9% of families | DSM-IV-TR | 2,920 children from 1,235 families participating in a national volunteer register, with at least one child clinically affected by ASD and at least one full biological sibling | |
| | USA | | 11 ADDM sites (Race/ethnicity study) | Population Prevalence | The Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) – 8 year olds Race/Ethnicity: Non-Hispanic White Non-Hispanic Black Hispanic Asian | Non-Hispanic White: 1 in 63 (1.6%) Non-Hispanic Black: 1 in 81 (1.2%) Hispanic: 1 in 91 (1.1%) Asian: 1 in 81 (1.2%) | DSM-IV-TR | | |
| | USA | | | Family Reoccurrence | The Autism and Developmental Disabilities Monitoring (ADDM) Network (2010) – 8 year olds Race/Ethnicity - Non-Hispanic White - Non-Hispanic Black - Hispanic - Asian - Other | 60.3% 15.7% 17.2% 3.3% 3.5% | DSM-IV-TR | | |
| | USA | | Male/Female Ratio | Population Prevalence | Epidemiological study: Review of 43 studies | 4.2% (4.2 male:1 female) | DSM-IV/Rating Scales/Clinical | | |

## Prediction phase
### Psychometric properties of screening instruments for autism spectrum disorder

The following section contains a list of screening and diagnostic instruments for autism. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
| Measure (Wikipedia Link) | Format (Reporter) | Age Range | Administration/ Completion Time | Free and Accessible Measures |
| Modified Checklist for Autism in Toddlers (M-CHAT) | Questionnaire (Parent report) | 18-30 months | 5-10 minutes | Free printable PDF MCHAT Free Online MCHAT |
| Autism Spectrum Quotient (AQ) | Questionnaire | 16 years and up | 10-15 minutes | Online version with scoring AQ free printable PDF Printable scoring guide |
| Parent Interview for Autism (PIA) | Questionnaire (Parent report) | 2-6 years | 15-20 minutes | PIA-CV printable version |
| Social Communication Questionnaire (SCQ) | Questionnaire (Parent report) | 4 years-adult | 10 minutes | Not free |
| Pervasive Developmental Disorders Behavior Inventory (PDDBI) | Questionnaire (Parent report) | 1-17 years | 10-15 minutes | Not free |
| Autism Diagnostic Observation Schedule (ADOS) | Direct Testing | 2 years-adult | 30-50 minutes | Not free |
| Autism Diagnostic Interview-Revised (ADI-R) | Questionnaire | 18 months-adult | 90-150 minutes | Not free |
| Childhood Autism Rating Scale (CARS) | Observation | 2 years-adult | 5-10 minutes | Not free |
| Mullen Scale of Early Learning (MSEL) | Direct testing | Birth-68 months | 15-60 minutes | Not free |
| Differential Ability Scales (DAS) | Direct testing | 2.5-17 years | 25-65 minutes | Not free |
| Wechsler Intelligence Scale for Children-IV (WISC-IV) | Direct testing | 6-16 years | 50-70 minutes | Not free |
| Stanford-Binet Intelligence Scales V | Direct testing | 2-85 years | 45-75 minutes | Not free |
| Leiter- Revised | Direct testing | 2-20 years | 25-90 minutes | Not free |
| Clinical Evaluation of Language Fundamentals (CELF) | Direct testing | 3-21 years | 30-45 minutes | Not free |
| Peabody Picture Vocabulary Test (PPVT) | Direct testing | 2.5-90+ years | 10-15 minutes | Not free |
| Expressive One-Word Picture Vocabulary Test-2000 (EOWPVT-2000) | Direct testing | 2-18 years | 10-15 minutes | Not free |
| Test of Language Competence (TLC) | Direct testing | 5-18 years | <60 minutes | Not free |
| Children's Communication Checklist (CCC) | Questionnaire | 5-17 years | 10-15 minutes | Not free |

### Likelihood ratios and AUCs of screening measures for ASD

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
* Screening Measure (Primary Reference)
* Modified Checklist for Autism in Toddlers (M-CHAT)
* Autism Spectrum Quotient (AQ)
* Parent Interview for Autism (PIA)
* Social Communication Questionnaire (SCQ)
* Pervasive Developmental Disorders Behavior Inventory (PDDBI)
* Autism Diagnostic Observation Schedule (ADOS)
* Childhood Autism Rating Scale (CARS)
* Mullen Scale of Early Learning (MSEL)
* Differential Ability Scales (DAS)
* Wechsler Intelligence Scale for Children-V (WISC-V)
* Stanford-Binet Intelligence Scales V
* Leiter- Revised
* Clinical Evaluation of Language Fundamentals (CELF)
* Peabody Picture Vocabulary Test (PPVT)
* Expressive One-Word Picture Vocabulary Test-2000 (EOWPVT-2000)
* Test of Language Competence (TLC)
* Children's Communication Checklist (CCC)

### Interpreting autism screening measure scores

* For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

* For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Recommended diagnostic interviews for autism spectrum disorder

Diagnostic instruments for ASD :
| Measure | Age Range | Administration/ Completion Time |
| Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) | | |
| Autism Diagnostic Interview, Revised (ADI-R) | 18 months-adult | 90-150 hours |
| Vineland Adaptive Behavior Scales-Second edition (VABS-II) | Birth-18 years | 20-60 minutes |
| Adaptive Behavior Assessment System, Second Edition (ABAS-II) | | |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Process phase

The following section contains a brief overview of treatment options for autism and list of process and outcome measures for autism. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

### Process measures

The following section contains a list of process and outcome measures for autism. The section includes benchmarks based on published norms and on those on the spectrum samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.
   There are many processes that may be considered important when evaluating a child or an adolescent with ASD; however, due to the diversity of the population and symptom expression, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The two measures provided below are commonly used to assess adaptive behaviors (including communication and socialization, core deficits in ASD) and may provide important information regarding levels of daily functioning of individuals with ASD.

### Outcome and severity measures

This table includes clinically significant benchmarks for autism specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks for ASD outcome measures :
| Benchmarks Based on Published Norms ||||||||
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Measure | Subscale | A | B | C | 95% | 90% | SE$_{difference}$ |
| CBCL T-scores (2001 Norms) | Total | 49 | 70 | 58 | 5 | 4 | 2.4 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 1 Social Affect Total | 8.1 | 12.5 | 10.2 | 2.3 | 1.9 | 1.1 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 1 RR Total | 0.4 | 4.4 | 2.7 | 1.1 | 0.9 | 0.5 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 2 Social Affect Total | 7.7 | 10.4 | 9.1 | 2.0 | 1.7 | 1.0 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 2 RR Total | 1.2 | 4.9 | 3.2 | 1.1 | 0.9 | 0.6 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 3 Social Affect Total | 3.7 | 9.8 | 7.1 | 2.1 | 1.8 | 1.1 |
| Autism Diagnostic Observation Schedule - Generic (ADOS-G)$^{6,12}$ | Module 3 RR Total | -0.4* | 3.3 | 1.9 | 0.9 | 0.8 | 0.5 |
| Childhood Autism Rating Scale (CARS) | Parent Total | 23.0 | 18.0 | 18.6 | 1.6 | 1.4 | 0.8 |
| Social Responsiveness Scale (SRS) Caregiver Report (Appendix B) | Total | 72.7 | 62.8 | 66.8 | 11.3 | 9.5 | 5.8 |

### Treatment

* Please refer to the page on Autism Spectrum Disorder for more information on available treatment or go to Effective Child Therapy for a curated resource on effective treatments for ASD.

## External Resources

* ICD-10 diagnostic criteria
* Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
* NIMH (information about schizophrenia)
* https://www.autismspeaks.org/what-autism/diagnosis/mchat Free online autism screen for toddlers
* OMIM (Online Mendelian Inheritance in Man)
** 209850
* Effective Child Therapy information on Autism Spectrum Disorder
** Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.