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

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## What is a "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above.
Want even 'more' information about this topic? There's an extended version of this page here.

## 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

| Demography | Setting (Reference) | Base Rate | Diagnostic Method |
| 11 ADDM sites | Autism and Developmental Disabilities Monitoring (ADDM) Network (2014) - 8 year olds *** | 1.5% (1 per 68) | Diagnosis by doctor based on DSM-IV-TR criteria |
| Epidemiological: 43,283 household surveys | National Health Statistics Report (NHIS; 2014), 3-17 year olds | 2.2% (1 per 45) | DSM-IV-TR |
| 11 ADDM sites: Male/Female Ratio | 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 |
| Came from family registry for those who had children under 18 years old in United States | Interactive Autism Network (IAN): Individual Sibling Recurrence | ASD status occurred in an additional child in 10.9% of families | DSM-IV-TR |
| 11 ADDM sites (Race/ethnicity study) | 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 |
| Male/Female Ratio | Epidemiological study: Review of 43 studies | 4.2% (4.2 male:1 female) | DSM-IV/Rating Scales/Clinical |
As noted above, the base rate of autism diagnosis is greater in males compared to females. However, research indicates that this sex difference could be due to a number of factors, perhaps leading to the under-identification of females with autism. Indeed, there is evidence that differential item functioning exists for some diagnostic screening tools for males and females with autism. Care must be taken to ensure that the manner in which autism symptoms are identified and assessed are not unduly influenced by sex, further perpetuating sex differences in the rate of diagnosis.

## 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 | Where to Access |
| Modified Checklist for Autism in Toddlers (M-CHAT) | Questionnaire (Parent report) | 16-30 months | 5-10 minutes / 20 questions | 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 |
| Childhood Autism Rating Scale (CARS) | Observation | 2 years-adult | 5-10 minutes | Not free |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.
In light of the COVID-19 pandemic, efforts have been made to develop autism screening tools that can be administered remotely. One such tool is the Brief Observation of Symptoms of Autism (BOSA), to be used by ADOS-trained clinicians and researchers. ROC analyses suggest high sensitivity and specificity, as well as high convergent validity with the ADOS.

### 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) | 12 months- 30 months | 40-60 minutes |
| Autism Diagnostic Interview, Revised (ADI-R) | 18 months- adult | 90-150 minutes |
| Adaptive Behavior Assessment System, Second Edition (ABAS-II) | Birth- 89 years | 20-30 minutes |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

### 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.