What do professionals look for when they conduct an autism assessment?
The assessment of young people with autism spectrum disorders (ASD) is multi-dimensional and there are usually several reasons why an assessment is initiated. Clinical psychologists look at the overall evidence, the questions raised by the referral and the source of the referral before proceeding with an assessment. This will invariably involve screening those at risk for developmental delay characteristics associated with ASD.
Clear guidance should be followed when determining if a young person meets eligibility criteria for an assessment of an autism spectrum disorder. Collaboration between professionals, parents and teachers is a necessary component of an effective assessment process, if we are to ensure an accurate interpretation of all available information. As an assessing clinician, here are some of things I would be looking for in my assessment.
Empathy and communication
On meeting the young person in the clinic’s reception, one of the first signs that we are looking for is whether they can demonstrate appropriate eye contact when meeting new or unfamiliar people. During the assessment, we are also looking at how the young person uses sentences. For example, do they make frequent grammatical errors, and if they are making errors, are these errors age and developmentally appropriate? We are also interested in assessing the overall voice tone. For example, does the young person’s voice volume seem unusual, are there any speech abnormalities or are they difficult to understand?
One of the important aspects of the assessment process is to try and capture whether the young person willingly provides information to the assessor. People with ASD often find offering information particularly challenging and try and avoid being open about some of their experiences, especially to someone who is not familiar to them.
It is vital to try and gauge whether the young person enquires about other people’s thoughts, feelings and experiences, as this will help provide another indication of the young person’s ability to engage in reciprocal interactive communication. We need to find out if the young person takes part in social chit-chat, and what the quality of their social engagement is like when interacting with peers. How does the young person react when someone says something to them or offers new information? For instance, does the young person comment on what is being said, then wait for a response and finally respond to the response?
We will also assess whether the young person can give a reasonable account of non-routine, every day events in a matter of fact way.
Throughout the assessment we are looking at the quality of eye contact the young person exhibits and if they are using this to regulate, initiate and terminate discussion. We are also checking if the young person uses pointing, nodding and shaking their head to communicate.
Social interaction skills
During the assessment, assessors strive to create a comfortable, interactive environment that could lead to conversations. We are also constantly evaluating responses and comments and the level of effort we need to employ to facilitate social interactions.
We observe how the young person uses directed facial expressions for the purpose of communicating effective enjoyment or frustration. Was the young person able to be appropriately responsive to the social situations presented to them?
We look at the quality of responses to standardised questions and how contextually appropriate they are. Another key indicator is whether a comfortable rapport is developed between the young person and the assessor or whether the young person is socially awkward.
Social overtures are observed in detail during assessments. If the young person displays restricted personal demands or only wants to focus on their interests, these factors can be vital clues in the overall assessment process. Assessors will look in detail at the young person’s insights into interpersonal relationships and how the underlying dynamics of relationships work for them. Examples might include asking the young person to comment on how they think relationships work and what their primary function is. Can they explain their own role in social relationships?
Those with autism will usually struggle with their social perspective taking skills and thus find reporting on friendships a challenge. It is important to explore understanding of the main difference between, for example, someone they meet at school on the playground and a friend. Young people with autism will usually find this very challenging.
We seek to understand how the young person labels the emotions of characters in stories we present to them and whether they are able to demonstrate empathy towards the characters involved. We are trying to assess if the young person can make sense of emotions.
Understanding feelings of loneliness is a key to understanding the inner world of a young person who may have autism. Equally, we are assessing whether the young person can tell if other people their age feel lonely. Several questions are posed around the concept of loneliness and the young person is asked to provide solutions for those who are deemed to be lonely. Most young people with autism find it hard to think that others can get lonely and can they struggle to come up with practical solutions to this dilemma.
Another key area in the assessment process is finding out what the young person thinks makes them happy, angry, sad, relaxed and afraid. These responses provide crucial clues to the young person’s inner emotional world. Once they have identified why they experience the emotions they do, the next task is for them to try to explain how this makes them feel.
The young person is encouraged to create a story that involves pretend play. This can enlighten us as to how the young person sees the world and how they use their imagination. Those with autism tend to struggle getting fully immersed in pretend play.
During assessments, we are also assessing whether the young person exhibits an adaptive capacity to think logically and coherently. Do they struggle to come to reasonable conclusions about social relationships and events? Do they depart from the conversation and display slightly strained reasoning and slightly loose associations, for example answering questions by talking about topics not linked to the conversation?
Each individual part of the assessment should be seen as part of a complex puzzle and should not be interpreted in isolation. We are looking to see if the young person displays communication characteristics similar to a young person with autism. During the assessment, did they engage with the assessor, was there a sense of reciprocity in interaction and how did they use gestures and other social cues to communicate? Does the young person display empathy and how do they understand social relationships?
To determine if a person is on the autistic spectrum we need to consider a wide range of interrelated factors, including their social interaction skills, communication skills and ability to empathise and understand emotions in others.
Dr Mark Chapman is a Clinical Psychologist at Springfield University Hospital, Tooting and Saba Khan is an Assistant Psychologist at CAMHS Neurodevelopmental Team, Springfield University Hospital: