Hey everybody, welcome back to another episode of The Testing Psychologist podcast. I am Dr. Jeremy Sharp. Good to be with you.
Today, I will apologize right off the bat for my scratchy voice. I have had this summer chest cold over the past week or so that is not going away. I don’t feel too bad, but the scratchiness is still there. So sorry about that. Bear with me here as I talk to you today. Hopefully, this will be gone within another week or so.
[00:01:00] Welcome. Good to be back doing podcasts again after a big break. I got back to it last week. I’m excited to be doing some more episodes and moving on with talking about testing.Today is exciting. Just on a little more personal note, I talked last time about coming back from Slow Down School and having some time to reflect and shift and change things here. Today is the first day that I’m putting some of those things into play. The fact that I’m here recording podcasts for probably the next 2 or 3 hours is a direct result of Slow Down School. Before this, I was doing it mainly on the weekends. Sometimes I’ll be able to squeeze one in during the week, but I was not doing a great job managing [00:02:00] my time. So, this is one of the first things that I set up. I got every other Thursday blocked out just for podcasts. I’m going to batch the episodes, record a few right in a row, do the editing, and get them all scheduled. I’m excited. This is cool. So this is episode number one for today, and we’ll be rolling with podcasts for 2 hours.
Today, I am going to be talking about my ideal battery for an Autism Spectrum assessment in both Kiddos and adults. There’s not a ton of variation there, but I will go into some of the differences, but I’ll focus mainly on kids again. That’s what I do, of course. And so, I’ll talk mainly about autism spectrum evals with kids and a little bit with adults as well.
Now, I should say, before I get going, everybody is going to have variations in their batteries. So this is not the gospel by [00:03:00] any means, but this is what I have found to give me the best information and to allow me to make what I think is a pretty accurate clinical assessment of functioning whenever the question is autism spectrum. So there will be some variation too, of course, depending on the age even of the kiddo, but I’ll generally talk about how I approach autism spectrum assessment and what measures I use. I get a lot of questions about this. I’m excited to tackle it and get into some practical assessment tools.
First of all, the standard of care for autism spectrum assessments guides us here pretty clearly. It says that an effective interview is really important, and then we try to couple that with an [00:04:00] observation, at least one behavioral checklist, and the ADOS. Those are the core components of my autism spectrum batteries. I do add other things in there to give me additional information, but those are the bedrock of each ASD eval that I do.
Starting with the interview, people will approach this differently. There is a comprehensive structured interview tool called the ADI-R. Sorry, that was super fast. ADI-R, Autism Diagnostic Interview-Revised. I will use this for young kids because it is geared toward those early developmental ages or stages. I found that if I try to ask parents all the questions from the ADI-R [00:05:00] at a point when the kiddo is older, they don’t remember or it’s unclear. The data isn’t as good. It’s almost too detailed for a kiddo who’s older in my practical experience. So, I’ll use the ADI-R usually up to about five, let’s say.
After that, I do what I call a modified version of the ADI-R, where I went through and picked out some of, I’d say the main themes and some specific questions, but I picked out the questions that map most closely onto the diagnostic criteria in the DSM-5. I’ll ask about language. When did parents first notice that there was something wrong? What were their concerns? Do they have any regressions in [00:06:00] language, any regression in other skills? How do they communicate before they had a coherent language? Did they have sign language? Did they use parents’ body parts to communicate or try to manipulate objects?
So I ask a lot about language and communication. Certainly, I ask about nonverbal stuff. So, eye contact, facial expressions, gestures, those sorts of pieces. I also ask them about reciprocity. Can they go back and forth in conversation? Can they make small talk? Do they seem to understand the idea of asking questions and showing interest in others? Do their facial expressions seem to match what they’re saying and mirror what’s being said in the conversation or reflect that accurately? So I ask a lot about reciprocity and [00:07:00] conversational skills.
Also, I ask about, of course, repetitive behavior. Did they line toys up when they were younger? Did they have a need for organization? Did they have hand mannerisms or other repetitive physical behavior? Do they repeat any phrases? Do they have quirky phrases? I run down a whole list of questions around that as well.
I also tend to end this modified ADI-R asking about strengths. And that’s another way to weave in the special interest component. So I’ll ask, is there anything that your kiddo is really good at, almost like he’s an expert in that subject? There’s often an answer to that. They’ll say, yeah, he knows everything about cars. He can identify cars when they’re 100 yards away without even seeing them, something like that. It’s a nice way to end the interview.
For kids older [00:08:00] than… I do that modified ADI-R until probably about, let’s say 12. And then again, past that, unless you have a parent who was keyed into early developmental milestones, they, in my experience, don’t tend to remember that stuff very clearly. So after about 12, I will do a standard clinical interview where I ask about all of the important components: the social piece, the reciprocity, and the repetitive behavior. But I’ll also… I had a lot of questions about friends. How do they make friends? Have they had friends over the course of their lives? Do they feel comfortable in groups? Do they know how to approach groups of kids? What does it look like when they interact with other kids? Do they have people over? Do they do sleepovers Do they get invited to birthday parties? All kinds of things around social as that gets a lot [00:09:00] more important as kids reach that late elementary, middle school age.
I also, of course, in the clinical interview, we are ruling out any number of other things that might look like autism spectrum. I would certainly be asking about anxiety, ADHD, and sensory issues. That’s part of the diagnostic piece, but I’m going to try to get at that as well. Also, asking about OCD Tics. Those are probably the big ones that I can think of right off the top of my head.
I know some people out there are probably saying well, what about thought disorder? That’s certainly a valid concern. I have a lot, not a lot, I’ve run into, let’s say several kids and young adults over the years where they come across as quirky and a bit [00:10:00] odd but they don’t necessarily meet the criteria for autism spectrum. So I’m always considering a thought disorder and will ask some of those questions too to try to get it prodromal thought issues or even florid psychotic things that might be going on.
So, good clinical interview. As I’ve said, my interviews tend to be about 2 hours to start with just with the parents. That forms a nice base to know where to go from there.
From that point, the next point of contact in the actual evaluation is typically a school observation. So I will do a school observation for pretty much anyone suspected to be on the spectrum. With other concerns, I tend to stop doing school observations when the kid gets to high school, it’s just harder to observe behavior [00:11:00] and kids tend to hide things a little better, but with autism spectrum, I will do school observations all the way up through high school. I think you get a lot of valuable information there.
In our district, I can be in the schools for about an hour most of the time regulation-wise. They ask me to take off after that, but you might be able to get a little bit longer time. The way that I go about that is I have our admin assistant simply get in touch with the principal and the school counselor. We usually do an email with both of those individuals copied and explain that I’m a psychologist. I am working with this particular student. We do have a release of information to conduct an observation in the school. Here are the details. I typically stick around for an hour. It’s anonymous. I don’t interact with the students. I don’t disrupt the educational process at all. Would that be okay if I come in and [00:12:00] sit in the room for an hour? Thus far, I’ve gotten no rejections. Fingers crossed that that’s not going to start happening here after 10 or 12 years.
So school observation is super important. I’ve talked about school observations on here before. There was a whole episode dedicated to doing a school observation. So, I’m not going to go into a ton of detail with that, but very briefly with kids on the spectrum, I will try to catch an academic period certainly, but I’m honestly more interested in the social component.
So I will make sure to get a recess time or a lunchtime or at the very least, an unstructured classroom time where they’re interacting with peers, doing small group stuff, or transitioning between classes so that I can get some sense of how they’re socializing with their peers. [00:13:00] And that has proven so valuable over the years just to be able to get some sense of that. Otherwise, it’s tough. You’re trying to make a diagnosis for a pretty huge set of criteria. Criteria A of the ASD diagnostic criteria is all about social stuff. So if you don’t have any idea how the kiddo is interacting with peers, that makes it tough. So school observation is the next point of contact. And then finally, we will bring the kiddo in for the actual testing.
Now, with kids up to 17, here are the core measures that I tend to use for an ASD battery. I pretty much always we’ll do the WISC. I prefer the WISC for an intelligence test. If there is any concern whatsoever for academic issues, [00:14:00] I will do the WIAT. That’s my preferred achievement test at this point. That was largely dictated by our school district. They have a set of criteria for tests that they will accept from outside providers as valid. That’s a whole other conversation, but our school district prefers the WIAT. So that’s what I use.
In some cases, I can certainly look for variation in academic skills and that can also help with areas of strength or spike skills. There’s some concern about that diagnostic label of nonverbal learning disorder. So, of course, it can be helpful to have some information around math skills. Again, that’s a whole other conversation we could get into in VLD and what that means and how that relates to autism, but maybe another podcast episode, for now, I will [00:15:00] just say that the WIAT is a part of the battery. And like I said, it gives you some good info with with math and many spike skills or weaknesses that might be present.
Now, this is where I vary a little bit, I think from some other folks. I will do the Rey Complex Figure test and the CVLT-C. I do those because I feel like I get a lot of good information from Rey in terms of how the child approaches the task. Often with kids on the spectrum, I’ll see a lack of appreciation for that larger figure and a much more piecemeal approach. I find that it gives me really concrete data to show parents too, to illustrate how the ASD mind might work.
I can say, okay, you see this, this is the big picture. This is what it would look like to have [00:16:00] integration of all these details in a coherent picture of this figure. Your kiddo instead is focusing on all of these tiny details and isn’t really sure how to tie them all together. That’s representative of the social skills situation. And so, I take that and use that as a springboard for explaining how the brain works to some degree. So I like the Rey.
I do the CVLT just to again, get a sense of how they are taking in information and organizing information. I think there are so many variables on the CVLT to look at, but a big one that I will look at is whether they have a big difference between the semantic and the serial clustering ratios. Are they learning the list based on categories or are they learning the list just based on memorization? I see a lot of kids on the spectrum who try to simply [00:17:00] rotely memorize the list rather than organizing by some sort of larger category. So I do those two for learning and memory and some additional info.
I do several subtests from the D-KEFS as well, which is an executive functioning battery. I do Color-Word Interference. I do Tower. I typically do Trails. Depending on the age of the kid, if they’re younger, I will do 20 Questions. If they are older than 16, I believe is the cutoff, I will do Proverbs. 20 Questions and Proverbs both get at abstract verbal reasoning and can they generalize to categorical reasoning or in the case of Proverbs, are they interpreting these statements literally or can they understand idioms? Do they understand metaphor? [00:18:00] So it really gets at that literal communication piece, which I think is valuable.
I do find sometimes that Proverbs can produce a lot of false negatives in the sense that bright folks on the spectrum or maybe who have read a lot or something like that can do pretty well in Proverbs. So that’s something to watch out for.
So if there’s a question of attention issues, of course, each of those can help as well. But if there is a question of ADHD, I’ll also give the Conners Continuous Performance Test (Conners CPT 3™). Again, we could have a whole conversation about performance tests or continuous performance tests, but that’s what I use.
Personality-wise, for older individuals, I typically prefer the PAI-A. I think it’s easier and more manageable than the Millon Personality Inventories. So I’ll do the PAI-A. [00:19:00] I don’t think any personality inventory honestly is great for folks on the spectrum, but for me, the Millon, the way the questions are worded, if you get someone who is interpreting those questions very literally, you can end up with a lot of funky answers. And so, I prefer the PAI-A. I think it’s a little more grounded and leaves less room for some of that misinterpretation via literal interpretation.
Getting back to that standard of care, checklists are super important for me. I used to do all of those typical ASD checklists like the CARS and the GARS and ASRS I think was one or ASDS, but I don’t know, but there are a lot out there. 2 maybe 3 years ago, maybe more than that, I finally dug in and figured out research-wise there aren’t a lot of [00:20:00] checklists for ASD that have great support. What I have settled on is I will typically only do the SRS-2 and in some cases I will also give an SCQ if for some reason the interview didn’t go very well or I feel like I need more information about that early developmental period.
The SCQ was derived or maps onto the ADI-R. It’s much shorter, but it gets at some of those core symptoms. It does give you a standardized measure of those symptoms. So I will sometimes give the SCQ, but not very often. So that leaves me with autism spectrum-specific questionnaires, I will just do the SRS-2.
I’m also a big fan of the BASC-3. The newest version, the three, they have a lot of good research and there’s a lot of good information in the manual actually about typical [00:21:00] profiles of folks on the spectrum. So I do the BASC-3. Again, if there’s a question of ADHD, I will do the Vanderbilt or the snap forward, depending on the age of the kiddo.
What else? If there is a question of adaptive functioning, then I will throw the ABAS-3 in there as well. I know people, you may go back and forth with the Vineland or the ABAS for adaptive functioning, but here in our community, our local community-centered board, the agency that provides adaptive services, they switched over and preferred the ABAS at some point. So I just switched to match that.
That is my core autism spectrum battery for kids. That’s basically anyone under 17. That’s the battery that they would get. Oh, and I should go back. Sorry. I forgot that I also do the BRIEF. [00:22:00] I love the BRIEF. At this point, we’re on the BRIEF-2, but I think it’s great. It’s still one of the best predictors of executive functioning skills. With the BRIEF in particular, of course, we’ll look at that cognitive flexibility and shifting. So emotional regulation can be important as well. That is my autism spectrum battery for kids under 17.
Now, once they get over 17, you have that gray area where kids might still be in high school. So a lot of those elements will remain the same. Of course, we switch to the WAIS when they get to be 17. A lot of the others stay the same, to be honest. The personality measure, I will flip over to the PAI, just the regular, adult version of the PAI.
The cool thing about [00:23:00] kids getting older is that it introduces more self-report measures. So I will give the self-report BASC. If they’re over 18 and certainly young adult territory, I will give the self-report SRS-2 as well. I still I’m doing the rule-outs and the interview. I’m still giving behavior checklists to as many informants or other sources of data as I can, but generally, the battery remains the same.
At this point, some of you are probably saying, wait a minute, what about the ADOS? Honestly, the ADOS is part of the battery, of course. We’re on the ADOS-2 at this point. As I was talking, I realized I assumed that everybody knew that I would do the ADOS. But just to make that very explicit, the [00:24:00] ADOS 2 is a huge part of the battery. And again, part of that standard of care. So yes, I’m always doing the ADOS -2 no matter what the age. Of course, you get into which module is appropriate and there’s a lot of great information in the manual but at this point, I think that we are still very much tied into the ADOS as a measurement tool for ASD.
Now, I know that the authors have made some statements over the past several months, maybe 2 years about getting away from using that term gold standard for the ADOS. I think for a while we got into the mindset that the ADOS was the only thing that you needed for an autism spectrum assessment. I’ve heard some things the authors have spoken out against that a bit where they’re saying, no, [00:25:00] wait just a minute. We need this more of the standard of care where we’re doing checklists, we’re doing a good interview, we’re doing an observation, and then the ADOS is a piece of that, certainly an important piece. It is still the best thing that we have for objectively gauging reciprocal social interaction. That’s certainly present and we need to use these other pieces as well. That said, on the flip side, like I said a bit ago, I do think the ADOS is a really important component of autism spectrum evals.
Now, there could be a whole other conversation, I think about two things. Diagnosing autism spectrum in females, particularly female adults, I think is a really tricky thing. You can get I think a lot of false negatives [00:26:00] certainly from the ADOS, but also from from the checklists as well when you’re looking at adult women with ASD. I still include that in the battery but put a lot more emphasis on the interview. With adults in general, I’ll do a lot of collateral interviews with their spouse, their parents, if possible, their siblings; anyone who is willing to do a collateral interview and can give me good information on that individual.
So like I was saying, particularly with adult women who suspect ASD, I will do a lot more collateral interviews and put more emphasis on those. I think that’s where it becomes super important to integrate all the sources of data. And there are some good resources out there too. Rudy Simone’s [00:27:00] Aspergirl’s book is really good. There are tons of great resources. That’s a little bit beyond the scope of this particular podcast, but I’ll just throw that out there that if you’re looking at ASD in girls and women, there is some emerging research saying that the diagnostic criteria do not fit super well for girls. It’s pretty male-centric. So we’re moving in the right direction, but at this point, that’s just a caveat that we need to take into account when we’re looking at autism spectrum in females that they may not present exactly the same as boys and men do.
Generally speaking, that is how I would approach an autism spectrum evaluation. That’s the battery that I tend to put together. As always, I would love to hear from [00:28:00] you and learn about what other batteries folks are using. I know that there are nuances and variations like I said at the beginning.
A few ways to give feedback. You can always email me. The best email address is jeremy@thetestingpsychologist.com. Another great way though to give some feedback but also connect with other folks, brainstorm batteries and things like that, and go back and forth about what people use and appreciate is in the Facebook community; that is The Testing Psychologist Community. You can search for that on Facebook or you can access it via thetestingpsychologist.com. There’s a link there to the Facebook Group. We have some great discussions in there. We’d love to have you. Membership is growing steadily. It’s really cool to see all of that discussion happening. If you are looking for more resources, you can always go to the [00:29:00] website, thetestingpsychologist.com for past podcast episodes, blog articles, and things like that.
Thanks as always for listening. This is fantastic. I love doing the podcast, love connecting with all of you, hearing from all of you, and knowing that there is some value here.
A little bit of an announcement. I’ll save the best for last, right? I will be doing a webinar with Pearson in September. We are nailing down the date and time, but we are doing a joint webinar. I’ll be talking all about Q-interactive and using Q-interactive in practice. Q interactive, if you haven’t heard, is the digital platform for administering tests. It’s super cost-effective, particularly if you’re just starting out. You have access to a wide variety of tests and you do it on the iPads. The research is good [00:30:00] behind it. I’ll be doing a webinar with them in September. I will do a little bit more of an announcement with the official date and time and everything shortly, but just to throw that out there so you can be thinking about signing up.
All right. Take care, everybody.