How does a diagnostician or clinician conduct an assessment for Aspergers?
Autism Spectrum Disorders are very complex, yet their features can be very subtle; they are not always obvious on the surface. As a result, an Aspergers (high-functioning autism) assessment will take more time than most other assessments. Below are the methods that clinicians who are new to the field of Aspergers can use as a guide. These are also the methods that moms and dads should look for to make sure they are getting a good assessment for their Aspergers child.
An assessment should be conducted by a doctor, psychologist, or psychiatrist who has expertise in Autism Spectrum Disorders (ASD). This is important because most degree programs may only give passing information about Aspergers. A clinician may have a lot of experience in evaluating and may know the DSM criteria for Aspergers – but knowing the criteria on paper is not the same as having the background to really know all of the subtle features to look for. If you are a clinician and do not have the background experience with Aspergers yet, consult with a clinician who does. If you are a mother or father getting an Aspergers assessment done, ask about the background experience of the clinician.
Assess each of the core areas of difficulty along with the more subtle characteristics. Aspergers involves qualitative difficulties in language, social interactions, and more stereotyped and repetitive behaviors and interests; however, there cannot be a real delay in language – but it does often involve difficulties in how language is being used.
It is not enough to question parents about language delays or social interactions or interests. A good assessment will look at how behaviors are being exhibited. Even if the Aspergers child is social, the clinician needs to look at whether he/she can take other people's perspective:
- Does he have imaginative play?
- Does he demonstrate sensory preferences that interfere with required or socially desires activities?
- Does he approach others and initiate interactions?
- Can he talk about someone else' preferred topic?
- Can he switch tasks when redirected fairly easily?
- Can he listen as well as talk?
These are just some of the more subtle behaviors that need to be observed in Aspergers kids who may be higher functioning. This goes beyond just asking, "Does your son or daughter socialize?"
Use observation in a variety of settings as the core of the assessment. Behaviors can be exhibited for more than one reason. For example, escape, reactions to sensory processing difficulties, attention seeking, and seeking rewards can all be the basis for behaviors. A question on a form reveals that a behavior is being exhibited, but does not reveal why or exactly what the behavior looks like. The only way to know the "why" of many behaviors is to observe in natural settings and to spend time with the Aspergers youngster.
It is not enough to simply observe the Aspergers child in a clinical setting. If clinicians take the child to an unfamiliar location and put her in a room with grown-ups that she has never seen before and then ask the parent to leave the room, you will not get a good picture of how this child interacts with others. If it is not possible to observe the child in a natural setting, then ask the parents if they can videotape their child during various activities.
It is critical to observe the child – close up – in a small playgroup. Observing play and social interactions may look good from a distance; however, when the clinician can (a) hear everything that is being said, (b) follow the child’s eyes, (c) see how he responds to interruptions and so forth, then the clinician can really assess the details of those interactions and begin to interpret them as possibly on the spectrum or not. The clinician can also tell if the child’s play is “parallel play” or if it is really “cooperative play.” Observations not only support the diagnosis, but they are essential in order to give individualized, rather than generic, recommendations.
Clinicians should pair observations with interviews, ratings scales and direct assessment. One rating scale alone should not be the actual assessment. However, rating scales should be given to support observations. If the results do match what is being observed, then check to make sure that the rating scales were completed correctly and ask the rater for examples of what was being rated high in the scales. For example, a behavior could be rated as being "frequently" observed. If it is occurring about 2 times per day, it may seem frequent, but according to the key on some scales, "frequent" is defined as 6 or more times in a 6 hour period. Thus, 2 times per day should be rated as "sometimes" observed. Also, make sure that the scoring follows the key, and get information about what the behavior looks like as well as examples of when and how it occurs. Many of the rating scales (e.g., Gilliam scales, CARS) have a high validity rating, and they are usually fairly correct; however, they are not always correct and cannot be used to make a diagnosis because the reported behaviors could be due to different causes.
Rule out other disorders that have similar characteristics. Many behaviors can be associated with more than one diagnosis. The trick is to look at what the underlying causes of the behaviors are – and what is maintaining the behaviors. With an Aspergers diagnosis, it is crucial to put all of the information together to get the big picture because Aspergers is a spectrum disorder (i.e., a spectrum of behaviors across three major areas of difficulty). If the clinician only looks at behaviors on the surface, then multiple diagnoses will be given for the same behaviors – or the child will get a misdiagnosis. If, for example, a child receives the diagnoses of ADHD, Bipolar, Autism, and ODD all at the same time, it’s likely that the clinician “cut some corners” and conducted a poor assessment. It is definitely possible to have a dual diagnosis that is accurate, but a good assessment will differentiate between diagnoses.
The Aspergers Comprehensive Handbook