Autism Spectrum Disorder (ASD) Evaluation

Autism Spectrum Disorder or ASD is a neurodevelopmental disorder that is characterized by difficulties in social and communication skills and the presence of repetitive/restrictive behavior patterns. The latter being a wide and diverse range of symptoms that can include sensory aversions and enthrallments (stimming), repetitive motor movements, needing routines and rituals with poor ability to adapt to unexpected changes, stereotyped play patterns, fixations on objects and/or intellectual subjects, echolalia, etc. Symptoms are often noticable in early childhood and lead to various development delays in functioning.

Any time I am evaluating for ASD, I am also evaluating for ADHD, high intelligence, sensory processing disorder, obsessive-compulsive disorder, and chronic dissociative symptoms. All of these conditions or issues share some similar characteristics with ASD. An argument could be made for several other conditions or issues as well, although I will focus on these for the time being.

Individuals with ADHD often display a level of hyper-focusing that appears like ASD fixation patterns. Their fidgeting and/or sensory seeking behaviors can look like repetitive/restrictive behaviors. Social difficulties for both populations can result in bullying and/or social withdrawal.

Highly intelligent individuals often have heightened sensory aversions and enthrallments and difficulties with navigating social nuances (e.g., think of Hollywood’s portrayal of characters that are eccentric and socially awkward professors). It is common for intelligent children and teens to be falling behind their peers in emotional regulation despite precocious verbal reasoning, which can look like ASD meltdowns or aggression. Intelligent individuals need to be stimulated at all times and this can often look like either ADHD hyper-focusing or ASD fixations.

Obsessive-Compulsive Disorder can appear ASD-like as both can display a strong desire for daily routines and behavioral rituals with limited ability to adapt to changes in routines. Individuals with OCD also often struggle socially, especially when they are unable to conceal their obsessions and compulsions from others.

Individuals with severe sensory processing difficulties can look like they have ASD as sensory seeking is labeled generically as “stimming”, which is then assumed to mean ASD is present. Sensory aversions can lead to very particular preferences for foods, levels of lighting, types of clothes that are wearable; which can resemble symptoms and behavior patterns that are present for some individuals with ASD.

Often overlooked as a possible cause of ASD-like symptoms is chronic dissociation. Individuals who chronically dissociate display developmental delays that are due to poor emotional coping skills development. This results in them struggling with emotional regulation (meltdowns, freezing up, and/or rages), easily overwhelmed by sensory stimuli, sensory or body related behavior patterns used to ground themselves in the present moment can look like repetitive/restrictive behaviors, retreat into fantasy as a substitute for real world interactions looks like poor social/communication skills, and social withdrawal can look like lack of interest in being social.

All of that to say…the Autism Spectrum is a very wide spectrum. Presentation of symptoms varies greatly based on level of intellectual functioning, gender, and even related to personality characteristics and other co-occurring conditions for each individual. Effective ASD evaluation requires expertise in various developmental frameworks, not just knowledge of a generic and static symptom criteria list. As I am evaluating different strands of symptoms or personal characteristics for an individual, I am doing so over the course of their life, and via different developmental perspectives (e.g., cognitive development, social development, coping skills development, identity development, etc.). What has and has not changed over time? Have compensation strategies shifted? What is being socially masked and what is not? What is the actual cause of this or that symptom or behavior pattern?

ASD evaluations rely heavily on thorough history gathering. Generally, some form of ASD screening tool is used to help guide this process, although ASD screeners in and of themselves are typically not sufficient. This is in part due to the fact that ASD symptom presentation varies widely per person. It also is in part due to the fact that compensation strategies are often contributing to concealment of symptoms. And it is also due to the fact that our ASD screeners are not good at ruling out other possible causes of the symptoms we are looking for with ASD. Hence, why I discuss the importance of utilizing various developmental frameworks for ASD evaluation to rule out other causes of symptoms.

Beyond history gathering, ASD evaluations often include cognitive evaluation (at least a Full Scale Intelligence Measure) and an Adaptive Behavior Functioning measure. These other measures are essential for those who wish to apply for State Developmental Disability services. For others, it is essential to determine if ADHD is also present with ASD. Untreated ADHD symptoms often results in ASD symptoms appearing much more severe than they actually are in reality. For still others, evaluation of mental health symptoms is necessary. There is no right testing battery for ASD evaluations, and it should vary based on the history and presentation of symptoms and abilities for each individual.

My emphasis in ASD evaluations is not just on diagnosis, although that can be important. My goal is to more fully understand who that individual is and how they got to where they are. This encompasses early symptoms, associated developmental delays, development of coping and/or socially masking strategies, development of personal and social identity over time, identification of secondary or co-occuring diagnoses, impact of cognitive abilities on functioning, personal strengths and weaknesses, etc. This style of ASD evaluation is highly conducive to those who are on the high functioning end of the spectrum, for females that socially mask many of their symptoms, and for anyone who does not present symptoms in a stereotypical fashion.