Adult autism assessment

[DoubtfulDoc]

Hi everyone, I do assessment regularly with adults. They’re non-neuropsych. However, I have been getting more and more Autism referral questions. I have been trying to do as much reading and CE’s about Autism assessment as I can to understand what, if anything, can an experienced assessment psychologist without significant neuropsych training do.

I understand and appreciate the significance of a strong clinical interview with attention to their presentation, disease course, and outcome while assessing for DSM criteria. So there are several structured or semi-structured interviews that could be beneficial for sure (CARS, MIGDAS-2 [though I don’t love that there is no psychometric data on purpose for that one…]). I understand the significant comorbidity and importance of exclusionary medicine. And I’m sensitive to some of the artefactual drivers of the changes in who gets diagnosed and why.

What I’m having trouble wrapping my head around is the use of neuropsychological-specific tests that objectively measure IQ, attention, working memory, executive functioning, etc.
Several sources (I’ll reference the 2020 Neuropsych Board book here) describe several expectations for neuropsychological assessment results like this: “Individuals with ASDs exhibit X profiles with a high degree of variability…” this seems true for X = IQ, achievement, attention/concentration, memory, adaptive behavior/skills. And then they go on to describe specific examples of those outcomes where you could or might see a difference.

Some testing outcomes are less variable (it seems), like social behavior, face processing as a feature of visuospatial abilities, verbally loaded processing speed tasks, and a few others.

Is it like ADHD, where there really isn’t a reason for neuropsychological tests for most adult referrals (unless accommodations are requested with specific instructions on what must be administered coming from a school or workplace)? Or do neuropsychological tests really have a place?

If so, which ones do you use? Or would you use self-report versions instead of performance-based tests (e.g., BRIEF-A instead of a D-KEFS)? Right now I’m considering an MMPI or PAI, structured clinical interview for common psych diagnoses (e.g., MINI), ABAS, BRIEF, social perception subtests of ACS, and a structured clinical interview (not an ADOS [i’m not trained]) for DSM ASD symptoms. What would you add? Am I way out of my depth?

Thanks for any suggestions and feedback you have!

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[AcronymAllergy]

Autism doesn't really have a neuropsychological "profile," as you've said. Neuropsych testing can potentially be useful for quantifying cognitive functioning, identifying strengths/weaknesses and informing recommendations, etc. And in adults, it might help provide information about cognitive effects from other conditions/factors. But I wouldn't personally use it diagnostically for ASD.

I'll certainly defer to some of our more informed and experienced colleagues, but to add to what you've suggested, as with ADHD, I'd see if it's possible to get collateral information. Ideally a parent or someone else who either knew the patient as a child or has at least known them for quite some time.

And I imagine it doesn't need to be said, but just to put it out there for anyone reading--have an Autism spectrum disorder of course doesn't rule-out other psychopathology (and vice-versa), like depression.

 

[DoubtfulDoc]

Autism doesn't really have a neuropsychological "profile," as you've said. Neuropsych testing can potentially be useful for quantifying cognitive functioning, identifying strengths/weaknesses and informing recommendations, etc. And in adults, it might help provide information about cognitive effects from other conditions/factors. But I wouldn't personally use it diagnostically for ASD.

I'll certainly defer to some of our more informed and experienced colleagues, but to add to what you've suggested, as with ADHD, I'd see if it's possible to get collateral information. Ideally a parent or someone else who either knew the patient as a child or has at least known them for quite some time.

And I imagine it doesn't need to be said, but just to put it out there for anyone reading--have an Autism spectrum disorder of course doesn't rule-out other psychopathology (and vice-versa), like depression.

Thank you @AcronymAllergy. I appreciate you bringing collateral up as well--like with my ADHD assessments I try to get collateral as well about specific symptoms, especially childhood symptoms to help map out the developmental course. I know the CARS, ABAS, BRIEF, and Baron-Cohen's Relatives Questionnaire are all easy options for me. And for sure, you can have an ASD as well as other comorbidities and it may even be expected given the high rates. I appreciate your time!

 

[borne_before]

I only test autism in those under the age of 18, unless it is very obvious that I got a an emerging adult who has made it to the age of majority without a formal autism diagnoses and they very clearly have autism.

I am also not aware of any neuropsychological profile that is indicative of autism. Other than their executive functions often suck.

On testing, and this is mostly qualitative experience, I see two profiles that are more common in kids with autism.:

The first profile I can see often is kids with absolute dog water verbal and fluid reasoning skills, but surprisingly high visual spatial reasoning skills. Indeed, often the full scale IQ is below 80 and and below 75 such that they are very close to getting a mild intellectual disability dx, save for intrapersonal strength and visual spatial reasoning. On adaptive testing, this cluster seems to be much worse than the one discussed below.

The next profile, is odd too. These kids have a much stronger full-scale IQ than the ones mentioned above. Usually, because they have very strong verbal reasoning skills, but lackluster or average other skills. Whenever I see this profile, it makes me wish Asperger's was still diagnosable.

But also, not everyone I test and dx into autism falls into those categories. It just that when I see them, I think "huh, maybe ASD might be worth examining" if I hadn't already considered it in my differential.

Honestly though, I think it is really important if you are making an autism diagnosis in an adult to rule out any Axis II kind of condition. I think a lot of people with borderline which much rather have an autism diagnosis.

But it also goes to the purpose of testing. Are we trying to diagnose autism so the kid or adult can get access to state services or interventions? Or is this just to document a condition for personal understanding or perhaps to help get some protections at work? Are girls they meet online taking their money and they need guardianship? All of those refocus assessment on adaptive impairment.

But when it comes to diagnosing autism, I really do think the fourth module of the ADOS-2 does a really good job of pressing for social impairment and understanding the individual's level of responsibility for their own life. Comorbid ADHD? I'd love if mum came to the intake as well so I could toss some questions at them and find out where the autism like traits are coming from (e.g., is dad an engineer) because it's pretty damn genetic.

WHen making a tough autism DX, like "this could go either way," I often think about how many good psychs would and wouldn't dx it.

 

[romanticscience]

But when it comes to diagnosing autism, I really do think the fourth module of the ADOS-2 does a really good job of pressing for social impairment and understanding the individual's level of responsibility for their own life.

I'd recommend the WPS Independent Study: ADOS-2 Training Video Program. I've found it helpful in differentiating autism from similar conditions forensically and therapeutically. As an example of the importance of the diagnosis, therapeutically, I've had some difficulty likely trying to do TFP with people who likely had mild autism, not BPO, and it accounts for the poor outcomes (confrontation and interpretation not going well, patient kind of getting worse with the interventions). The structural (dynamic) interview ("Tell me about yourself;" What is your partner like as a person?" has oddly similar questions to the ADOS). I personally like the alternative model of personality disorders (AMPD), which I assess for using the SCID-AMPD.

Seeing the ADOS scoring criteria with the LPFS criteria, especially regarding empathy, helps appreciate the differences in the disorder constructs.

 

[borne_before]

I'd recommend the WPS Independent Study: ADOS-2 Training Video Program. I've found it helpful in differentiating autism from similar conditions forensically and therapeutically. As an example of the importance of the diagnosis, therapeutically, I've had some difficulty likely trying to do TFP with people who likely had mild autism, not BPO, and it accounts for the poor outcomes (confrontation and interpretation not going well, patient kind of getting worse with the interventions). The structural (dynamic) interview ("Tell me about yourself;" What is your partner like as a person?" has oddly similar questions to the ADOS). I personally like the alternative model of personality disorders (AMPD), which I assess for using the SCID-AMPD.

Seeing the ADOS scoring criteria with the LPFS criteria, especially regarding empathy, helps appreciate the differences in the disorder constructs.

The closest I ever get to a personality disorder diagnosis is conduct disorder and recommending dbt.

 

[Therapist4Chnge]

Much like ADHD in the TBI world…symptoms can overlap and confuse the diagnostic picture. Autism dx in adults has an entirely diff set of complications compared to eval’ing a child. In peds cases they are usually still sorting genetic considerations, developmental milestones, etc.

 

[DoubtfulDoc]

I only test autism in those under the age of 18, unless it is very obvious that I got a an emerging adult who has made it to the age of majority without a formal autism diagnoses and they very clearly have autism.

I am also not aware of any neuropsychological profile that is indicative of autism. Other than their executive functions often suck.

On testing, and this is mostly qualitative experience, I see two profiles that are more common in kids with autism.:

The first profile I can see often is kids with absolute dog water verbal and fluid reasoning skills, but surprisingly high visual spatial reasoning skills. Indeed, often the full scale IQ is below 80 and and below 75 such that they are very close to getting a mild intellectual disability dx, save for intrapersonal strength and visual spatial reasoning. On adaptive testing, this cluster seems to be much worse than the one discussed below.

The next profile, is odd too. These kids have a much stronger full-scale IQ than the ones mentioned above. Usually, because they have very strong verbal reasoning skills, but lackluster or average other skills. Whenever I see this profile, it makes me wish Asperger's was still diagnosable.

But also, not everyone I test and dx into autism falls into those categories. It just that when I see them, I think "huh, maybe ASD might be worth examining" if I hadn't already considered it in my differential.

Honestly though, I think it is really important if you are making an autism diagnosis in an adult to rule out any Axis II kind of condition. I think a lot of people with borderline which much rather have an autism diagnosis.

But it also goes to the purpose of testing. Are we trying to diagnose autism so the kid or adult can get access to state services or interventions? Or is this just to document a condition for personal understanding or perhaps to help get some protections at work? Are girls they meet online taking their money and they need guardianship? All of those refocus assessment on adaptive impairment.

But when it comes to diagnosing autism, I really do think the fourth module of the ADOS-2 does a really good job of pressing for social impairment and understanding the individual's level of responsibility for their own life. Comorbid ADHD? I'd love if mum came to the intake as well so I could toss some questions at them and find out where the autism like traits are coming from (e.g., is dad an engineer) because it's pretty damn genetic.

WHen making a tough autism DX, like "this could go either way," I often think about how many good psychs would and wouldn't dx it.

The majority of people that are receiving this referral for an ASD assessment where I work seem to just want to know for their own sakes, to explain how they’ve felt for a part(s) of their life, explain relational experiences, build insight, etc. Few if any are actually intending to seek formal services or accommodations through work or the state.

I feel like if they wanted actual accommodations or recommendations then neuropsychological might be helpful not because there is a cognitive profile for Autism they’ll identify but that the testing may be able to articulate their personal strengths and weaknesses which could generate specific recommendations.

 

[borne_before]

The majority of people that are receiving this referral for an ASD assessment where I work seem to just want to know for their own sakes, to explain how they’ve felt for a part(s) of their life, explain relational experiences, build insight, etc. Few if any are actually intending to seek formal services or accommodations through work or the state.

I feel like if they wanted actual accommodations or recommendations then neuropsychological might be helpful not because there is a cognitive profile for Autism they’ll identify but that the testing may be able to articulate their personal strengths and weaknesses which could generate specific recommendations.

Absolutely. I think that should be part of any good assessment and is one of my most fav things about testing. But it's non specific to any disorder.

 

[ClinicalABA]

I stick to kids under three (and mostly under 2). I do this not just because toddler are super fun to work with, but because it's relatively easy, with minimal (and no real complicated) rule-outs/differential diagnosis. Certainly no neuropsych profile for that age group, and nothing reliable enough for adults that I'm aware of. I directly (standardized testing) measure cognitive and linguistic abilities, but that's primarily for toddle specific rule-outs (purely language disorder; global delays in development) and for determining level of ASD and treatment dosage. For the occasional 3-5 year old I see, I will often do a measure of inference related language, as well as pragmatic language, but that's not diagnostic, as children with ASD can have good inference and pragmatic language (though many do not). The NEPPSY has affect recognition and theory of mind scales, but those are similarly non-diagnostic (and- IMHO- not great measures anyways). Diagnosing ASD generally involves using several criterion-based measures, rather that any standardized measures. Despite the scoring algorithm and ASD cut-offs on the ADOS-2, it really is a criterion-based measure.

 

[PsyDr]

I know medical ethics kinda frown on diagnosis without treatment. I wonder what the ethical implications are present here.

If the individual stops doing things after the diagnosis, I know that is Maleficence. It's one of the things in the medical ethics literature about withholding a diagnosis.

 

[DoubtfulDoc]

I know medical ethics kinda frown on diagnosis without treatment. I wonder what the ethical implications are present here.

If the individual stops doing things after the diagnosis, I know that is Maleficence. It's one of the things in the medical ethics literature about withholding a diagnosis.

That’s a good point. Most of the people that get referred for an Adult ASD assessment would likely be so mild they wouldn’t really need (nor do we have locally) a lot of adult ABA trained providers. In other words, if I were to diagnosis they wouldn’t get much specific treatment for the ASD. If I were to identify a different or comorbid condition, like an anxiety disorder I could recommend and reasonably expect for them to participate in treatment given the more abundant anxiety treatment resources available.

Do you have a resource you could share about medical ethics and diagnosis without treatment? I’d like to learn more.

 

[oliversacks4thewin]

I stick to kids under three (and mostly under 2). I do this not just because toddler are super fun to work with, but because it's relatively easy, with minimal (and no real complicated) rule-outs/differential diagnosis. Certainly no neuropsych profile for that age group, and nothing reliable enough for adults that I'm aware of. I directly (standardized testing) measure cognitive and linguistic abilities, but that's primarily for toddle specific rule-outs (purely language disorder; global delays in development) and for determining level of ASD and treatment dosage. For the occasional 3-5 year old I see, I will often do a measure of inference related language, as well as pragmatic language, but that's not diagnostic, as children with ASD can have good inference and pragmatic language (though many do not). The NEPPSY has affect recognition and theory of mind scales, but those are similarly non-diagnostic (and- IMHO- not great measures anyways). Diagnosing ASD generally involves using several criterion-based measures, rather that any standardized measures. Despite the scoring algorithm and ASD cut-offs on the ADOS-2, it really is a criterion-based measure.

Truly not trying to engage in flaming. Based on your history of postings, I respect your expertise on this subject matter immensely, and was genuinely just curious why you feel like these specific measures are "not great anyways?"

 

[PsyDr]

Do you have a resource you could share about medical ethics and diagnosis without treatment? I’d like to learn more.

Pretty much any medical ethics textbook will discuss how diagnosis is related to non-maleficence. In short: is it helpful or harmful to provide a diagnosis, without intent to treatment?

Then you can go into the ethics of ordering non-clinically indicated lab tests, which is pretty popular in the ethics journals. Maybe look up the neuroscientific ethics of incidental findings on cerebral MRIs in control subjects.

OR

 

[borne_before]

Truly not trying to engage in flaming. Based on your history of postings, I respect your expertise on this subject matter immensely, and was genuinely just curious why you feel like these specific measures are "not great anyways?"

With NEPSY theory of mind: are you measuring inability to perspective take? or poor language comprehension? That's why it sucks.

BTW - I give it all the time.

 

[oliversacks4thewin]

With NEPSY theory of mind: are you measuring inability to perspective take? or poor language comprehension? That's why it sucks.

BTW - I give it all the time.

That is a solid point. Appreciate the perspective, as I also give both subtests frequently and honestly never considered that specific piece. I thought it may be sensitivity or specificity issue-which it kinda sounds like it is, lol, but I was wondering if there was research that demonstrated poor statistical significance for their use that I was unaware of.

 

[oliversacks4thewin]

Thoughts on this: He just turned 4. He is showing really strong nonverbals, social overtures, etc. I really screened the hell out of him. However, there is one odd behavior that I just can't get over. He does this gibberish jargoning reflexively. That is the main concerning symptom. You ask him something and it's like "tika blaka tika babble babble" and then you prompt him to use his real words and he does (getting better). He does have some intense interests, but they are all age-appropriate. He has been co treated by an SLP at my work. We do not think autism, but my God is the jargoning odd. We are going to do some parent management, but I wonder if a closer look would on earth some things. In speech, he is responding to intervention and becoming more verbal. Mom does not have autism concerns. Jargoning is almost like habit that has been reinforced in a chaotic household (three under 4).

Makes total sense in this context. Do you find there is sometimes a discrepancy in scores of the verbal vs contextual components of the Theory of Mind Task, that may be the deciding factor for confirmation of the presence of the diagnosis, given the description you gave? Admittedly, I am out of my depth here lol. I did my dissertation on ASD and quickly noped my way out of that as a professional interest...

 

[borne_before]

Makes total sense in this context. Do you find there is sometimes a discrepancy in scores of the verbal vs contextual components of the Theory of Mind Task, that may be the deciding factor for confirmation of the presence of the diagnosis, given the description you gave? Admittedly, I am out of my depth here lol. I did my dissertation on ASD and quickly noped my way out of that as a professional interest...

Honestly, not usually. the verbal tasks are like 18 different items, whereas the contextual stuff is only like 6. Id love to see more contextual stuff.

 

[ClinicalABA]

Truly not trying to engage in flaming.

No worries- yours is very reasonable question about a rather irresponsible statement on my part. Just saying that they are not "great measures" is inadequate and insufficient. The reader is left to assume exactly what they are great measures of (social interaction ability? Free throw shooting percentage?), and this forum is meant for students who cannot be expected to make inferences from my statement about the relatively obscure tests.

Based on your history of postings, I respect your expertise on this subject matter immensely, and was genuinely just curious why you feel like these specific measures are "not great anyways?"

In the context of what I could use these test for globally speaking they have not proven to be helpful or even necessary. I my case, I do evaluations with children ages 1-4ish with the goal of (a) identifying or ruling out ASD; and (b) making recommendations for general type and quantity of treatment necessary. With that in mind, given the minimum ages for administration (3yo) I would only be using these tests on a very small age band (3-4 yo).

I have found that for this population, scores on these tests are not reliably predictive of diagnosis. This has typically been in the direction of children who I end up giving an ASD dx score pretty well on these tests (for maybe 20-25% - working from memory here- of the kids who i give an ASD dx will have a scaled score equivalent of 8 or higher). Just as importantly, I have never had a case where, given all the other measures (e.g., ADOS-2, language testing, even parent questionnaires), there was any incremental validity added by considering the result of either of these test. In the case of the Theory of Mind (TM) test, at lower age bands, small raw score differences can mean relatively large difference in scaled scores. A child who has been taught what a thought bubble means or who is really good at gross motor imitation will score higher. For older children, the narrative stuff (answering questions about a story) cannot be interpreted in the absence of direct measure of narrative memory (and if narrative memory scores are relatively low, low scores on these TM items are basically un-interpretable). I have actually found that scores on the CASL-2 inference scale are somewhat more predictive (though for similar reason still not great) of ASD for children with average general language scores (e.g., word- and sentence-level receptive and expressive abilities).

In regard to the Affect Recognition (AR)- it's a similar situation). I will say that a scoring low on AR has seemed to me to be a better predictor of ASD than scoring high is a predictor of not having ASD. When you look at the task, that sort of makes sense. The AR test is basically a visual discrimination task where the examinee has to indicate if two stimuli are the same or different based on some subtle difference (e.g., which of these three pictures below is the same as this picture here). From the standpoint of what you can directly observe the child doing, it's not a dissimilar task to recognizing similarities or difference in abstract figures with subtle differences. We just give it more importance because the stimuli are pictures of people. We assume that these pictures represent specific emotional states. If a 3-4yo child does poorly identifying differences between static pictures of just a face in an analog setting, I don't think it's unreasonable to assume that they might have difficulties identifying emotions in non-analog social setting where there is movement, multiple visual stimuli, and multiple modalities of stimuli present. However, I have found it to be a mistake to assume that a 3-4yo who can identify differences with two-dimensional stimuli in the analog setting can also do so in the "real world." If you were to provide me with the TM and AF scores of child, I'd make an unreasonable amount of errors predicting how that child would function or behave in social situation. Give me their ADOS-2 overall scores and overall receptive and expressive language scaled scores and I'd make significantly less (but still a non-zero amount of!) errors. Add in a cognitive measure that distinguished between the child actually attending to attempting the tasks vs. just ignoring me or lining up or mouthing the testing materials, and I'd make less errors. Adding the TM and AR scores to this data would not- imho- change the error rates of my predictions enough to warrant the effort of trying to get that child to sit and point to more pictures in a book.

As far as using TM or AR scores to recommend even general treatment, I just don't see the utility. I'm inclined to operate just off of face validity and say that a low AR score might suggest that the child needs some instruction on recognizing facial expression in static pictures, but I can't say this with any objective certainty or empirical evidence to back it up (though that admittedly might just be a limitation in my knowledge and understanding of the literature in that area). In regard to how scores on TM should inform treatment, well... your guess is as good as mine. I'm not convinced that theory of mind can be directly taught beyond improving performance on analog tasks assumed to represent some internal ability.

TLDR- There's only so much effort I can put into making a preschooler sit and point at pictures in a book. I have found that that effort is much better spent on other standardized measures (language, to some extent cognitive) that add to criterion based tests (ADOS-2) an improve my ability to correctly make a differential diagnosis and recommend appropriate quantity and quality of treatment. Also, I hate that whole finger play item in TM, and just feel silly doing it!

 

[ClinicalABA]

With NEPSY theory of mind: are you measuring inability to perspective take? or poor language comprehension? That's why it sucks.

BTW - I give it all the time.

Even it it did measure the bolded, is theory of mind really about not being able to take another's perspective, or about the inability to recognize that other perspectives could possibly exist? I'd argue that it's more about the latter. Not recognizing that others could have thoughts different than yours leads to things like not asking or requesting because the other person already knows what you want (or doesn't have any info different that what you have, so no need to ask about something). Not taking the perspective of others means you'd still ask, but get mad when they don't give you what you want- you'd know they have a different thought/opinion than yours, you just wouldn't care. In regards to testing theory of mind, I think the "what would they say is in the box test" is a pretty good measure (assuming appropriate receptive and expressive language abilities, which you shouldn't assume and better test for!). And I mean the item where you actually put stuff in the box and ask the kid what the other person would say is in there, not the one with just the picture of the cookie box where mom snuck in some spaghetti (and why the hell would a mom be so mean as to do do that?!?)

 

[ClinicalABA]

With NEPSY theory of mind: are you measuring inability to perspective take? or poor language comprehension?

Do you find there is sometimes a discrepancy in scores of the verbal vs contextual components of the Theory of Mind Task,

The NEPSY-II Clinical and Interpretative Manual highlights correlations between the different subtests and- amongst other things- WIAT-II subtests.

TM correlates at .46 with listening comprehension and .74 with oral expression. That .74 is very high, and would seem to be a bit of confound if you are working with a client with low oral expression abilities and still a big threat to validity if otherwise.

AR scores correlate at -.45 and -.40 with Devereux scores of Conduct and Externalizing, which should prompt at least a little "chicken or the egg" internal discussion, if not a bigger questioning of what you are actually measuring.

Take a look on pg. 174 of the Interpretive Manual at chart breaking down what different construct of Theory of Mind specific items are proposed to measure. If you are going to use the TM subtest, I'd offer that it may give you a more detailed perspective of what you might actually be measuring, rather than some general concept of "theory of mind abilities." Perhaps using the TM subtest as more of a criterion-based measure use for an idiographic and non-parametric assessment of what the kiddo was able to do would be more useful than aggregating data measuring several different concepts?

 

[cara susanna]

We actually have that question a lot here, including for things other than autism. Like, someone looks up NPD on Google and now wants to know if they have NPD. Do we still assess them, if it isn't for purposes of treatment?

 

[oliversacks4thewin]

Even it it did measure the bolded, is theory of mind really about not being able to take another's perspective, or about the inability to recognize that other perspectives could possibly exist? I'd argue that it's more about the latter. Not recognizing that others could have thoughts different than yours leads to things like not asking or requesting because the other person already knows what you want (or doesn't have any info different that what you have, so no need to ask about something). Not taking the perspective of others means you'd still ask, but get mad when they don't give you what you want- you'd know they have a different thought/opinion than yours, you just wouldn't care. In regards to testing theory of mind, I think the "what would they say is in the box test" is a pretty good measure (assuming appropriate receptive and expressive language abilities, which you shouldn't assume and better test for!). And I mean the item where you actually put stuff in the box and ask the kid what the other person would say is in there, not the one with just the picture of the cookie box where mom snuck in some spaghetti (and why the hell would a mom be so mean as to do do that?!?)

1) Thank you so much to both of you for taking the time to provide such thorough answers to the posed question. I love discussions like this where the objective is to grow as a profession on our opinions based on empirical and clinical data and find the suggestions you both make to be quite enlightening and informative to my overall practice.
2) I think the reason for my question results from the specific clinical capacity I work in, where I am applying these subtests/measures outside of the normative evaluation sample that is more typical for ASD. I tend to get referrals for school-age to adolescent children, and while certainly advocate for the gold standard of the ADOS-2, recognize that frequently in my setting, screening and triage to higher levels of evaluation is sometimes the role I have to play lol. For example, I love the "what's in the box" task too, as it is a quick litmus test for egocentric thinking patterns that may indicate need for more in-depth testing, but again, view this as a screening tool for understanding the complexities of arriving at an accurate diagnosis. To compare to adult settings, I think of the NEPSY-II similar to how I think about the RBANS-Update. Better than a face valid screening but still predominately a screening tool that better informs next steps in assessment. As I write this out though, I recognize my physician colleagues all continue to advocate for less-time consuming evaluation models and have to wonder if we are moving to be more in line with the screening + clinical judgement = diagnosis model, and the possible changes to the direct litmus tests or push to remain with the current structure of screen for further evaluation will look like over the next 15-20 years... Either way, thank you for the interesting discussion and perspective shift!

 

[ClinicalABA]

As I write this out though, I recognize my physician colleagues all continue to advocate for less-time consuming evaluation models

As we should as well. Parsimony is such an overlooked concept. We should be realistic about the actual possible outcomes of our work (e.g., accurate differential diagnosis and general treatment recommendations) and we should do the minimum amount of testing necessary to accomplish those goals. If a specific test/subtest- regardless of it's validity- does not directly contribute to our ability to validly diagnose or recommend treatment, then we just shouldn't do it.

 

[ClinicalABA]

I love discussions like this where the objective is to grow as a profession on our opinions based on empirical and clinical data

Hopefully you can tell from my posts that I like and appreciate these types of discussions. They make me a better clinician!

 

[DoubtfulDoc]

Pretty much any medical ethics textbook will discuss how diagnosis is related to non-maleficence. In short: is it helpful or harmful to provide a diagnosis, without intent to treatment?

Then you can go into the ethics of ordering non-clinically indicated lab tests, which is pretty popular in the ethics journals. Maybe look up the neuroscientific ethics of incidental findings on cerebral MRIs in control subjects.

OR

Ah ok. I think I mixed up intent to treat v recommending appropriate interventions following a requested evaluation. I’m tracking now.

 

[PsyDr]

Ah ok. I think I mixed up intent to treat v recommending appropriate interventions following a requested evaluation. I’m tracking now.

Maybe relevant to your search:

Responding to Patient Requests for Nonindicated Care

Physicians are not obligated to offer testing or treatments that are not medically indicated—even if patients demand them. This does not mean, however, that a physician should be dismissive of the patient’s concerns.

journalofethics.ama-assn.org

There is also some legal implications in terms of the False Claims Act.

 

[borne_before]

Hopefully you can tell from my posts that I like and appreciate these types of discussions. They make me a better clinician!

Dude, what does ur picture mean?

 

[WisNeuro]

Dude, what does ur picture mean?

Hernstein's Law

 

[DoubtfulDoc]

As we should as well. Parsimony is such an overlooked concept. We should be realistic about the actual possible outcomes of our work (e.g., accurate differential diagnosis and general treatment recommendations) and we should do the minimum amount of testing necessary to accomplish those goals. If a specific test/subtest- regardless of it's validity- does not directly contribute to our ability to validly diagnose or recommend treatment, then we just shouldn't do it.

Yes, the minimum necessary is so important. I still see licensed psychologists giving excessive amounts of tests for no justifiable reason and really have to encourage them and our interns to break that habit. No one wants to interpret all that and referring providers don’t want to read it. Concise, up front summaries, that answer the referral question are hard to come by!

 

[AcronymAllergy]

Yes, the minimum necessary is so important. I still see licensed psychologists giving excessive amounts of tests for no justifiable reason and really have to encourage them and our interns to break that habit. No one wants to interpret all that and referring providers don’t want to read it. Concise, up front summaries, that answer the referral question are hard to come by!

And of course not just in autism assessment. I don't want to push back too hard by saying that psych testing/assessment has no place in most situations, but yeah, if I see one more 8-hour test battery for a straightforward outpatient dementia eval in an 80-year-old that wasn't given primarily for training purposes, and where the report details every test given in excruciating detail...

...although on the flip side, if I see one more "dementia" diagnosis slapped on a 65-year-old reporting that they occasionally misplace their keys and who scored a 29 on the MMSE...

 

[ClinicalABA]

Dude, what does ur picture mean?

Hernstein's Law

Yep- more commonly referred to as the matching law (this is the simplified matching law) put out by Hernstein. Basically, the ratio of behavior 1 to behavior 2 is the same as the ratio of reinforcement for behavior 1 to the ratio of reinforcement for behavior 2. Given a few other things, it's a pretty good explanation for and predictor of why we do some things instead of others.

 

[borne_before]

Yep- more commonly referred to as the matching law (this is the simplified matching law) put out by Hernstein. Basically, the ratio of behavior 1 to behavior 2 is the same as the ratio of reinforcement for behavior 1 to the ratio of reinforcement for behavior 2. Given a few other things, it's a pretty good explanation for and predictor of why we do some things instead of others.

Can you give me an example?

 

[ClinicalABA]

Can you give me an example?

I'll break it out into another thread so we don't get too off topic here...

 

[alexfefun]

Thank you for this thoughtful question about autism assessment. As someone who has worked with psychological assessments, I can share some insights.


First, you're absolutely right about the complexity of adult autism assessment. The variability in neuropsychological profiles makes this particularly challenging. Based on current research (which we've also discussed on raads-r test), here's my perspective:

• Core Assessment Components:

• Your proposed battery (MMPI/PAI, structured interviews, ABAS, BRIEF, ACS) forms a solid foundation

• Consider adding the RAADS-R (Ritvo Autism Asperger Diagnostic Scale-Revised) - it's specifically designed for adult autism assessment

• Neuropsychological Testing:

• Unlike ADHD, some neuropsych testing can provide valuable diagnostic information

• Focus on tests measuring social cognition and executive functioning

• Consider adding:

• WAIS-IV (selected subtests)

• Social Cognition tests (beyond ACS)

• TMT for processing speed

• Self-Report Measures:

• The BRIEF-A is appropriate

• Consider adding the SRS-2 (Social Responsiveness Scale)

• Autism Quotient (AQ) can be helpful as a screening tool

You're not out of your depth, but I would recommend:

• Establishing a referral network with neuropsych specialists

• Documenting limitations in your reports

• Focusing on functional impact rather than just test scores

Remember, comprehensive autism assessment is about pattern recognition across multiple domains, not just individual test scores.

 

[WisNeuro]

Wow, what a nice advertisement for a test that looks like it was written by AI!

 

[ClinicalABA]

Based on current research (which we've also discussed on raads-r test), here's my perspective:

The following ad appears on the linked raads-r test page:

Seems legit, right?

 

[DoubtfulDoc]

Thank you for this thoughtful question about autism assessment. As someone who has worked with psychological assessments, I can share some insights.


First, you're absolutely right about the complexity of adult autism assessment. The variability in neuropsychological profiles makes this particularly challenging. Based on current research (which we've also discussed on raads-r test), here's my perspective:

• Core Assessment Components:

• Your proposed battery (MMPI/PAI, structured interviews, ABAS, BRIEF, ACS) forms a solid foundation

• Consider adding the RAADS-R (Ritvo Autism Asperger Diagnostic Scale-Revised) - it's specifically designed for adult autism assessment

• Neuropsychological Testing:

• Unlike ADHD, some neuropsych testing can provide valuable diagnostic information

• Focus on tests measuring social cognition and executive functioning

• Consider adding:

• WAIS-IV (selected subtests)

• Social Cognition tests (beyond ACS)

• TMT for processing speed

• Self-Report Measures:

• The BRIEF-A is appropriate

• Consider adding the SRS-2 (Social Responsiveness Scale)

• Autism Quotient (AQ) can be helpful as a screening tool

You're not out of your depth, but I would recommend:

• Establishing a referral network with neuropsych specialists

• Documenting limitations in your reports

• Focusing on functional impact rather than just test scores

Remember, comprehensive autism assessment is about pattern recognition across multiple domains, not just individual test scores.

Thank you for the feedback!