I’m sure
@ClinicalABA can add more thoughts since this is the population he works with, but having worked with kids on the spectrum, I think your coworker is a ***** and is missing the forest for the trees. Technically, isn’t the ADOS, GARS and other standardized measures for assessing autism essentially observations and rating scales? Your coworker is missing 2 key issues in her argument: service provision and the likelihood of comorbid disorders.
1. Service provision. In my state for Medicaid, in order for a provider to bill for autism services including ABA, an evaluation that includes a standardized autism assessment tool such as above must have been administered by the appropriate professional qualified to administer it. I suspect commercial insurances have similar requirements. Without that evaluation, Medicaid will not approve of any autism services. Other states and insurance companies may have different expectations. But if the state you work in has similar requirements, your coworker
could be causing her families to lose out on potential important treatments that will help the child.
2. Comorbid diagnosis. Individuals diagnosed with autism often have comorbid diagnoses, such as intellectual disability, expressive or receptive communication disorder, sensory issues, learning disabilities, mental health etc etc etc. Without a multidisciplinary evaluation that
includes a psychological eval, those needs will get missed and the individual will continue to struggle. A speech and language evaluation can help assess if the social communication deficits are due to language problems or the social reciprocity problems, or both. Depending on the level of functional impairment, additional services may be needed to support that individual, and like most other services in healthcare, likely requires an evaluation to pay for said services.
But hey, maybe your coworker works exclusively with rich people who can afford all of this out of pocket
Yes- this is what I do. I can only really comment on the younger kiddos (1-3) as that's who I work with. I only do assessments on children with potential ASD. I agree with what MAClinician and others have said. I'm looking to do a few things
1. Identify the behaviors that meet the DSM-5 criteria for ASD
2. Rule out other more likely explanations (i.e. diagnoses) for those behaviors. With my population, going from most common to least common, that's:
-Language Disorder
-Global Developmental Delays/cognitive deficits
-Social (Pragmatic) Communication Disorder
-Selective Mutism
With older kiddos, there's a few more and it gets more complicated. I'll stick to the little ones, thank you!
3. Identify any comorbid conditions that may impact treatment progress and/necessitate additional treatment (e.g., speech/articulation difficulties; motor skills problems)\
4. Identify the severity of negative impact of the symptoms (e.g., assign a level of ASD; establish a baseline for cognitive/language delays)
While in many cases, I can do #1 above just by setting eyes on the kid in the waiting room and asking the caregivers a few questions to fill in the blanks on (e.g., related to social interactions with other children and adults), I can not do so in all cases. Also, some of the diagnostic criteria can be subtle and not something that parents would pick up on. Like criteria A-2- deficits in non-verbal communication. Many time parents know that something isn't right, but they aren't specifically noting thinks like speech, gestures, and eye contact being used separately but not combined. Structured questionnaires (I used the SRS-2 and the BASC-3) can pick up on some of these, but I can't tell you how many times the results of parent ratings don't match what I or the other professional involved in the case report. (I'm typically doing the assessment with and early intervention developmental specialist, speech therapist, and/or OT in the office with me). Many of the symptoms require a specific "social press" to identify, and that's where the criterion based ADOS-2 comes in.
#2 requires a little bit more than just observation and questionnaires, and that's where formal cognitive and language testing come into play (I'll use the Bayley cog and language test for younger kiddos, WPPSI and PLS-5 for older kiddos. I've had some parents who will report that their child's speech and language is fine, but they are unaware of where it should be.
#3 requires some observation and interaction. For example, I may note that I can't understand the child initially, but the parents can and I get better in context or as the session progresses. I'm gonna recommend a speech/language eval to identify any problems with oral-motor skills, articulation, etc. For other kiddos I may note that they seem to have some of the test stuff figured out cognitively, but fine motor stuff is getting in the way of them accurately placing or rotating the pegs or puzzle pieces on the Bayley Cognitive test. If there are specific and severe motor skills deficits note at intake, i may do the Bayley motor skills assessment as well to get a baseline (most often when I'm specific delays in multiple areas of development).
#4 is informed by everything- interview, rating scales, criterion-based as well as norm-referenced testing, observations, etc.
So, can I make an accurate diagnosis based on an unstructured observation and some rating scales? Yes, if the scales are completely accurately and honestly (not always the case), the data from the observation are a representative sample of the "population" of data, and -just as importantly- I'm focusing on identify and documenting the necessary behaviors. That last one can be tricky in just a brief unstructured observation. when things are unstructured and brief, It's easy to be distracted by some obvious diagnosis supporting or non-supporting behaviors, jump to conclusions, and make an inaccurate diagnosis (we have some local general and developmental pediatricians who DO THIS ALL THE TIME!!). I should also say that I'm not dealing with a representative sample. As I've mentioned, I only see really young kiddos. By the time they get to me, the parents have noticed something isn't right developmentally, the pediatrician has referred them to EI, and EI has referred them to me. My type of service is in high demand (I'm currently booking in May-June 2020) and the EI staff referring kids to me are doing triage and only sending me the most obvious/or needy cases so that they can get the services. Despite all that, it's still not always clear from just the interview, observation, and rating scales.
TLDR- in some cases you could get the DX right with just the interview, unstructured observation, and rating scales. However, IMHO, you'd make an unacceptable amount of errors and kiddos would either not get what they need when they need it and could most benefit, or they would get a inappropriate label that could have lasting negative impact and be hard to get rid of. You'd also potentially miss some comorbid or differential diagnoses. Finally, DX without some formal testing (e.g. ADOS-2) may not qualify for certain services.
