If you had four hours for an autism eval, what would you do?

[borne_before]

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Here are the parameters:

• You are bringing them in to the clinic for four hours.
• This is your first contact with them.
• Referred by a medical provider at your gig (think neuro/genetics/pediatrician/etc) and you will most likely have access to some history all ready.
• Most kids will have some genetic or medical condition.
• You will have 2, 3, 4 hours to write everything up.
• Ages will be from 2 to ten.
• No academic testing needed, the goal is more differentiate autism from intellectual disability or dx both, or maybe ADHD kinds of things.

 

[ClinicalABA]

Assuming I did an intake and have some background info on developmental history, medical/gentic histories, neonatal history, etc.before testing (if not, add 30 min or so):

Under 2.5yo- Bayley cognitive and language, ADOS-2, Bayley Social Emotional Adaptive Behavior Questionnaire (or Vineland-3). Add Bayley Motor if any concerns for motor skills development. ~2hours direct testing, scoring as i go along. 30 minutes feedback, hour or so write-up. If you're not good at building rapport, dealing with typical toddler separation anxiety and other assorted nonsense, add an hour or so.

2.5-3.5yo- add in an SRS-2. Maybe an additional 15 minutes of scoring and write up time.

3.5- 4yo- WPPS-IV, CASL-2 (receptive and express everything scales at a minimum, sentence level scale if warranted, and grammatical morphemes and pragmatic language if the kids a talker), ADOS-2, SRS-2, Vineland-3, BASC-3 to identify potential internalizing stuff. If nothing comes up to suggest some kind of precocious anxiety/depression, and kid is generally cooperative (50% are, 40% aren't but can be persuaded to participate, 5% make you question your career choices, 5% make you question your life choices) you may be able to get away with 2.5 hours direct testing, 20 minutes scoring, 30 minutes feedback, and then type fast so you take less of a loss on the write-up. If something comes up that makes you think there's some type of internalizing disorder or executive functioning problems, add another 1-2 hours for additional structured diagnostic interview, NEPPSY-2 substances, etc.

4-5yo- getting it done, scored, and written up in 4 hours would be a stretch. Too many other differential diagnoses to look at/test for, and preschoolers and early elementary will often need 2 testing sessions, as cognitive and language in one day can push third limits and thus you may not get accurate data if you do the ADOS on same day.

Over 5 yo- refer out!

There are several client factors that can make things go quicker or slower. Low verbal skills or cognitive skills= hitting those "5 incorrect in row" ceilings much faster than the averagely verbal, average intelligence kid. If you need to use a translator for interview, administration, or feedback, add 10% more time. Very non-compliant, extreme separation anxiety, etc, ad 20%+ more time.

All this assumes that you are very efficient with the admin and scoring of the tests, as well as with your write-ups. Obviously, ymmv in the area.

EDIT- I copied the above from another thread without some of the info @borne_before posted above. If the 4 hours is only the direct contact time, then you should be able to get it done (cognitive, language, and ADOS testing definitely, with an hour or so left over for additional executive functioning testing and/or ruling out internalizing stuff. Have questionnaires completed beforehand by parent/caregiver (ideally online and scored), with maybe a 15-30 minute phone or zoom interview. Template out your write up and stick to the important stuff, and get her written in 2 hours max.

 

[niceman]

This is similar to the multidisciplinary clinic I was in. Younger kids (<5) typically see an OT or SLP depending on their referral concerns while I was included in the evaluations with school-aged kids. I also sometimes saw <5 kids.

1. Check state laws/guidelines, especially for intellectual and developmental disabilities. For example, I was in a state that does not recognize the UNIT-2. You can help the family by administering a similar test so they don't have to go through another IQ test, especially if their functioning is so low that it won't make much of a difference. I'm also in a state where autism can be diagnosed with a CARS, so make sure you check what is required.

2. Get the Developmental Profile-4. Most of the time you can get direct testing data for their cognitive functioning. And even with behavioral challenges, we really try. However, once in a while, the kid is not giving you anything. They may hate it here. They may not understand you. And the family is desperate. The DP-4 can give you some data to support what you want to do (ID if clearly ID, treat before second testing attempt etc.) and get the ball rolling in case they need further support elsewhere, and the other providers and agencies can try again.

Our batteries are similar to ClinicalABA's with some variations depending on referral concerns and current functioning.

A) Cognitive: DAS-II, WPPSI, WISC, WNV, SB, WASI. The DAS-II is good and fast if there's no significant fine motor concerns. The extended norm is particularly good for kids who are too old for the WPPSI but can't do the WISC. It's also better for kids from other cultural/linguistic backgrounds. Get the online scoring though or the scoring will slow you down. The abbreviated ones are more for kids who already had an IQ done by the school or another provider with no/little cognitive concerns.

B) Adaptive: ABAS-3 or Vineland-3. The ABAS is faster if the caretaker can read but you really have to explain to them the difference between a 0 and a 1 or you may end up having no 0s for a 5-year-old. The Vineland can take a while, especially if you're working with an interpreter so you'd want to factor that in.

C) Social: ADOS+CARS+one of the autism questionnaires. I personally also prefer the SRS-2 due to its specificity. CARS is done in conjunction with the DI and you take all the data into account.

D) Emotional/Behavioral: Vanderbilt/BASC-3/ASEBA forms. The ASEBA forms are pretty old, but they're available in 100+ languages so they come in handy if you see patients who speak/read other languages.

E) Language/EF: CELF/NEPSY/DKEFS. Since kids with speech/language concerns would see an SLP, I typically didn't include language testing. When I did, it was more to test their ability to follow instructions (NEPSY comprehension or instruction or CELF following directions). Speech/language disorders are also more important differentials for younger kids than older kids since speech/language difficulties are more easily identified and intervened. But if they haven't had anything done for speech/language in the past and you suspect that, feel free to test further. You can also throw in EF tests if there are concerns or if you have time, but if you're doing same-day feedback and your primary goal is to diagnose, you may not have much time for it.

If you template everything and use bullets for interview questions and answers, you should be able to finish the report in 2 hours.

 

[PsyDr]

Is the question categorical?

Because in the long long long time ago, a young psydr worked as a paraprofessional for an autism clinic. The psychologist asked me to retrieve the autistic kid from the waiting room. I asked her, “how will I know which one is autistic?”. She said, look for the one who looks autistic.”.

And she was right.

If the question is ordinal: then… like probably.. snd like … 50%?

That’s like asking if some random woman in a bar. walking up to me is interested.. like 50%.

 

[borne_before]

Really appreciate all the replies - seriously. It’s always cool (and honestly kind of fun) to see how other clinicians are structuring things. There are so many ways to do this work well.

I’ve been in this new role about two weeks now, seeing families independently, and I’m finally starting to get a sense of the landscape. This isn’t my rodeo, and I’ve done north of a thousand evals of varying complexity at this point, but the referral questions here are definitely narrower than in my previous clinic, so it’s been a bit of a recalibration.

A couple things make this setting a little different:

1. We only see kids with medical or genetic complexity: epilepsy, rare genetic syndromes, metabolic disorders, etc. So, the ID vs ASD question feels especially important here.
2. The waitlist has been massive, and it used to be over 5,000! Now it's under 1,000 after triaging to medically involved internal referrals ages ~4 to 10 and tightening with developmental pediatrics more (they generally take the younger kids).
3. I’d love to get it to a more humane 3–6 months for internal medically complex referrals. Because the waitlist went unmanaged for so long, a lot of our other providers were frustrated with psychology, and I think repairing that is important.

Also worth saying that this clinic was basically built by an extremely sharp, hardworking psychologist who has been going at alone over the last ~18 months. I’m early-career too, but this person is dialed in and I learn from them daily. We don’t agree on every single workflow detail (no two testing psychs ever do), but I feel lucky to be here benefiting from their experience, expertise, and trail breaking.

The long-term expectation is 6 evals/week scheduled. That number initially had me stressing! But after looking at no-show rates and actual flow, I think the realistic average will land around 4–4.5 completed evals/week, which is intense but doable. And honestly, part of why we’re salaried is for the occasional heavy week. And there are real perks here that make it feel worth it: trainees, occasional psychometrist support, research potential, institutional resources, etc.

My workflow right now looks roughly like:

• Clinical interview (60–75 min): Checking boxes, helping parents feel heard, aligning the goals of assessment, limitations,
• Cognitive estimate (30–60 min): Differentiating ID vs ASD is huge here. I’m trying to get quicker with the DAS-2 (my brain still rebels at the stimulus book layout), can do a WISC fast, have PTONI/CTONI/WASI/etc. as well. Getting Bayley training soon but manipulatives annoy me but I do see the value for GDD.
• Rating scales: ABAS most often; DP-4 has been useful; BASC available; planning to advocate for ASRS.
• ADOS-2 (~40 min)
• Quick score + diagnostic formulation (~20 min)
• Same-day feedback at end of session - Nothing overly deep but enough to orient parents and establish plan and next steps

When I am locked in, I try to crank out the report in about ~2 hours. The biggest challenge honestly is not letting chart consume me because these medical files can be a lot and this institution has a pretty awful EMR. I try to write the medical section in a way that’s digestible for schools and community providers.

Ditto that a good evaluation makes a report that is both a clinical document and a key for navigating systems (i.e., making bureaucracies happy).

Four hours goes fast, but with structure, templates, and staying focused on the core question -it feels manageable. I can also touch other questions like ADHD, anxiety, etc. time permitting.

I wonder about a minimal viable product in this niche.

 

[borne_before]

Is the question categorical?

Because in the long long long time ago, a young psydr worked as a paraprofessional for an autism clinic. The psychologist asked me to retrieve the autistic kid from the waiting room. I asked her, “how will I know which one is autistic?”. She said, look for the one who looks autistic.”.

And she was right.

If the question is ordinal: then… like probably.. snd like … 50%?

That’s like asking if some random woman in a bar. walking up to me is interested.. like 50%.

This hits on so much of what I’ve been feeling about assessment lately.

I occasionally leave and rejoin the Testing Psychologist Facebook group. On one side, you’ve got the same ten people who reply to everything with absolute confidence and rigid opinions. On the other, it’s the “what’s a good test for dyslexia?” posts that make me rage-quit every time.

At my last clinic, I worked with another amazing psychologist, and we’d often joke that a valid diagnosis of autism is made when I say the kid has autism highlighting the reality that diagnosis ultimately rests on the expertise of a trained clinician.

But that’s also a little terrifying, because we all know there’s huge variability in clinician quality and the general public really can’t tell the difference. I have a close friend (my first call whenever something is going on professionally, I need advice about), and she is constantly frustrated by a mutual acquaintance, someone who washed out of our graduate program but is now suddenly everywhere. Media interviews, “expert” panels, social media, etc.

This person is… an interesting case. I like them personally, they’re entertaining, but they’re not a serious clinician (not bad, but also not the best). Yet somehow, they’re getting all this credibility and attention for “expertise." It used to be baffling, and then it clicked for me:

They are proof that doing something is better than overanalyzing and planning nearly every time. They don’t overthink, they don’t wait until they have mastery, they just act and act confidently. And in a world where most people can't assess clinical competence, the person moving fast will always beat the person thinking deeply. As an aside, I find the fact that it bugs my friend so funny. This friend couldn't legally drink when we started our doc program. She has a thriving private practice. She's killing it and is the smartest person I know. So it's funny when something gets under her skin a little - especially when that person is a bit of a dunce.

I think what you’re saying touches on that old Supreme Court justice quote about the difference between pornography and art: “You know it when you see it.” It’s the same with dyslexia. I just need to see how a kid spells and watch them read, and I can usually make a pretty accurate call. The testing is more about clarifying how to help. I actually did my doctoral minor under one of the top dyslexia researchers in the world - their name is literally on tests that get used daily in most schools. And even they agreed with you know it when you see it. The tests they publish are there to help reading specialists plan interventions and less knowledgeable clinicians avoid missing or bungling the diagnosis.

Autism, though, feels like it’s in danger of becoming a garbage diagnosis (if we’re not already there). Just like how the specific learning disability is now an elephant graveyard for all academic underachievement.

But let’s be real with autism: most of the time, you know it when you see it. The testing can feel like going through the motions, but you do it because that’s what gets the kid access to services. You’re essentially testing in hopes of creating a document that both the underfunded state DD agency worker and the insurance pre-auth reviewer can understand and approve.

I also worry that the more we rely on tests, the more we start subordinating our own expertise to them. Tests are useful tools, but they’re not perfect - and they can be misused pretty easily. At the end of the day, it’s still about the clinician. How much in testing do we outsource the intangible meaning of what it means to be a good clinician? All to assuage or reduce anxiety by hiding behind data.

 

[singasongofjoy]

Really appreciate all the replies - seriously. It’s always cool (and honestly kind of fun) to see how other clinicians are structuring things. There are so many ways to do this work well.

I’ve been in this new role about two weeks now, seeing families independently, and I’m finally starting to get a sense of the landscape. This isn’t my rodeo, and I’ve done north of a thousand evals of varying complexity at this point, but the referral questions here are definitely narrower than in my previous clinic, so it’s been a bit of a recalibration.

A couple things make this setting a little different:

1. We only see kids with medical or genetic complexity: epilepsy, rare genetic syndromes, metabolic disorders, etc. So, the ID vs ASD question feels especially important here.
2. The waitlist has been massive, and it used to be over 5,000! Now it's under 1,000 after triaging to medically involved internal referrals ages ~4 to 10 and tightening with developmental pediatrics more (they generally take the younger kids).
3. I’d love to get it to a more humane 3–6 months for internal medically complex referrals. Because the waitlist went unmanaged for so long, a lot of our other providers were frustrated with psychology, and I think repairing that is important.

Also worth saying that this clinic was basically built by an extremely sharp, hardworking psychologist who has been going at alone over the last ~18 months. I’m early-career too, but this person is dialed in and I learn from them daily. We don’t agree on every single workflow detail (no two testing psychs ever do), but I feel lucky to be here benefiting from their experience, expertise, and trail breaking.

The long-term expectation is 6 evals/week scheduled. That number initially had me stressing! But after looking at no-show rates and actual flow, I think the realistic average will land around 4–4.5 completed evals/week, which is intense but doable. And honestly, part of why we’re salaried is for the occasional heavy week. And there are real perks here that make it feel worth it: trainees, occasional psychometrist support, research potential, institutional resources, etc.

My workflow right now looks roughly like:

• Clinical interview (60–75 min): Checking boxes, helping parents feel heard, aligning the goals of assessment, limitations,
• Cognitive estimate (30–60 min): Differentiating ID vs ASD is huge here. I’m trying to get quicker with the DAS-2 (my brain still rebels at the stimulus book layout), can do a WISC fast, have PTONI/CTONI/WASI/etc. as well. Getting Bayley training soon but manipulatives annoy me but I do see the value for GDD.
• Rating scales: ABAS most often; DP-4 has been useful; BASC available; planning to advocate for ASRS.
• ADOS-2 (~40 min)
• Quick score + diagnostic formulation (~20 min)
• Same-day feedback at end of session - Nothing overly deep but enough to orient parents and establish plan and next steps

When I am locked in, I try to crank out the report in about ~2 hours. The biggest challenge honestly is not letting chart consume me because these medical files can be a lot and this institution has a pretty awful EMR. I try to write the medical section in a way that’s digestible for schools and community providers.

Ditto that a good evaluation makes a report that is both a clinical document and a key for navigating systems (i.e., making bureaucracies happy).

Four hours goes fast, but with structure, templates, and staying focused on the core question -it feels manageable. I can also touch other questions like ADHD, anxiety, etc. time permitting.

I wonder about a minimal viable product in this niche.

There's no way to get it all done in 4 hours if you're including writeup. Ideally you've got families completing report measures on ipad or something where it can be auto-scored to save you that time, maybe even have them do it in advance. We send measures in advance which families can return in advance or bring iwth them on date of eval (though sending links to complete electronically would be more efficient, it's cumbersome with our overall setup). Depending on the case i will also send a CARS parent questionnaire in advance and highlight the instruction to provide specific examples for any categories endorsed, which can help streamline/focus the interview. I also do like the BRIEF, especially if i can get school report too - I like how it breaks apart aspects of exec fx bc a clear peak in the "shift" subscale in comparison to most oher subscales even if others are elevated too (as is often the case) is another data point in favor of ASD.

If you've got any admin support to help with this, while people are on the long waitlist, get them to get evaluation through the school system if they typically do an OK job in your area, and make sure families provide that in advance of the evaluation. If you get decent cognitive / developmental testing from the school, depending on other variables in some cases you may be able to forego or do something more abbreviated as a gut-check or use the time to administer supplemental subtests etc. In our area they will often have the teachers complete the SRS, CBCL, sometimes ABAS. I've taken to screenshotting portions of school reports / IEPs / medical chart (especially results of previous testing, scores and whatnot) and copy-pasting for the sake of efficiency in really complex cases where i feel that info is important to include (like "for additional detail on xyz, see addendum 1 which contains select excerpts from (source/date)." Not elegant, but efficient.

Are you doing the interview and testing on the same day? It's hard to imagine a kid hanging iwth it that long, tbh, especially when you start getting test time interference with naptimes for the littler kids, so i would worry about the viable product for that reason as well.

 

[Justanothergrad]

TAT emot relationship cards. The qualitative data you get in their description of how relationships work, etc are remarkably useful. I usually give like 4ish cards and use it narratively within a constructist framework. Short, easy, and has always been a good use of a few minutes in these evals.