Assessing Asperger’s and High-Functioning Autism: Tips for Clinicians
Developmentally-based assessments of cognitive, communicative, and other skills provide information important for both diagnosis and program planning for kids with Asperger’s Syndrome (AS) and High-Functioning Autism (HFA). Careful documentation of a youngster’s unique strengths and weaknesses can have a major impact on the design of effective intervention programs and is particularly critical due to the fact that unusual developmental profiles are common.
Given the multiple areas of difficulty, the efforts of experts from various disciplines are often needed (e.g., audiology, neurology, pediatrics, physical and occupational therapy, psychiatry, psychology, speech and language pathology). The level of expertise required for effective diagnosis and assessment may require the services of professionals other than those usually available in a school setting.
In some cases, psychological and communication assessments can be performed by existing school staff, depending on their training and competence in working with kids with AS and HFA. However, other services (e.g., management of seizures, drug therapy, genetic testing, etc.) are managed in the health care sector. Some kids may fall between systems, and therefore not be served well.
Several principles underlie assessment of a youngster with AS or HFA:
1. A developmental perspective is important. Given the strong association of mental retardation with Autism Spectrum Disorders, it is important to view results within the context of overall developmental level.
2. Behavioral difficulties must be considered, since they affect both the youngster’s daily functioning and considerations for intervention.
3. Functional adjustment should be assessed. Results of specific assessments obtained in more highly structured situations must be viewed in the broader context of a youngster’s daily functioning and response to real-life demands. The youngster’s ability to translate skills into real world settings is particularly critical.
4. Multiple areas of functioning should be assessed, including current intellectual and communicative skills, behavioral presentation, and functional adjustment.
5. Social dysfunction is probably the most defining feature of AS and HFA, so it is important that the effect of a youngster’s social challenges on behavior be considered.
6. Variability of behavior across settings is typical. Behavior of a youngster will vary depending on such aspects of the setting as novelty, degree of structure provided, and complexity of the environment. Thus, observation of facilitating and detrimental environments is useful.
7. Variability of skills is typical, thus it is important to identify a youngster’s specific profile of strengths and weaknesses rather than simply present an overall global score. Similarly, it is important not to generalize from an isolated skill to an overall impression of general level of ability, because such skills may grossly misrepresent the youngster’s typical abilities.
Various diagnostic instruments can be used to help structure and quantify clinical observations. Information can be obtained through observation (e.g., Autism Diagnostic Observation Scale) as well as the use of various diagnostic interviews and checklists (e.g., Autism Diagnostic Interview-Revised; Childhood Autism Rating Scale; Autism Behavior Checklist; Aberrant Behavior Checklist). An adequate assessment will involve both direct observation and interviews of mothers, fathers and educators.
The range of symptoms in AS is quite broad and spans the entire range of IQ. A diagnosis can be made in a low-functioning youngster as well as in a youngster who is intellectually gifted. In addition, children with AS vary along a number of other dimensions (e.g., levels of communicative ability, degree of behavioral difficulties, etc.). As a result, in working with the youngster, considerable expertise is required. Clinicians must consider the quality of the information obtained (both in terms of reliability and validity), the involvement of mothers/fathers and educators, the need for interdisciplinary collaboration, and the implications of results for intervention. Coordination of services and facilitating discussion between members of assessment/treatment teams and mothers/fathers is critical.
A range of components must be part of a comprehensive educational evaluation of kids with AS and HFA. These include:
Given the multiple areas of difficulty, the efforts of experts from various disciplines are often needed (e.g., audiology, neurology, pediatrics, physical and occupational therapy, psychiatry, psychology, speech and language pathology). The level of expertise required for effective diagnosis and assessment may require the services of professionals other than those usually available in a school setting.
In some cases, psychological and communication assessments can be performed by existing school staff, depending on their training and competence in working with kids with AS and HFA. However, other services (e.g., management of seizures, drug therapy, genetic testing, etc.) are managed in the health care sector. Some kids may fall between systems, and therefore not be served well.
Several principles underlie assessment of a youngster with AS or HFA:
1. A developmental perspective is important. Given the strong association of mental retardation with Autism Spectrum Disorders, it is important to view results within the context of overall developmental level.
2. Behavioral difficulties must be considered, since they affect both the youngster’s daily functioning and considerations for intervention.
3. Functional adjustment should be assessed. Results of specific assessments obtained in more highly structured situations must be viewed in the broader context of a youngster’s daily functioning and response to real-life demands. The youngster’s ability to translate skills into real world settings is particularly critical.
4. Multiple areas of functioning should be assessed, including current intellectual and communicative skills, behavioral presentation, and functional adjustment.
5. Social dysfunction is probably the most defining feature of AS and HFA, so it is important that the effect of a youngster’s social challenges on behavior be considered.
6. Variability of behavior across settings is typical. Behavior of a youngster will vary depending on such aspects of the setting as novelty, degree of structure provided, and complexity of the environment. Thus, observation of facilitating and detrimental environments is useful.
7. Variability of skills is typical, thus it is important to identify a youngster’s specific profile of strengths and weaknesses rather than simply present an overall global score. Similarly, it is important not to generalize from an isolated skill to an overall impression of general level of ability, because such skills may grossly misrepresent the youngster’s typical abilities.
Various diagnostic instruments can be used to help structure and quantify clinical observations. Information can be obtained through observation (e.g., Autism Diagnostic Observation Scale) as well as the use of various diagnostic interviews and checklists (e.g., Autism Diagnostic Interview-Revised; Childhood Autism Rating Scale; Autism Behavior Checklist; Aberrant Behavior Checklist). An adequate assessment will involve both direct observation and interviews of mothers, fathers and educators.
The range of symptoms in AS is quite broad and spans the entire range of IQ. A diagnosis can be made in a low-functioning youngster as well as in a youngster who is intellectually gifted. In addition, children with AS vary along a number of other dimensions (e.g., levels of communicative ability, degree of behavioral difficulties, etc.). As a result, in working with the youngster, considerable expertise is required. Clinicians must consider the quality of the information obtained (both in terms of reliability and validity), the involvement of mothers/fathers and educators, the need for interdisciplinary collaboration, and the implications of results for intervention. Coordination of services and facilitating discussion between members of assessment/treatment teams and mothers/fathers is critical.
A range of components must be part of a comprehensive educational evaluation of kids with AS and HFA. These include:
- communicative assessment
- consultation regarding aspects of motor, neuropsychological, or other areas of functioning
- medical evaluation
- obtaining a thorough developmental and health history
- psychological assessment
This information is important both to diagnosis and differential diagnosis and to the development of the IEP.
The psychological assessment should establish the overall level of cognitive functioning as well as delineate a youngster’s profiles of strengths and weaknesses. This profile should include consideration of a youngster’s ability to remember, solve problems, and develop concepts. Other areas of focus in the psychological assessment include:
- social cognition
- play
- motor and visual-motor skills
- adaptive functioning
Kids with AS and HFA will usually need to be observed on several occasions during more and less structured periods.
The choice of assessment instruments is a complex one and depends on the youngster’s:
- ability to cope with transitions in test activities
- ability to respond to complex instructions
- ability to respond to social expectations
- ability to work rapidly
- level of verbal abilities
Kids with AS and HFA often do best when assessed with tests that require less social engagement and less verbal mediation. In addition to the formal quantitative information provided, a comprehensive psychological assessment will also provide a considerable amount of important qualitative information. It is important that the clinician be aware of the uses and limitations of standardized assessment procedures and the difficulties that these kids often have in complying with verbal instructions and social reinforcement. Operant techniques may be helpful in facilitating assessment.
Difficulties in communication are a central feature of AS and HFA, and they interact in complex ways with social deficits and restricted patterns of behavior and interests in a given child. Accurate assessment and understanding of levels of communicative functioning is important for effective program planning and intervention. Communication skills should be viewed in a broad context of the child’s development. Standardized tests constitute only one part of the assessment of communication abilities in young people with AS and HFA. The selection of appropriate assessment instruments, combined with a general understanding of these disorders, can provide important information for purposes of both diagnostic assessment and intervention.
In addition to assessing expressive language, it is critical to obtain an accurate assessment of language comprehension. The presence of oral-motor speech difficulties should be noted. In kids with AS and HFA, the range of communicative intents may be restricted in multiple respects. Delayed and immediate echolalia are both common and may have important functions. In addition, various studies have documented unusual aspects even of very early communication development in AS and HFA.
In assessing language and communication skills, parent interviews and checklists may be used, and specific assessment instruments for kids with AS and HFA have been developed. For kids under age 3, scores on standardized tests may be particularly affected by difficulties in assessment and by the need to rely on parent reports and checklists. For preverbal kids, the speech-communication assessment should include observation of a youngster’s level of awareness of communication from others, the youngster’s sense of intentionality, the means used for attempting communication, and the quality and function of such means, sociability, and play behaviors. The clinician should be particularly alert to the youngster’s capacity for symbolic behavior since this has important implications for an intervention program.
There are also several standardized instruments that provide useful information on the communication and language development of pre-verbal kids with AS and HFA. These include:
- Mullen Scales of Early Learning
- MacArthur Communicative Development Inventor
- Communication and Symbolic Behavior Scales
For kids with some verbal ability, social and play behaviors are still important in terms of clinical observation but various standardized instruments are available as well, particularly when the youngster exhibits multi-word utterances. Areas to be assessed include:
- articulation
- expressive language and comprehension
- morphology
- pragmatics
- prosody
- receptive and expressive vocabulary
- semantic relations
- syntax
The choice of specific instruments for language-communication assessment will depend on the developmental levels and chronological age of the youngster. Additional observations may address aspects of topic management and conversational ability, ability to deal with non-literal language, and language flexibility. The clinician must be flexible and knowledgeable about the particular concerns related to assessment of kids with AS and HFA.
Motor abilities may represent an area of relative strength for a youngster, but as time goes on, the development of motor skills in both the gross and fine motor areas may be compromised, and motor problems are frequently seen in young kids with AS and HFA. Evaluations by occupational and physical therapists are often needed to document areas of need and in the development of an intervention program. Standardized tests of fine and gross motor development and a qualitative assessment of other aspects of sensory and motor development, performed by an expert in motor development, may be helpful in educational planning.
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