By: Clinical Psychologist, Shannon Grassby
Introduction
Autism is a neurodevelopmental difference or brain style. It is part of neurodiversity in how an individual’s brain develops and is ‘wired’ across three broad areas of difference – (1) sensory use and interests, (2) social relationships and emotional responses, and (3) language and communication.
Autistic people have different preferences of social communication which is different to neurotypical people. For example:
- Preferring to be able to “info-dump” on one topic rather than taking turns or engaging in back and forth conversation.
- They may have a more narrow set of interests than their neurotypical peers.
- Their sensory experience may be heightened or dulled compared to neurotypical peers depending on the sense.
- They may like to engage in the same activities, speech or motor movements again and again.
- It may be difficult for them to understand their internal experience around their emotions and may often seem heightened or feel dysregulated in their emotions.
Because of these differences, they may have difficulties connecting with or making and keeping friends with their neurotypical peers and may also experience other mental health challenges due to difficulties coping with their environment or due to the pressures of masking to fit in.
An assessment process is often the first step in understanding themselves or understanding their loved ones with autism. Assessment assists people in understanding their brain type, their needs and what supports they may require.
Why Formally Assess?
We understand that formal assessment processes can be lengthy, cost-prohibitive, and potentially not available in your area especially if you live in a rural or remote area.
However, a formal assessment process can be very useful and important for both children and adults. It helps to ensure that the supports that are provided are tailored and appropriate, as some supports or strategies which may be suitable for a neurotypical person may not be the best choice for an autistic person.
For children, a formal assessment process and diagnosis can assist you and your child in accessing appropriate supports, such as medication or therapeutic supports. It assists health professionals in having a “short-hand” but accurate summary of the strengths and difficulties your child may have, and it can help schools to better understand your child also.
For adults, a formal assessment process is often a validating experience, providing recognition and better understanding of many strengths and difficulties that person may have experienced over their life. A formal process can often be more reassuring than a self-diagnostic process for some people.
Formal assessment processes also allow for consideration and possible assessment of other co-occurring or differential diagnoses or brain styles which may also form an important piece of understanding a person’s strengths and differences.
What are Co-occurring and Differential Diagnoses?
All assessment processes should include appropriate consideration of co-occurring brain styles or diagnoses as well as differential diagnoses. Co-occurring brain styles or diagnoses are those that are present at the same time as Autism or the primary diagnosis. Differential diagnoses are different diagnoses which should be considered which may better explain the current difficulties a person is experiencing.
Common co-occurring or differential presentations or diagnoses that your chosen assessor may consider include, but are not limited to;
- Anxiety
- Depression
- ADHD
- OCD
- Behavioural Difficulties including diagnoses such as Oppositional Defiant Disorder or Conduct Disorder
- Cognitive difficulties
- Tic Disorder or Tourettes
- Sensory Processing or Auditory Processing Disorder
As an adult, and increasingly as an adult woman, people may have received wrong diagnoses such as Bipolar Disorder or Borderline Personality Disorder
Your assessor may include additional questionnaires or tests to appropriately consider, and “rule-in” or “rule-out” the presentations, conditions, diagnoses or brain styles which are relevant to you and your child.
If throughout the course of the assessment process, your assessor feels it is important to consider in more detail potential co-occuring brain styles or diagnoses, they may add to the assessment procedures to include more specific questionnaires or assessments.
The Assessment Process
Assessment: What to Expect
Throughout the assessment process, you should expect to be asked detailed questions throughout unstructured or structured interviews (or both), as well as for you to complete a variety of formal questionnaires. This takes place over a number of sessions, sensitive and accommodating of the needs of children, and is also tailored to the needs and age of the child or adult.
Most of all, you should expect to be listened to and to feel heard and validated by your assessor and the assessment process. You should also expect the assessment process to be conducted in a neuro-affirming way, which means that you are able to feel that the strengths and differences of your brain are understood and taken into account, rather than feeling that there is something “wrong”, “deficit”, “disordered” or “bad” about you or your child.
If your assessment is being conducted by a psychologist, at the completion of the assessment you should also expect to receive a feedback session where the outcome of the assessment is shared with you and you are able to review the report that your assessor has compiled, as well as their recommendations for support.
Assessment Tools and Methods
A Comprehensive assessment process should include information gathering from a range of sources, using a range of methods and across large periods of the person’s life. This is the same for both children and adults.
Assessment Tools
For your child, you should expect the assessment process to include;
- An initial biopsychosocial interview with your chosen health professional, taking detailed information as to the current difficulties, education history, medical history, developmental history, family history, social history, mental health screening and appropriate differential diagnoses considered such as anxiety or other mental health conditions.
- Use of validated psychological questionnaires and tools including structured interviews, with reports from parents, school, and self (if age appropriate) and may include:
- Formal behaviour assessments may include the Autism Diagnostic Observation Schedule (ADOS) or Monteiro Interview Guideline for Diagnosing the Autism Spectrum (MIGDAS).
- Autism Spectrum Rating Scale or Social Responsiveness Scale as validated questionnaires.
- Detailed parent interview which may include the Autism Diagnostic Interview Revised (ADI-R).
- Mental health screeners may also be used, or other relevant questionnaires.
- Functional Capacity Assessment – at Spencer Health, we utilise the Vinelands tool to assist with the possible access to the NDIS scheme pending the outcome of the assessment.
- The assessing health professional may wish to speak to your child’s teachers or educators.
- At Spencer Health, we also include a cognitive and academic assessment in order to appropriately account for the diagnostic specifiers within the DSM criteria as outlined below. This assessment also allows us to understand a child’s cognitive development to date and make relevant recommendations for supports at school if required.
- Review of any relevant documents, such as previous assessment reports, letters, school reports.
When conducting an assessment for an adult, you should expect the assessment process to include;
- An initial biopsychosocial interview with your chosen health professional, taking detailed information as to the current difficulties, education and work history, medical history, developmental history, family history, social history, drug and alcohol history, previous intervention or support history including previous assessments that may have been conducted.
- Use of validated psychological questionnaires and tools including structured interviews, with reports from self and an “observer” report. People often choose to nominate their parent or partner to complete the observer report.
- Use of a structured diagnostic interview, such as the MIGDAS to gather information as to an autistic lived experience. Typically this interview is also conducted with your chosen “observer” to provide collateral information.
- Questionnaires such as the ASRS, AQ, CAT-Q, BRIEF or mental health questionnaires.
- Review of any relevant documents, such as previous assessment reports, letters, school reports.
Assessment Criteria
At Spencer Health, whilst we do take into account the diagnostic criteria of autism as laid out by the Diagnostic and Statistical Manual of Mental Disorders 5th Edition Revised (DSM-V-TR), we also listen to the lived experience and the narrative of the lives of autistic and unrecognised autistic people. This is important in order to ensure that our assessments are both useful to the person from the perspective of accessing healthcare systems, such as Medicare of the National Disability Insurance Scheme (NDIS), but more importantly, are useful for the person and their family to understand themselves and to be neuro-affirming and supportive of their understanding of their own strengths and differences.
The formal criteria that the DSM-V-TR set out when assessing for an autistic brain style in both children and in adults are:
| Criteria A | Differences in social communication (must include all of the below). |
| · Differences in understanding emotions of self and others, differences in social approach and response, differences in conversational style. | |
| · Differences in use of non-verbal communication for social communication purposes, for example, eye-contact, gestures, facial expressions and other body language. | |
| · Differences in ability to make and keep friends with neurotypical peers, differences in play and imaginative play, differences in interest in others. | |
| Criteria B | Restricted or repetitive use of behaviour, interests or activities (must include 2 of the below).
|
| · Repetitive motor movements, objects or speech. | |
| · Difficulties coping with changes and preference for sameness in routines, schedules and expectations. | |
| · Strong interest areas, often in a few areas, and seem narrow when compared to other children. | |
| · Differences in sensory experience of light, taste, touch, sound, smell, vestibular, proprioceptive input. | |
| Criteria C | Differences present in early development, but may not become identifiable until later in life due to eg. masking or learned strategies. |
| Criteria D | These differences impact negatively on the person’s social, occupationa,l or other important areas of functioning. |
Please note- the wording of the above has been changes from the original to remove use of the word “deficits”
The Monteiro Interview Guidelines for Diagnosing the Autism Spectrum (MIGDAS) offers a different conceptualisation of the above diagnostic crtieria and is generally considered to be a more neuroaffirming approach due to its emphasis on understanding strengths and differences of autistic social communication and brain style when compared to neurotypical social communication and brain style.
The MIGDAS approach outlines strengths and differences in three key areas;
- Sensory Use and Interests.
- Social Relationships and Emotional Responses.
- Language and Communication.
At Spencer Health, we use our knowledge of the autism spectrum, as informed by the MIGDAS guidelines and lived experience of autistic people as well as our understanding of the diagnostic criteria as laid out in the DSM in order to provide a comprehensive assessment and report for our clients.
Gender Differences
More recently, there has been a greater understanding as to how gender can affect how a person’s symptoms of their autistic brain style are expressed which can lead to missed opportunities for recognition or their brain style, or wrong diagnosis.
Generally, girls and women may be more aware of aspects of their social environment and may be able to determine from a younger age that certain aspects of them or how their brain copes with their environment may not be socially acceptable or appropriate. As such, they may seek to hide or cover-up for these differences in some way so as to reduce negative feedback, or how much they stand out from their peers, or may find other ways to compensate or mask. This is referred to as an “internalised” presentation, and it can make it difficult for caregivers, teachers and professionals to detect these “hidden” or “masked” difficulties.
Greater public awareness of the internalised, or masked, presentation of Autism, particularly in girls and women has enabled many people to understand themselves and their brain in a more complete way, and it is important that your chosen assessor understands this presentation and takes this into account when conducted the assessment.
Ready to Take the Next Step?
At Spencer Health, we assess and work with autistic children, adults, parents and neurodiverse or neurospicy families. We offer a range of services including assessment, therapy and coaching with many services being delivered via telehealth. If you are ready to book in for an assessment for yourself or your child, or are maybe interested in just having an initial conversation with one of our trained psychologists to decide if it is worth pursuing an assessment, please get in touch. Spencer Health is a neuroaffirming organisation and we are lucky to count many neurodivergent psychologists as colleagues.
If you would like to meet more of our team, or learn more about our services you can do so here https://spencerhealth.com.au/spencer-health-team/ or if you are ready to book in, you can do so here https://spencerhealth.com.au/contact/