Autism Assessment- we could debate methods and their validity all day but ask me my views on key considerations in assessment in adults, my mind jumps straight to the challenges in the use of ADOS and ADI-r, which during my time were the ‘must do’ components of diagnostic assessment.
Personally, I love the ADI-r, but the notion of the ‘detailed developmental history’ is often problematic in adult caseloads. I have sat in many a diagnostic formulation where the phrase ‘Consensus: Insufficient evidence to rate’ is recorded because of the lack of evidence of life-long difficulties in any one area of functioning.
Is there an informant? If there is, are the retrospective recollections sufficiently detailed (and therefore reliable) enough to satisfy the diagnostic criteria? Of course, in the absence of a third-party informant, you can review early medical/social/school records- though this information is generally more scant and tends to be more and more difficult to retrieve with the increasing age of the individual. I have to add, that sitting with the parents of the adult being assessed and getting a run of “I’m sorry, but I really don’t remember” is heart-breaking. I tend to ‘group’ similar items together to aid a broader discussion around a particular area, which tends to make it less pain-staking. And, despite repeated refrains of “the important things will stand out in your memory”- they don’t always, and the guilt felt by the families is usually horribly clear 🙁
And current behaviours? Compared to children, the clinical picture is more likely to be complex. People have typically learned to mask and compensate for their autistic traits and have often developed co-occurring mental health conditions. Diagnostic overshadowing is rife. Trust me, I’m not well-read enough on the sensitivity and validity of the ADOS in adults to discuss this in any detail, but I know sometimes the ADOS (module 4, obvs) is not enough to inform observations of current functioning. As a Speech and Language Therapist I found using other clinical (SLT) assessments one of the most helpful differentials when it got to formulation. I was scared to use the information gathered from ‘other’ assessments at first but I soon realised how much they can bring- for example I often would complete the test of pragmatic language (TOPL) – being able to comment on things like the person’s ability to attend to prior knowledge or adjust communication to audience in a test scenario would really help the quality of information provided within our diagnostic formulation document. The Pragmatic Profile is another great one, allowing the inclusion of self and other reports to gain insight into a person’s communication in everyday life. Maybe it’s time to rethink the whole ‘gold-standard’ in autism assessment being just a combination of ADOS and ADI-r?