Autism Assessments Are Not All the Same: What Question Are You Paying to Have Answered?
When parents begin looking for an autism evaluation, they are usually looking for two things: answers and help.
Maybe a pediatrician has raised concerns. Maybe a teacher has noticed differences in social development or behavior. Maybe a child has been struggling for years and the pieces are finally beginning to point toward autism. And for some families, there is additional urgency because an evaluation and diagnosis may be necessary to access insurance-funded services such as Applied Behavior Analysis (ABA).
So, understandably, parents start looking for the fastest way to get an answer.
Today, there are many options. Some autism evaluations are brief and highly focused. Some are offered virtually. Others involve a much broader assessment of a child’s development, behavior, cognition, attention, emotional functioning, learning and adaptive skills. The important question isn’t necessarily which evaluation is better.
It is: What question are you paying to have answered?
Before You Choose an Autism Evaluation
If what you need to know is simply, “Does my child meet diagnostic criteria for Autism Spectrum Disorder?”, a focused autism diagnostic evaluation may be exactly what you need.
For families trying to access ABA, this can also be the shortest route toward obtaining the diagnostic documentation required by many insurance plans. Once a diagnosis has been established, a BCBA can assess the child’s behavior and develop an individualized ABA treatment plan. (The BCBA credential on its own does not qualify someone to diagnose autism.)
But establishing that a child meets criteria for autism does not necessarily tell us whether autism explains the entire clinical picture. And establishing that a child doesn’t have autism may leave an even bigger question:
Then what is going on?
That’s the difference between diagnostic confirmation and differential diagnosis. I hear this problem frequently when parents request psychological testing.
“I Just Want to Know if My Child Has ADHD.”
A parent may come to us and say, “I just want to know whether my child has ADHD. I don’t want all of that other testing.” They have a specific concern and don’t want to subject their child to unnecessary testing or incur unnecessary expense. But I usually ask them to imagine something.
How would you feel if we sat down after the evaluation and I told you, “Your child doesn’t have ADHD”?
I imagine the next question would be: “Okay…then what is it?”
But then, my answer may legitimately be: “I don’t know. You asked me to answer whether it was ADHD. To answer the larger question, we need more information.”
That is the problem with defining an evaluation too narrowly. Autism assessment is no different. A good psychological evaluation isn’t simply an exercise in confirming or rejecting the diagnosis we suspected before we started. It is a process of developing and testing reasonable clinical hypotheses.
Autism Can Look Like Other Things. Other Things Can Look Like Autism.
Difficulties with social interaction, flexibility, emotional regulation, communication, attention, sensory experiences or relationships may be associated with autism. But some of those same difficulties can also occur with ADHD, anxiety, language disorders, learning disabilities, intellectual or developmental differences, trauma-related conditions and other psychological or developmental concerns.
And sometimes it isn’t one versus the other.
A child can have autism and ADHD. A child can have autism and anxiety. A child can have autism and a learning disability.
Finding autism doesn’t mean we should stop being curious about the rest of the child.
This becomes especially important with older children and adolescents, whose presentations can be considerably more complex. A socially uncomfortable 12-year-old with poor eye contact, limited friendships, rigid behavior and difficulty participating in conversation may have autism. But those observations exist within a much larger developmental and psychological picture.
The purpose of an evaluation is to understand that picture.
So, What About the ADOS?
The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) is a well-established and extremely useful tool in autism assessment. We use it at Cadenza. It provides a standardized opportunity for a trained clinician to observe social communication, interaction and behaviors associated with Autism Spectrum Disorder.
The ADOS is just one part of an autism evaluation, but it was not designed to independently answer every differential diagnostic question about a child, and professional guidance is clear that autism diagnosis should not be based upon a single instrument. The ADOS findings need to be interpreted in the context of developmental history, other available information, clinical observation and professional judgment.
There is research illustrating why this matters, particularly in more complex cases.
Greene and colleagues studied 214 children and adolescents, ages 5–16, who received the ADOS-2 Module 3 as part of an autism evaluation. Module 3 is used with verbally fluent children and young adolescents. Importantly, this was a clinical referral population—not a representative sample of all children receiving an ADOS.
The researchers found that some children who ultimately did not receive an autism diagnosis nevertheless obtained elevated ADOS-2 scores. Within this particular sample, the false-positive rate was 34%, and greater anxiety observed during the ADOS was associated with false-positive elevations.
That does not mean that the ADOS has a 34% false-positive rate. It means that in this particular clinical population, behaviors observed during the ADOS could not always be interpreted accurately without the larger diagnostic picture.
The authors’ own conclusions are: “The ADOS-2 should not be used in isolation to assess for ASD, and, in psychiatrically-complex cases, RRB symptom severity may be particularly helpful in differentiating ASD from other psychiatric conditions. Additionally, heightened levels of anxiety, more so than overactivity or disruptive behavior, may lead to non-ASD specific elevations in ADOS-2 scores.”
This is precisely why the authors cautioned against using the ADOS-2 in isolation, particularly with children who have complex psychiatric presentations. The lesson isn’t that the ADOS is unreliable, it is that the ADOS needs context.
Three Evaluations Can Answer Three Very Different Questions
It may help parents to think about autism assessment this way.
An autism diagnostic evaluation asks “Does my child meet diagnostic criteria for Autism Spectrum Disorder?”
A differential diagnostic evaluation asks “What best explains what we’re seeing? Is this autism, ADHD, anxiety, a language or learning disorder, another condition—or some combination of them?”
A comprehensive neurodevelopmental or psychological evaluation asks “How does my child think, learn, communicate, pay attention, regulate emotions, interact socially and function in everyday life—and what does that overall pattern tell us about what they need?”
None of those is inherently the “right” evaluation because the right evaluation depends upon the question that needs to be answered. And, “comprehensive” doesn’t simply mean more tests. It means that the assessment is sufficiently broad to answer the relevant diagnostic and functional questions without unnecessarily testing areas that aren’t clinically indicated.
Why We Approach Evaluation Differently at Cadenza
Families rarely come to Cadenza because they are looking for one specific answer. Usually, there is a story. When a family asks us, “Does my child have autism?”, we take that question seriously. But we also want to understand the questions underneath it.
Our job isn’t to find autism, it’s to understand the child.
Something isn’t working at school. Friendships are difficult. Behavior has changed. A child isn’t progressing as expected. Parents are seeing things at home that teachers aren’t seeing at school—or vice versa. Previous treatment hasn’t worked as expected. There may already be one diagnosis, but it doesn’t seem to explain everything.
Why is my child struggling? What are we missing? What are their strengths? Is something else happening too? And what kind of help does my child actually need?
Before choosing any evaluation, parents deserve to understand its scope. That is why our evaluations are individualized to the child and the referral question. Depending upon the concerns presented, an evaluation may examine cognitive abilities, attention and executive functioning, learning, adaptive skills, emotional and behavioral functioning, developmental history and other areas in addition to autism-specific assessment.
Sometimes that leads to an autism diagnosis. Sometimes it doesn’t. And sometimes autism is clearly present but turns out to be only one part of a much larger clinical picture.
A focused autism evaluation can be an appropriate and efficient way to answer a focused question—particularly when timely diagnostic confirmation is necessary to access care.
Understanding why your child is struggling—and what will actually help them—is the bigger goal.
Greene, R. K., Vasile, I., Bradbury, K. R., Olsen, A., & Duvall, S. W. (2022). Autism Diagnostic Observation Schedule (ADOS-2) elevations in a clinical sample of children and adolescents who do not have autism: Phenotypic profiles of false positives. The Clinical Neuropsychologist, 36(5), 943–959.
