IS THIS AUTISM?
A Companion Guide for Diagnosing

Chapter 1 describes the diagnostic criteria as presented in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR, 2022) and in the International Classification of Disease (ICD-11, 2019). The language of the DSM and the ICD is not neurodiversity affirmative. However, because healthcare providers must follow the guidelines provided by these diagnostic tools, the language in this chapter (and this chapter only) uses the language of the medical model.  

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The criteria are divided into two major areas: (A) social and communication challenges, and (B) repetitive and restricted behaviors (RRBs). Social and communication challenges include (1) social/emotional reciprocity, (2) nonverbal communication, and (3) relationship management. Repetitive and restricted behaviors, include (1) repetitive or idiosyncratic behavior, (2) inflexibility, (3) restricted interests that are intense or atypical, and (4) sensory differences. A person must show differences in all three of the social/communication differences, as well as two of the four repetitive/restricted behaviors in order to qualify for a diagnosis of autism. Individuals can meet criteria on both groups either currently or by history. The chapter closes with a description of the differences and similarities between the DSM-5-TR and ICD-11. 

Chapter 2 provides guidelines that will help clinicians determine whether autism should be considered and whether an evaluation is indicated. The author uses the concept of “pink flags” to describe behaviors, traits, and experiences that may indicate the possibility of autism, but which are not as obvious as the more common “red flags” that clinicians already know to look for. The author cautions clinicians to be particularly sensitive to these signs in females. She provides a detailed list of autistic traits, behaviors and experiences that include social, behavioral, or emotional functioning, cognition, language, or academic skills, and medical/developmental history. Clinicians will also learn about traits that are sometimes inappropriately cited as reasons for ruling out autism, and frequently asked questions provide guidance about issues such as when to refer a client for an in-depth evaluation, raising the possibility of autism with a client, and considering a diagnosis of autism if the clinician has had little to no formal training with this population.

Chapter 3 first describes the reasons why the parent interview is important. The author provides general principles to follow, such as balancing structure with flexibility and how to incorporate an understanding of culture. The chapter then provides detailed guidance on how to structure a parent interview, including ways to encourage parents into storytelling mode as well as the importance of gathering specific examples. A simple format to facilitate note-taking during the interview will help clinicians organize their thoughts. The author then provides a detailed list of potential questions, categorized according to the DSM-5-TR diagnostic criteria for autism. Clinicians will find examples of questions for children, adolescents, and adults, pertaining to social reciprocity, relationships, nonverbal communication, repetitive or idiosyncratic behavior, inflexibility, intense/atypical interests, and sensory issues. The latter includes sensory under- and over-responsivity (a.k.a. sensory sensitivities) as well as sensory craving (a.k.a. sensory seeking). Next are recommendations for questions to encourage parents/caregivers to share their perspective on family history, client strengths, and their goals for therapy/testing. The chapter ends with a section on what to do when parents’ perspectives are different from teachers’ and also when parents do not agree with each other.

Chapter 4 explains why a detailed client interview is essential, highlighting the importance of the client’s subjective experience, as they may camouflage around non-autistics, hiding their autism. This chapter includes many quotes from autistic adults that provide valuable insights on interviewing, particularly for non-autistic clinicians. The author provides general principles for the client interview, such as asking about communication preferences, using explicit communication, avoiding implicit or figurative language, and the possible need to avoid open-ended questions. She argues that it is important to suspend judgment about what social interactions and relationships should look like and to instead strive to understand their clients’ inner experiences, both positive and negative. Readers will learn how to consider countertransference when clients raise the possibility that they are autistic. The author provides detailed lists of possible questions to ask, categorized by presenting concerns, social interactions, relationships, nonverbal communication, camouflaging, repetitive behaviors/stimming, flexibility, intense or atypical interests, sensory experiences, and positive experiences for the client. Frequently asked questions address issues such as what to do when a client sees themselves differently than other people see them, and how to work with a client who is already convinced that they are autistic.

Chapter 5 explains the importance of a thorough documentation review, including private and public school report cards, OT or speech therapy reports (even if they are outdated), prior testing, school reports/education plans, and emails from teachers discussing concerns. The author describes what to look for, as these documents often contain rich information; including prior diagnoses and interventions, and behavioral observations at the time of the documentation.

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This chapter also covers why and how to include collateral interviews in the assessment process. These can include teachers (past and present), extended family members, friends or parents of friends, and other healthcare professionals, to name a few. The author provides example questions, to help the reader look for strengths and patterns over time, as well as support needs. Collateral interviews are essential  for understanding the client from different points of view and can point to possible environmental modifications that may be helpful. The author offers examples of specific questions to ask, and provides guidance for how to cope with challenging situations, such as when the client or parents do not want collateral interviews or do not want to share prior records.

Chapter 6 reviews rating scales and self-report measures used as part of a social cognition evaluation. The author provides guiding principles for choosing and using these measures, and advises evaluating what each scale actually measures before using it. She explains why it is important to ask multiple informants for ratings, and argues against translating scores directly into diagnoses. Clinicians will learn why they should interpret self-report questionnaires with caution, being particularly attuned to over- or under-reporting, as well as item misinterpretation. They will also learn how to understand discrepancies between raters. A section on cultural considerations highlights the importance of understanding how cultural differences may impact responses on scales. The author describes the Social Responsiveness Scale (SRS-2), Autism Spectrum Quotient (AQ), Ritvo Autism Asperger Diagnostic Scale - Revised (RAADS-R), Camouflaging Autistic Traits Questionnaire (CAT-Q), and Childhood Autism Rating Scale, High Functioning (CARS2-HF). She also describes other instruments that may be helpful, including comprehensive measures (e.g., the BASC3 and the Achenbach), and assessments of other traits, including adaptive functioning (e.g., the Vineland and the ABAS), executive functioning (e.g., the BRIEF), emotions/personality (e.g., the MMPI), and other domains (e.g., sensory, OCD, trauma, alexithymia, career inventories, interoception).

Chapter 7 explains the importance of careful behavioral observations and provides general principles for collecting them. The author encourages clinicians to observe with active curiosity and without judgment — noting that diagnosis does not depend on the presence or absence of specific behaviors — and offers suggestions for eliciting social behaviors. Readers will learn how to look for strengths as well as weaknesses. 

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The chapter then describes what to look for in a testing environment, including observing how a client negotiates the unfamiliar environment, whether they have an unusual communication style, and noticing any unusual language, eye contact, affect, sensory responses, or insensitivity to context. The last part of the chapter describes what to look for in a psychotherapy environment — noting how someone behaves during the initial phone call, in the waiting room or in video sessions, as well as attending to difficulty with flexibility, differences in communication style, or comments on their sensory experience. The author highlights themes to watch for, including the client’s understanding of relationships, difficulty with a sense of self or creating balance in their lives, emotional dysregulation or disconnect, low motivation, difficulty connecting what happens to them to the big picture, and/or slow progress in therapy. 

Chapter 8 first describes general principles for social cognition testing, noting that tests provide an organized way to gather information, that scores are not the only type of data and should never be used in isolation to make a diagnosis, and that a cutoff score does not determine whether criteria are met. The author notes that many current social cognition tests are insensitive to some presentations of autism and that there is no gold standard test for clinical diagnosis of autism. Other topics include: the importance of performance validity measures, identifying strengths, and the absence of evidence for an autistic profile in cognitive testing. The Connecting Culture section discusses test bias and cultural sensitivity of testing materials.

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The chapter then reviews a number of social cognition measures, including the Social Language Development Test (SLDT), Advanced Clinical Solutions for WAIS-IV and WMS-IV (ACS), Roberts Apperception Test (Roberts-2), the MIGDAS-2, and the Autism Diagnostic Observation Schedule, 2nd edition (ADOS-2). Answers to frequently asked questions explain that, in many cases,  clinicians can diagnose autism without social cognition or neuropsychological testing.

Chapter 9 describes the overlaps and differences between autism and some commonly confused diagnoses. The focus of this chapter is on differentiation rather than co-occurrence, and particularly on reasons why autism may be missed. The author recommends starting with general principles, such as the law of parsimony, considering the developmental history and trajectory, understanding the context and the client’s subjective experience when evaluating behavior, and attending to the “fine print” in the DSM. She then provides an in-depth discussion of an important and often-misunderstood differential in children (giftedness), as well as one common in adults (personality disorders). She reviews other confusing diagnoses/challenges, including ADHD, anxiety disorders (including social anxiety, OCD, and selective mutism), oppositional defiant disorder (ODD), bipolar disorder, depression, disruptive mood dysregulation disorder (DMDD), eating disorders, trauma, reactive attachment disorder, psychosis, social (pragmatic) communication disorder, non-verbal learning disorder (NVLD), and the broader autism phenotype.

Chapter 10 describes the many benefits of using a structured and consistent process for organizing and synthesizing their data — including forcing the clinician to considering everything, avoiding the trap of relying too much on intuition, determining whether there is missing data, providing clarity about the client’s primary challenges, uncovering the client’s strengths, and helping to prioritize recommendations — with the goal of providing a structured process for educating and convincing the patient, their family, and the other involved professionals. The author also notes that following a structured process will increase the clinician’s confidence when faced with a challenging case.

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The author then provides general principles for organizing and integrating clinical data, such as being aware of countertransference and remembering that data should be considered whether it was true in the past or present. She cautions against using just one example to satisfy a criterion, using the same example in support of multiple criteria, and ruling out autism because there are some “non-autistic” traits or behaviors. Finally, the author describes how to use The Worksheet, a specific guide for structuring the decision-making process. She provides specific examples and a completed sample Worksheet.

Chapter 11 explains how to have neurodiversity-affirmative conversations about autism. When done properly, these conversations help clients understand themselves (or their child) and help them feel heard, understood, and validated. The author first offers general principles for feedback sessions, such as setting a neurodiversity-affirmative and collaborative tone, being inclusive and sensitive to potential vulnerabilities regarding culture, providing structure, and adjusting communication style and tone to suit each client. The author recommends clarifying what will be provided in writing and when, as well as avoiding jargon, test names, and scores. She also encourages clinicians to use visual aids, while validating all emotions without being defensive if the client disagrees with the diagnosis. The author then describes a structure for feedback sessions, highlighting the importance of reviewing the diagnostic criteria and focusing on the client’s areas of strength. The chapter ends with answers to frequently asked questions, which address what to do when parents agree with the diagnosis but do not want to tell their child, how to provide feedback when the client or parents want a diagnosis of autism and don’t get it, discussing the findings with other involved professionals, offering feedback to child/adolescent clients, and providing written documentation.

This chapter describes recommendations to consider once your client has been recognized as autistic. Rather than trying to follow a one-size-fits-all approach to specific interventions, the focus is on general principles that can guide your thinking about next steps. Traditionally, recommendations for autistic clients have aimed to make the autistic person look less autistic (e.g., social skills groups, discouraging stimming). In contrast, the principles in this chapter aim to help the autistic individual feel safe, understood, and to develop strategies for living an authentic life as an autistic person in a world designed for non-autistics. All recommendations are offered using a neurodiversity-affirmative framework. These include balancing camouflaging with authenticity, preventing neurocrash and burnout, promoting self-advocacy, exploring new communication/interaction patterns, suggestions for accommodations, and more.