Psychiatric Assessments

Beyond the measures of challenging behavior reviewed earlier, there are psychiatric assessments that may be warranted when challenging behavior is accompanied by other symptoms of a psychiatric disorder. Individuals with ASD have high rates of co-occurring psychiatric conditions (Rosen et al., 2018). Challenging behaviors may occur in the context of, or even be due to, a wide range of psychiatric disorders. Therefore, it is important to consider assessment of psychiatric conditions, particularly in the context of a new onset of challenging behavior or a worsening of challenging behavior.

Psychiatric assessment should be viewed as complementary to behavioral assessment as the identification of co-occurring psychiatric conditions should be incorporated into case conceptualization and treatment planning. There are existing resources that cover the topic of psychiatric conditions in ASD in depth (i.e., The Oxford Handbook of Autism and Co-Occurring Psychiatric Conditions, White et al., 2020).

Notably, there are no preferred or gold-standard ‘go-to’ validated mental-health assessments that reliably identify co-occurring psychiatric conditions in addition to ASD. Below we describe currently available and developing measures in psychiatric assessment and ASD.

What's Comprehensive?

In general, structured interviews are considered the most comprehensive psychiatric diagnostic assessments, but can be time consuming. The gold standard assessments are emphasized in the box below.

The above structured interviews can take several hours to complete and require a substantial amount of training in administration and scoring.

What's Fast?

The Mini International Neuropsychiatric Interview (MINI; [Lecrubier et al., 1997]) has been considered in ASD with promising psychometrics (Mosner et al., 2019). Although additional evaluation is needed, it may offer a brief (~15 min) alternative to longer structured interviews. While some interviews have been developed for intellectual and developmental disabilities and ASD populations (e.g., Autism Comorbidity Interview [Leyfer et al., 2006]; Baby and Infant Screen for Children with Autism Traits [Matson et al., 2007]), they are also not in widespread use and are more likely to be utilized in research contexts.

Questionnaires may be a more feasible initial screen for psychiatric diagnoses. The Child and Adolescent Symptom Inventory (Gadow, 2015) has been widely utilized in ASD and is designed to map onto DSM-5 criteria. It is a standardized behavior rating scale for children ages 5 to 18. It provides symptom count cutoff scores, symptom severity scores, impairment cutoff scores, and clinical cutoff scores for all major DSM-5 disorders.

The previously described ASEBA measures and BASC-3 also provide indices of psychiatric diagnoses and can be useful as psychiatric screening questionnaires. One caution is that it is not uncommon for individuals with ASD to score high on the CBCL and BASC-3 psychiatric diagnoses indicators even when not meeting criteria for co-occurring diagnoses. It is possible that these measures also capture common impairments seen in ASD even when a separate diagnosis is not warranted. This may reflect difficulty in the differential diagnosis of psychiatric symptoms in ASD as well as symptom overlap (e.g., symptoms of withdrawal in both ASD and depression, repetitive actions in both ASD and OCD, etc.).

What's Next?

Further, the Academic Autism Spectrum Partnership in Research and Education (AASPIRE), a partnership between researchers and autistic adults, is developing a toolbox of mental health measures for adults, many of which have been modified to be more appropriate and valid in ASD (Nicolaidis et al, 2020). There are also some recent and ongoing initiatives to develop new psychiatric symptoms measures for autism (e.g., the Pediatric Anxiety Rating Scale; Maddox et al., 2020). As such, the assessment of mental health concerns in ASD is an area with anticipated future growth.