Editorial—Needed: A Standard Battery of Assessments
By Stephen M. Edelson, Ph.D. Executive Director, Autism Research Institute
Editorial—Needed: A Standard Battery of Assessments
Currently, there is no shortage of assessments for children or adults with autism. In fact, dozens of such assessments are in use today.
However, I believe there is a clear need for a standardized battery of assessments— and I believe that establishing such a battery will benefit researchers, therapists, clinicians, and, most importantly, individuals with autism spectrum disorders.
The current status of assessments
There are several well-established diagnostic tools in wide use today. Popular ones include the Autism Diagnostic Observation Scales (ADOS), the Autism Diagnostic Interview–Revised (ADI-R), and the Childhood Autism Rating Scales (CARS).
Over the years, other types of assessments have been developed. These include, but are not limited to, assessments of anxiety, communication, sensory dysregulation, repetitive and challenging behaviors, sleep, and social interaction.
Such assessments are often used by researchers to determine the incidence of symptoms, behaviors, and conditions (SBC), monitor changes over time, and evaluate individuals before and after treatment. Clinicians and therapists frequently rely on these assessments to determine appropriate treatments as well as to monitor their clients’ progress.
Many SBC assessments were originally developed for individuals with developmental disabilities, while others were designed specifically for autism. SBC assessments developed to evaluate the non-autistic population include the Conners Comprehensive Behavior Rating Scale for evaluating ADHD symptoms and the Multidimensional Anxiety Scale for Children. Popular assessments specifically designed for autism include the Autism Behavior Inventory, the Anxiety Scale for Children with Autism Spectrum Disorder, and the Autism Social Skills Profile.
A number of assessments have also been adapted to take into account the unique challenges associated with autism. Adaptations often involve replacing self-reports (for instance, asking if an individual feels anxious) with observation of symptoms and behaviors typically associated with a condition (for instance, observing whether the individual exhibits behaviors indicating anxiety).
Arguments for a standard assessment battery
Researchers and clinicians do not always rely on the same set of assessments when evaluating study participants or patients. In fact, their selection of assessments varies considerably and may depend on cost as well as the amount of time required and the ease of administering them. However, one cannot assume that all assessments are equally sensitive when measuring the same SBC.
I believe that it is time for us to actively make comparisons between assessments. This will allow us to weed out assessments that may be less useful, and to rely only on the most accurate as well as the most valid and reliable tests.
(Note: An assessment is considered valid if it can be shown to measure what it is intended to measure. It is considered reliable when different users obtain similar scores when reporting on the same individual, or when ratings collected at different times for the same individual are consistent.)
Narrowing down the current number of assessments to a standardized battery will admittedly be a challenging job. However, the results will benefit all professionals working with individuals with ASD.
With respect to research, for instance, it is preferable to compare findings using the same assessment measures, especially when researchers are attempting to replicate previous findings. As researchers as well as critics often comment, the autism field is replete with mixed findings. Although the heterogeneity of the spectrum is one reason for such discrepancies, the use of different assessment measures is another significant factor.
Optimally, the results from a standard battery of assessments would help therapists decide what treatment approaches to use, and even suggest specific interventions within an approach. Examples might include identifying a behavioral strategy such as differential reinforcement of other behaviors (DRO) to treat an individual’s aggression, and a sensory integration approach, such as deep pressure, to help the individual fall asleep.
A standard battery of tests would also help clinicians plan treatments more effectively. Currently, some physicians simply offer a basic physical exam while others rely on extensive laboratory testing. Dr. Robert Hendren, a psychiatrist at the University of California, San Francisco, surveyed a group of experienced clinicians in order to learn about medical assessments used to determine potential biomedical interventions. (Note: This study did not examine the general medical assessment of ASD.) Dr. Hendren found little commonality among them. This finding was surprising since most of these physicians were known to communicate regularly through emails and at meetings.
Of course, when developing a standard battery of assessments, factors other than accuracy will need to be considered. As mentioned earlier, the cost as well as the ease and amount of time to administer the tests should also be taken into account. It is possible that the most accurate assessment measures are simply not practical for all research, clinical, and therapeutic settings.
In fact, a one-size-fits-all assessment for SBCs may not be possible. For example, some assessments may be more accurate for those with severe forms of autism, whereas others may be more accurate for those with little or no communication difficulties. Care will need to be taken to ensure that the selected battery of tests is not too limited to meet the needs of all individuals on the spectrum.
A standard battery of assessments will also need to include those SBCs that are prevalent in the autism population but are not considered as core autism features by popular diagnostic tests. These include gastrointestinal function, sensory sensitivities, nutritional status, communication difficulties, sleep problems, social interaction, and social antecedents and consequences of challenging behaviors.
Clearly, developing a standard battery of tests will take significant time and effort. However, given the number of assessments available today, it is definitely a “doable” undertaking. Such an initiative can be successful if it is supported by the medical, scientific, and autism communities.
A standard battery of assessments is the first step needed to develop an evidence-based standard of care for those on the autism spectrum. Now is the time for those of us in the autism field to take this step.
Stephen M. Edelson, Ph.D. Executive Director, Autism Research Institute
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