What should be included in the initial psychiatric interview when evaluating a patient for autism spectrum disorder?

Initial Psychiatric Interview for Autism Spectrum Disorder

The initial psychiatric interview for autism evaluation must include standardized direct behavioral observation using the Autism Diagnostic Observation Schedule (ADOS), structured developmental history via the Autism Diagnostic Interview-Revised (ADI-R), comprehensive cognitive and language testing, adaptive functioning assessment, and systematic screening for comorbid psychiatric conditions. 1, 2

Core Diagnostic Components

Structured Observational Assessment

• Administer the Autism Diagnostic Observation Schedule (ADOS) as the gold standard observational measure during the initial evaluation, which has 91% sensitivity and 76% specificity for ASD diagnosis 1, 2
• Conduct direct behavioral observation focusing on social communication deficits (reduced eye contact, impaired joint attention, limited social reciprocity) and restricted/repetitive behaviors (stereotyped movements, rigid adherence to routines, restricted interests) 1, 2
• Note that brief clinical impressions within the first 5 minutes are insufficient—while 92% of children initially appearing to have ASD are ultimately diagnosed, 24% of children initially thought not to have ASD also meet criteria, indicating high miss rates 3

Developmental History Collection

• Use the Autism Diagnostic Interview-Revised (ADI-R) to obtain structured developmental history from caregivers, which has 80% sensitivity and 72% specificity 1, 2, 4
• Document early developmental milestones with specific attention to: no response to name when called by 12 months, absence or limited use of gestures in communication, lack of imaginative play, reduced social attention, impaired social communication, and repetitive behaviors with objects 5, 2
• Gather information about the child's baseline behavior across multiple settings (home, school, community) to identify discrepancies that may indicate environmental accommodations masking symptoms 6

Cognitive and Developmental Assessment

Intellectual Functioning Evaluation

• Conduct cognitive testing with both verbal and nonverbal components to determine intellectual functioning, as approximately 50% of children with autism have severe or profound intellectual disability, 35% have mild to moderate intellectual disability, and 20% have normal-range IQs 1
• Assess sustained attention, working memory, and processing speed, as these deficits are prominent across the autism spectrum and partially mediate IQ reductions 6
• Compare behaviors to the child's developmental level (not chronological age) to avoid pathologizing developmentally appropriate behaviors in children with delays 6

Language and Communication Assessment

• Evaluate all language domains including receptive language, expressive language, and pragmatic (social) language skills through formal speech/language pathology assessment 6, 1, 7
• Document decreased receptive and expressive language test scores, which are prominent characteristics in many autism cases 6
• For nonverbal or minimally verbal children, assess need for augmentative/alternative communication devices 6, 7

Adaptive Functioning Assessment

• Measure adaptive functioning across multiple domains (communication, daily living skills, socialization, motor skills) to evaluate real-world functional abilities 1, 7
• Assess how impairments in dressing, bathing, eating, and other daily living skills may exacerbate psychiatric or behavioral symptoms 6
• Document motor dysfunction, which has been observed in the early developmental course of nearly all autism cases 6

Comorbidity Screening

Psychiatric Comorbidities

• Screen systematically for comorbid psychiatric conditions, as approximately 75% of children with ASD have comorbid psychiatric disorders 1, 8
• Evaluate for ADHD (present in significant proportion of ASD cases), anxiety disorders (11% vs 5% in general population), depression (20% vs 7% in general population), oppositional defiant disorder, and conduct disorders 5, 2, 8
• Assess for challenging behaviors including aggression, self-injury, pica, and elopement, which occur in a minority but require functional behavioral assessment 6

Medical and Developmental Comorbidities

• Screen for sleep disturbances (13% vs 5% in general population), which are 2.8 times more likely in youth with autism and associated with behavioral and psychiatric disorders 6, 2
• Evaluate for epilepsy (21% in those with co-occurring intellectual disability vs 0.8% in general population) 2
• Assess for learning disabilities, language disorders, developmental coordination disorder, and tic disorders 5

Environmental and Psychosocial Assessment

Environmental Factors

• Document changes in routine, residence, schools, or staff that may trigger psychiatric symptoms, as individuals with autism are sensitive to environmental changes and have difficulty adapting 6
• Evaluate whether the educational/habilitation program meets the child's needs, as inappropriate educational placements are a major cause of emerging psychiatric and behavioral symptoms 6
• Assess stressful life events including moves to new residences, problems with family/friends/caregivers, problems with authorities, recent trauma/abuse, and substance use problems 6

Psychosocial Stressors

• Screen for trauma and abuse history, as individuals with autism are at increased risk for being bullied and have elevated risk for trauma throughout life (11.3% of substantiated child maltreatment cases involve children with intellectual/developmental disabilities) 6
• Evaluate caregiver stress, exhaustion, or psychopathology that may contribute to symptom presentation 6
• Assess changing family roles, individuation challenges, and relational difficulties with peers 6

Medical Evaluation and Genetic Testing

Physical Examination

• Conduct physical examination with specific attention to dysmorphic features to screen for genetic syndromes associated with autism 6, 1
• Measure head circumference, as macrocephaly (head circumference >2.5 SD above mean) indicates need for PTEN gene testing 6
• Perform formal audiogram to rule out hearing loss as a contributing factor 1

Genetic Testing

• Order chromosomal microarray analysis as the first-line genetic test for all patients 6, 1
• Conduct fragile X DNA testing for all patients undergoing autism evaluation 6, 1
• Consider MECP2 gene testing for females and PTEN gene testing if macrocephaly is present 6

Interview Technique Adaptations

Communication Strategies

• Simplify questions and allow extra time for the child to process information and articulate responses when interviewing the child directly 6
• Avoid leading questions and monitor for comprehension to prevent rote responses (simply saying "yes") or echolalia (repeating the interviewer's last words) 6
• Seek observational information about children with limited verbal ability rather than relying solely on direct questioning 6

Informant Interviews

• Obtain information from knowledgeable informants across multiple settings to construct a complete picture of baseline strengths and weaknesses in cognitive functioning, emotional expressivity, language skills, and typical behavior 6
• Have caregivers qualify symptoms in terms of change from baseline (new behavior, worsening intensity/frequency, new contexts) and note discrepancies across settings or with different caregivers 6

Common Pitfalls to Avoid

• Do not rely on screening tools alone for diagnosis—the M-CHAT and similar instruments are for screening only, not diagnostic confirmation 1
• Avoid diagnostic overshadowing—do not attribute all behavioral symptoms to autism without evaluating for comorbid psychiatric conditions 6, 1
• Do not conduct single-provider evaluation—autism diagnosis requires multidisciplinary team assessment including psychologist, developmental pediatrician or child neurologist, and speech/language pathologist 1
• Do not delay intervention pending complete diagnostic workup—initiate behavioral interventions immediately when autism is suspected 1, 7
• Do not pathologize developmentally appropriate behaviors—compare presentation to developmental level, not chronological age 6
• Do not omit genetic counseling—provide recurrence risk information to all families (4% if affected child is female, 7% if male; 30% if second child already has autism) 6, 1