What is a structured template for the initial psychiatric interview when evaluating a patient for Autism Spectrum Disorder?

Initial Psychiatric Interview Template for Autism Spectrum Disorder

The initial psychiatric interview for ASD should follow a structured, multidomain assessment framework that systematically evaluates developmental history, current symptoms across core domains, comorbidities, environmental factors, and medical/genetic contributors, using standardized tools and informant-based data collection. 1

Pre-Interview Preparation

Gather Collateral Information

• Obtain records from multiple settings (home, school, community) to identify behavioral discrepancies that may mask symptoms 1
• Review prior developmental assessments, educational records, and any previous psychiatric evaluations 2
• Collect reports from teachers, therapists, and other caregivers who observe the child in different contexts 1

Structured Interview Components

Developmental History Collection

Early Milestone Assessment (Birth to 24 Months)

• No response to name by 12 months is a critical early indicator 1
• Limited or absent gestural communication (pointing, waving, showing objects) 1
• Lack of imaginative or pretend play 1
• Reduced social attention and eye contact 1
• Repetitive object use or unusual sensory interests 1

Language Development Timeline

• Document age of first words and first phrases 1
• Note any regression in language or social skills, particularly after age 3 years (suggests mitochondrial disease if multiple regressions occur) 3
• Assess current receptive, expressive, and pragmatic language abilities 1

Motor Development

• Early motor dysfunction is observed in nearly all ASD cases 1
• Document gross and fine motor milestone achievement 1

Core Symptom Assessment Using Standardized Tools

Gold-Standard Observational Measure

• Administer the Autism Diagnostic Observation Schedule (ADOS), which demonstrates 91% sensitivity and 76% specificity for ASD diagnosis 1
• This direct observation of the child's behavior is essential and cannot be replaced by interview alone 1

Structured Caregiver Interview

• Use the Autism Diagnostic Interview-Revised (ADI-R), which provides 80% sensitivity and 72% specificity through structured developmental history 1
• Focus on the two core DSM domains: social communication impairment and restricted interests/repetitive behaviors 4

Social Communication Domain Assessment

Current Social Deficits

• Difficulty with back-and-forth conversation and social reciprocity 1
• Impaired understanding of nonverbal communication (facial expressions, body language, gestures) 1
• Challenges developing and maintaining peer relationships appropriate to developmental level 1
• Reduced sharing of interests, emotions, or affect with others 1

Pragmatic Language Evaluation

• Assess social use of language beyond vocabulary and grammar 1
• Note echolalia, scripted speech, or idiosyncratic language use 5
• Evaluate use of finger-pointing to indicate interest versus verbalization 5

Restricted/Repetitive Behavior Domain Assessment

Stereotyped Behaviors and Interests

• Repetitive motor movements (hand-flapping, rocking, spinning) 1
• Insistence on sameness and distress with routine changes 1
• Highly restricted, fixated interests that are abnormal in intensity or focus 1
• Hyper- or hypo-reactivity to sensory input or unusual sensory interests 1

Critical Note: The autism group shows significantly higher frequencies in 6 of 8 items in this category compared to PDD-NOS, making thorough assessment essential for accurate diagnosis 5

Cognitive and Adaptive Functioning Assessment

Cognitive Testing Requirements

• Must include both verbal and non-verbal components to avoid underestimating abilities 1
• Approximately 50% of children with ASD have severe/profound intellectual disability, 35% have mild-to-moderate disability, and 20% have average-range IQ 1
• Assess sustained attention, working memory, and processing speed, as deficits in these areas partially mediate IQ reductions 1

Adaptive Functioning Domains

• Communication skills (functional use of language in daily life) 1
• Daily living skills (dressing, bathing, eating, toileting) 1
• Socialization (peer interactions, play skills) 1
• Motor skills (coordination, fine and gross motor abilities) 1
• Impairments in daily living skills can exacerbate psychiatric or behavioral problems 1

Comprehensive Comorbidity Screening

Psychiatric Comorbidities (Present in ~75% of Cases)

• ADHD symptoms: inattention, hyperactivity, impulsivity 1, 6
• Anxiety disorders: present in approximately 11% versus 5% in the general population 1, 6
• Depression: affects approximately 20% versus 7% in the general population 1, 6
• Oppositional defiant disorder and conduct disorder 1
• Aggression, self-injury, pica, and elopement (warrant functional behavioral assessment when present) 1

Medical Comorbidities

• Sleep disturbances: affect 13% of youth with ASD versus 5% of peers (2.8 times more likely) 1, 6
• Epilepsy: present in 21% of those with co-occurring intellectual disability versus 0.8% in general population 6
• Learning disabilities, language disorders, developmental coordination disorder, tic disorders 1

Environmental and Psychosocial Assessment

Environmental Triggers

• Changes in routine, residence, school, or staff can trigger psychiatric symptoms 1
• Inappropriate educational or habilitation placements are a major source of emerging psychiatric and behavioral problems 1

Stressful Life Events

• Recent moves or transitions 1
• Family or caregiver conflicts 1
• Legal issues or involvement with child protective services 1
• Recent trauma or abuse (children with ASD have elevated risk; 11.3% of substantiated child maltreatment cases involve children with intellectual/developmental disabilities) 1
• Bullying experiences 1
• Substance-use problems in the family 1

Caregiver Factors

• Assess caregiver stress, exhaustion, or psychopathology, as these can influence the child's symptom presentation 1

Physical Examination Components

Dysmorphology Assessment

• Conduct a focused examination for dysmorphic features to screen for genetic syndromes associated with ASD 3, 1
• Measure head circumference: macrocephaly (>2.5 SD above the mean) prompts PTEN gene testing 3, 1
• Microcephaly with autism is rare and warrants neuroimaging, especially if acquired rather than congenital 3

Sensory and Neurological Examination

• Assess for hypotonia (common in ASD) 1
• Evaluate visual processing concerns 1
• Document atypical sensory responses (hyper- or hypo-reactivity) 1

Audiometry

• Perform formal audiometry to rule out hearing loss as a contributing factor that can mimic autism-related behaviors 1

Genetic and Medical Testing Protocol

First-Tier Genetic Testing

• Chromosomal microarray (oligonucleotide array-CGH or SNP array): expected diagnostic yield of 10% 3, 1
• Fragile X DNA testing: yield of 1-5%, should be performed routinely for all males and for females with family history or suggestive phenotype 3, 1

Second-Tier Genetic Testing (Based on Clinical Indicators)

• MECP2 sequencing for all females with ASD: yield of 4% 3, 1
• MECP2 duplication testing in males if phenotype is suggestive 3
• PTEN testing only if head circumference is >2.5 SD above the mean: yield of 5% in this subgroup 3, 1

Metabolic and Mitochondrial Testing (When Indicated)

• Consider if constitutional symptoms, hypotonia, repeated regressions after age 3 years, or multiple organ dysfunctions are present 3
• Metabolic screening may include complete blood count, serum metabolic profile, serum amino acids, and urine screening for glycosaminoglycans 3

Neuroimaging (Selective Use)

• Brain MRI is NOT routinely recommended for all patients with ASD 3
• Obtain MRI only in the presence of specific indicators: microcephaly, neuroregression, seizures, or history of stupor/coma 3, 1
• Consider combining MRI with magnetic resonance spectroscopy when metabolic etiology is suspected 3

Interview Technique Adaptations

Direct Child Interview Strategies

• Simplify questions and allow extra processing time when interviewing the child directly 1
• Avoid leading questions and monitor for rote "yes" responses or echolalia 1
• For children with limited verbal ability, prioritize observational information over direct questioning 1
• For non-verbal or minimally verbal children, assess the need for augmentative/alternative communication devices 1

Informant Interview Approach

• Obtain information from knowledgeable informants across multiple settings to construct a comprehensive picture of baseline cognitive, emotional, language, and behavioral functioning 1
• Ask caregivers to describe symptoms relative to baseline change: new behavior, increased intensity/frequency, or appearance in new contexts 1
• Note any setting-specific discrepancies in symptom presentation 1

Critical Clinical Pitfalls to Avoid

Diagnostic Errors

• Screening tools (e.g., M-CHAT) are for initial screening only and should not be used as the sole basis for diagnosis 1
• Avoid diagnostic overshadowing: evaluate for comorbid psychiatric conditions rather than attributing all symptoms to ASD 1
• Compare behaviors to the child's developmental level rather than chronological age to prevent pathologizing age-appropriate actions 1

Assessment Limitations

• A multidisciplinary team—including a psychologist, developmental pediatrician or child neurologist, and speech-language pathologist—is required for accurate ASD diagnosis 1
• Confirmation of ASD diagnosis should be made by a professional trained in diagnosing autism using objective criteria and standardized measures 2

Treatment Delays

• Behavioral interventions should be initiated promptly when ASD is suspected, without waiting for the complete diagnostic work-up 1

Genetic Counseling

• Provide genetic counseling to all families, with recurrence risk estimates of 4% for families with an affected female child, 7% for an affected male child, and 30% if a second child already has autism 1