Can you provide a template for the initial psychiatric interview of an 8‑year‑old child being evaluated for Autism Spectrum Disorder (ASD)?

Initial Psychiatric Interview Template for an 8-Year-Old Child Being Evaluated for Autism Spectrum Disorder

For an 8-year-old child being evaluated for ASD, structure your interview to systematically assess the two core diagnostic domains—social communication deficits and restricted/repetitive behaviors—while screening for common comorbidities that affect approximately 90% of children with ASD. 1

Pre-Interview Preparation

Environmental Modifications

• Reduce sensory stimuli by dimming lights, minimizing background noise, and limiting visual clutter in the interview room 2
• Have visual communication systems (picture cards) available, including images of common interview activities and medical equipment 2
• Plan for brief breaks every 10-15 minutes, as many children with ASD can only remain on task for short periods 2
• Allow the child to bring comfort items or fidget toys to reduce anxiety 2

Developmental History (From Caregivers)

Early Developmental Milestones (Birth to Age 3)

• Did the child respond to their name by 12 months? (Failure to respond has 86% specificity for developmental abnormality) 2, 1
• Did the child point to show interest in objects or events between 20-42 months? (Lack of pointing is highly specific for ASD versus language disorders) 2, 1
• Did the child use conventional gestures (waving bye-bye, nodding yes/no) between 20-42 months? 2, 1
• Did the child engage in pretend or imaginative play by age 2-3 years? 3
• When did the child say their first words and first phrases? (Note: In ASD, verbal skills are typically more impaired than nonverbal skills) 1
• Did the child show social smiling and make eye contact as an infant? 2

Developmental Trajectory

• Were there any periods of regression (loss of previously acquired language or social skills)? If yes, at what age? (Regression after age 3 may suggest metabolic disorders) 3, 4
• Was the child described as "too good" or undemanding as an infant? (This atypical early presentation is common in ASD) 1
• How did developmental skills progress over time—steady, plateaued, or declining? 2

Core ASD Symptom Assessment

Social Communication and Interaction Deficits

Nonverbal Communication

• How does the child use eye contact during conversations? (Reduced or awkward eye contact is characteristic) 1
• Does the child use gestures naturally when communicating (pointing, showing, nodding)? 1
• Can the child read facial expressions and body language of others? 1

Social-Emotional Reciprocity

• Does the child initiate conversations or interactions with peers, or only respond when approached? 1
• When talking, does the child engage in back-and-forth dialogue or tend to talk "at" others about preferred topics? 1
• Does the child share interests, emotions, or achievements with others spontaneously? 1
• Can the child take another person's perspective or understand how others might feel? 1

Peer Relationships

• Does the child have age-appropriate friendships? 1
• What type of play does the child engage in—parallel play, cooperative play, or interactive games? 1
• Does the child understand unwritten social rules (personal space, turn-taking, reading social cues)? 1

Restricted and Repetitive Behaviors

Inflexibility and Routines

• Does the child insist on specific routines or become distressed when plans change? 1
• Are there rigid preferences (specific routes to school, fixed order of activities, particular foods)? 1
• How does the child handle transitions between activities or settings? 2, 1

Restricted Interests

• Does the child have intense, focused interests in specific topics that dominate conversations and activities? 1
• Is the level of preoccupation with these interests interfering with other activities? 1

Repetitive Behaviors

• Does the child engage in repetitive motor movements (hand-flapping, rocking, spinning)? 1
• Does the child use repetitive speech patterns (echolalia, scripted language from movies/TV)? 1
• Does the child line up toys or objects in specific ways? 3

Sensory Sensitivities

• Is the child over-sensitive to sounds, lights, textures, or smells? 1
• Is the child under-sensitive to pain or temperature? 1
• Does the child seek out or avoid specific sensory experiences? 1

Language and Communication Profile

Verbal Ability

• Is the child's speech overly formal, pedantic, or lacking social nuance? 1
• Does the child interpret language literally and struggle with idioms, sarcasm, or figurative expressions? 1
• Does the child interrupt conversations, dominate topics, or fail to adjust communication based on the listener? 1
• For minimally verbal children: What alternative communication methods are used (gestures, pictures, AAC device)? 3

Comorbidity Screening

Psychiatric Comorbidities (Present in ~75% of Children with ASD) 3

ADHD (Affects >50% of Children with ASD) 1

• Does the child have difficulty sustaining attention on tasks? 3
• Is the child hyperactive or impulsive? 2
• How does inattention compare at home versus school? 3

Anxiety Disorders (11% vs. 5% in General Population) 1, 3

• Does the child have excessive worries or fears? 3
• Are there panic attacks, separation anxiety, or social anxiety symptoms? 3
• Does anxiety worsen during transitions or changes in routine? 3

Depression (20% vs. 7% in General Population) 3

• Has there been persistent sadness, irritability, or loss of interest in activities? 3
• Are there changes in sleep, appetite, or energy level? 3

Obsessive-Compulsive Disorder

• Are repetitive behaviors ego-dystonic (distressing to the child) or ego-syntonic (not distressing)? (In ASD they are typically ego-syntonic; in OCD they are ego-dystonic) 1, 4
• Does the child have intrusive thoughts that drive compulsive behaviors? 1

Disruptive Behaviors

• Is there aggression toward others or property destruction? 3
• Are there episodes of self-injurious behavior? 3
• Does the child have oppositional or defiant behaviors? 3

Medical Comorbidities

Sleep Disturbances (Affect 13% vs. 5% in Peers; 2.8× More Likely) 3

• What is the child's sleep schedule and quality? 3
• Are there difficulties falling asleep, staying asleep, or early morning awakening? 3

Seizures/Epilepsy (Affects 20-33% of Children with ASD) 1

• Has the child had any seizures or episodes of staring spells? 3

Gastrointestinal Issues

• Are there chronic constipation, diarrhea, or abdominal pain complaints? 1

Motor Coordination

• Does the child have clumsiness or difficulty with fine/gross motor tasks? 3

Functional Impact Assessment

Adaptive Functioning Across Settings

• Communication: How does the child communicate needs at home, school, and in the community? 3
• Daily living skills: Can the child dress, bathe, and eat independently for their age? 3
• Socialization: How does the child interact with family members, peers, and unfamiliar adults? 3
• School functioning: What educational supports are in place (IEP, 504 plan, aide)? 3

Safety Concerns

• Does the child elope (wander away from supervision)? 3
• Are there self-injurious behaviors during meltdowns? 3
• Does the child have awareness of dangers (traffic, strangers, heights)? 3

Environmental and Psychosocial Factors

Recent Life Changes (Major Triggers for Psychiatric Symptoms in ASD) 3

• Have there been recent changes in routine, residence, school, or staff? 3
• Is the current educational placement appropriate for the child's needs? (Inappropriate placements are a major source of behavioral problems) 3
• Have there been stressful life events: family conflicts, moves, legal issues, trauma, or abuse? 3
• Has the child experienced bullying? (Children with ASD have elevated risk) 3

Caregiver Factors

• What is the level of caregiver stress, exhaustion, or mental health concerns? 3
• What support systems are available to the family? 3

Physical Examination Indicators

Dysmorphic Features

• Examine for dysmorphic facial or bodily features suggesting syndromic causes of ASD 3, 4

Head Circumference

• Measure head circumference; macrocephaly (>2.5 SD above mean) indicates PTEN gene testing 3, 4
• Microcephaly warrants neuroimaging for structural brain abnormalities 4

Skin Examination

• Perform Wood's lamp examination for hypopigmented macules (tuberous sclerosis) 4

Cognitive and Language Assessment Planning

Cognitive Testing

• Plan for both verbal and nonverbal cognitive testing (approximately 30% of children with ASD have co-occurring intellectual disability) 1, 3
• Assess sustained attention, working memory, and processing speed (commonly impaired in ASD) 3

Language Evaluation

• Assess receptive, expressive, and pragmatic language domains 3
• For minimally verbal children, evaluate need for augmentative/alternative communication devices 3

Genetic and Medical Testing to Order

First-Tier Genetic Testing (For All Children with ASD) 3, 4

• Chromosomal microarray analysis (10% diagnostic yield) 3, 4
• Fragile X DNA testing (1-5% yield) 3, 4
• MECP2 sequencing for females (4% yield) 3, 4
• PTEN testing if macrocephaly present (5% yield in this subgroup) 3, 4

Audiometry

• Formal hearing evaluation to rule out hearing loss 3

Metabolic Screening (If Indicated)

• Consider if there is regression after age 3, constitutional symptoms (hypotonia), or multisystem involvement 3, 4
• Panel may include: complete blood count, serum metabolic profile, serum amino acids, urine glycosaminoglycans 4

Neuroimaging (Only If Specific Red Flags Present) 4

• Do NOT routinely order brain MRI 4
• Order MRI only if: micro- or macrocephaly, neuroregression, seizures, or history of prolonged loss of consciousness 4

Interview Technique Adaptations

When Interviewing the Child Directly

• Simplify questions and allow extra processing time 3
• Avoid leading questions; monitor for rote "yes" responses or echolalia 3
• For children with limited verbal ability, prioritize observational information over direct questioning 3
• Use desensitization strategies: approach gradually, bend down to the child's level, allow the child to play with interview materials first 2

Informant Interviews

• Obtain information from multiple settings (home, school, community) to identify discrepancies that may mask symptoms 3
• Ask caregivers to describe symptoms relative to the child's baseline functioning (new behaviors, increased intensity/frequency, new contexts) 3

Diagnostic Tools to Administer

Gold-Standard Assessments

• Autism Diagnostic Observation Schedule (ADOS): 91% sensitivity, 76% specificity 3
• Autism Diagnostic Interview-Revised (ADI-R): 80% sensitivity, 72% specificity 3

Critical Pitfalls to Avoid

• Do not use screening tools (M-CHAT) as the sole basis for diagnosis—they are for initial screening only 3
• Do not attribute all symptoms to ASD (diagnostic overshadowing)—actively screen for comorbid psychiatric conditions requiring specific treatment 3
• Do not delay evaluation with "wait and see"—early identification enables timely intervention with significantly improved outcomes 1, 4
• Do not compare behaviors to chronological age alone—compare to the child's developmental level to avoid pathologizing age-appropriate actions 3
• Do not assume all repetitive behaviors are simply autistic traits—screen for comorbid OCD, which requires specific treatment 1
• Do not rule out ASD based on brief observation—clinicians miss 24% of ASD cases when relying on initial 5-minute impressions 5

Multidisciplinary Team Coordination

Required Team Members for Accurate Diagnosis 3

• Psychologist or developmental pediatrician
• Child neurologist or child psychiatrist
• Speech-language pathologist
• Occupational therapist (for sensory and motor assessment)

Initiate Behavioral Interventions Promptly

• Do not wait for complete diagnostic work-up to begin interventions 3
• Early intensive behavioral interventions (20-30 hours per week) focusing on communication and social skills are first-line therapy 4

Genetic Counseling

Provide Recurrence Risk Estimates to All Families 3

• 4% recurrence risk if an affected female child in the family 3
• 7% recurrence risk if an affected male child in the family 3
• 30% recurrence risk if a second child already has autism 3