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[00:00:00] Hey everyone. Welcome back to another episode of The Testing Psychologist podcast. I’m your host, Dr. Jeremy Sharp, a licensed psychologist, group practice owner, and private practice coach.

Today, I am going to be talking with you all about remote options for autism assessment or teleassessment options for an autism assessment.

And you might be saying to yourself, but Jeremy, today is Thursday, and Thursdays are for business topics.  Well, this topic, I think straddles business and clinical. I am going to really approach it more as a business topic because this seems to be a bit of the final frontier in our remote assessment world. A lot of folks have moved back or have found good alternatives for cognitive, personality, and behavioral assessment as far as teleassessment and remote options, but autism remains challenging. So that’s the rationale here. I’m excited to talk with you about it. Let’s go.

All right, everyone. Here we are back talking about remote options for an autism assessment in the age of COVID-19. At the time of this recording, it is mid to late June, and a lot of people are still struggling with how to conduct assessments for autism remotely.

There are a few options out there. I don’t know that any of them are perfect, but I would like to talk through each of the options that I know of in hopes that some of you might be able to utilize these options and get back to doing those autism assessments and adding that element back into your practice so that you can get closer and closer to normal in terms of income and client flow, and so forth.

I’m not going to dig into the clinical pieces as much here, or I should say, not going to dig into the research as much with each of these options. I will do an overview of the research that’s available. Frankly, the theme throughout all of these measures is that there is not much research, to be honest. I know there is some promising research for nearly all of them. So just keep that in mind.

This is meant to be a brief overview and discussion of your remote options for an autism assessment. I will certainly include links in the show notes to each of these options, and you can continue to dig in and learn for yourself what might be the best fit for your practice. So, let’s get started.

The first option that I’m going to talk with you about is perhaps the most well-established option, although that really is like splitting hairs considering the state of the research for most of these choices. So, this first option is an approach called TELE-ASD-PEDS. This is an approach that really emerged out of Vanderbilt University. It was originally developed as a means of providing Autism assessment to folks in rural areas so that they wouldn’t have to drive hours and hours into the clinic to get an autism diagnosis.

What the TELE-ASD-PEDS approach does is basically, in my mind, these are not their words, but it distills some of the more meaningful tasks from the ADOS into a bunch of shorter administration where you are… Basically, you’re doing some free play. You are doing some parent-involved play. You doing some ignoring or the parent is doing some ignoring, rather. They leave the kid alone for a few minutes to see how the kid reacts. There’s a joint attention task where the parent points to see if the kid responds. There’s a name-calling task and there is an anticipation of a routine task.

All of these tasks are meant to occur over, the website says 10 to 20 minutes. In the times that I’ve administered this measure, I have fallen more in the range of 30 to 40 minutes. And honestly, I think that’s just me wanting to be deliberate and be careful and get plenty of time for each of these tasks. But the target is about 20 minutes and it is really meant to be administered over telehealth.

The way that you set it up is, the parent gathers toys and objects in their home that they should theoretically already have in their home and use them during the assessment. What I’ve done is send a list of potentially acceptable toys ahead of time so the parents can gather those items and then they find a room that is hopefully fairly non-distracting. And then you remote in and coach the parent over the phone while watching the administration over video and scoring appropriately.

Key points here are that the camera is pointed in the right direction and that you can hear and see that the field of vision is what you need it to be to get a good idea of the kid’s behavior. It’s been good in my experience. I’ve done a few of these now and some clinicians in our practice have done a few of these and they have worked well.

The research is still under review. Nothing is published yet as far as I know. The research has said that it is best for younger kids, so toddler module, and module one type kids from the ADOS. They say it’s likely not best for kids with fluent free speech. So, the kids who you would typically do an ADOS module two or above. A positive point is that the materials are free and you can access those via the website, which again, will be in the show notes. So that’s the TELE-ASD-PEDS approach.

The next approach that I want to talk about is NODA. NODA is an interesting approach to autism assessment that is also actually developed on a telehealth remote assessment platform. It’s not like you’re modifying another measure from in-person assessment to remote assessment. It was developed specifically for remote observation behavior.

The research is relatively limited thus far. The best research that I know of says that it was “normed” or validated on a sample of about 11 kids. The ages are 3 to 7. So, it’s also aimed at younger kids. It’s not meant to be used with older children. The methodology here is that the parent is instructed to capture a series of 10-minute videos across a few structured vignettes or defined vignettes rather as a better way to put it. And those are the kid playing alone, the kid playing with others, mealtime, and just other general times of parent concern.

So the NODA framework allows the parent to share these videos with you in a secure fashion, you being the clinician, and then, you were able to rate the videos and tag the videos using descriptive tags that label certain behaviors as neuro-typical or maybe more consistent with autism. It’s meant to go along with the DSM criteria.

It is $75 per case. That is something to keep in mind. And it produces a report that you can share with parents, or you can opt not to share that with parents and just include their report in your own report which would be part of a more comprehensive battery.

Now, I’ve heard reports out there. I have not used NODA and no one at our clinic has used NODA. So that’s something just to know, but for others out there, the reports are pretty good. People seem to find it helpful and have had a positive experience with it. So I think it is certainly a viable option for consideration if you work with little kids.

The next option I’m going to talk about is the clear autism diagnostic evaluation framework. CADE is the bigger acronym. So this was developed actually by 2 women out of Denver, Colorado, Marcy Willard and Anna Kroncke. They are close to home here. I’ve had a lot of interaction with them over the past two years. So they developed a tool that is I would say an advanced screener/diagnostic tool for autism. And they’ve been working on this for years. And they’ve also been conducting remote assessments of autism for a number of years as well. And this is just a piece of that.

The CADE tool is a lengthy I would say questionnaire/assessment tool where parents, teachers, clinicians, and other providers can answer any number of questions that gauge behaviors along several dimensions that are relevant for autism. So there are 11 different dimensions, and again, you rate the behavior of the child along each of these dimensions, and then it produces an outcome in terms of autism diagnosis or likelihood of autism diagnosis. A cool part of this tool is that they also have a built-in method for producing recommendations. So that is part of the outcome of the tool as well.

Now, the research on that is also somewhat limited, but very promising. So they conducted a validation study with an EN of 191 cases. They found that their tool was 98% consistent with ADOS diagnostic outcomes. So when the tool diagnosed autism, it was 98% consistent with ADOS diagnoses. They also spoke about the reliability, achieving a Cronbach’s alpha of 0.95. They did not specify which type of reliability exactly, but that’s promising.

I believe they are offering free access to the tool through the end of June. I could be wrong there. Marcy, Anna, if y’all are listening, please don’t shoot me if I got that wrong. So, it might not be free folks, but it was for a while. Either way, they are happy to consult with folks about the tool if you are interested. And then again, that will be in the show notes. 

The next two tools are going to be very familiar I think to a lot of us who have conducted autism assessments for any length of time. I’m going to talk about the MIGDAS and the ADOS.

The MIGDAS is a tool that was developed by Marilyn Monteiro. It’s been around for a few years now. It’s now on the second version. A lot of people like the MIGDAS. We use the MIGDAS here at our practice. It’s a structured interview much like the ADOS to gauge behaviors consistent with autism. It is meant, designed, and was normed as an in-person measure, keep that in mind, but Marilyn Monteiro, the author, has been speaking recently on its utility and application over telehealth.

Now, as far as I know, there’s no research on the telehealth application or validity, but again, the author, Marilyn Monteiro has said that it can be used over telehealth and the data that you can gather is still quite relevant in the picture of the diagnostic picture. So the MIGDAS is another option that we are likely familiar with, but one that we can adapt to telehealth with Marilyn Monteiro’s blessing.

And last but not least, I do want to touch on the ADOS-2. A lot of us use the ADOS in our day-to-day autism assessments with good reason. That’s been around for a long time. There’s a lot of research behind it. It is still the go-to measure I think for many insurance companies and other agencies who need a formal “autism diagnosis.”

The downside is that Catherine Lord, author of the ADOS, has said pretty clearly that you cannot obtain a valid ADOS-2 algorithm score if you’re administering with masks or PPE or plastic shields or plastic dividers or over telehealth. If you go through any of those options, unfortunately, you, cannot really calculate a valid algorithm score.

Now, she did say that it is still helpful for gathering information. So, if you’re a fan of the ADOS and you like the questions and the information that you can get from it, I think there’s still something to be said for administering the ADOS over telehealth, at least the questions from the models that you can do over telehealth. In-person interaction is probably not going to be happening in most areas right now simply because of social distancing and COVID restrictions and requirements for in-person interaction.

So, that’s going to likely not to be an option for most people, but she did say, and others have certainly said that you can do the ADOS with masks on and get as much information as you can, but just know that that you really can’t calculate that algorithm score.

Catherine Lord did speak about the brief observation of social communication change(BOSCC), which is an alternative instrument that uses the ADOS scoring criteria or rubric, I’m not sure what the right word is there, but it’s an alternative measure that is quite similar, but more amenable to telehealth assessment and remote assessment. So, that is something to look into. You do have to be trained in the ADOS and be very familiar with the ADOS to administer the BOSCC and interpret it correctly. But I know that we’re all just looking for whatever options we can find when it comes to autism assessment and this could be one of them.

All right. Like I said, that’s just a brief overview of the options for a remote autism assessment. As I said, here in our practice, we’ve been mostly doing the TELE-ASD-PEDS. We’ve been doing the MIGDAS and some ADOS questions over telehealth. We have also used the CADE framework really over the past two years just as an additional assessment measure. 

Each of those comes with their pluses and minuses. And at least as far as we’re concerned, putting those measures together has really helped to create some kind of coherent picture for autism assessment. I think we’re all still just waiting to be able to go back to in-person, but in many areas, that is not advised right now.

So I think it’s worthwhile to do your research and really dive into one of these or some of these remote assessment means and try to figure out a way to get these kids assessed. As we all know, with autism, six months might as well be a lifetime for a little one if it means a delay in intervention. And so, I think this is really a time to employ some flexibility wherever possible and just acknowledge that we may not be doing what we’re used to, but we can do our best. And that could be good enough.

So that’s all that I have for you today. Like I said, there’ll be several links in the show notes to each of these options. You can dig in, do your research. There’s been a fair amount of discussion in The Testing Psychologist Community on Facebook as well as the Teleassessment Listserv/Google Group. So there are some resources there as well.

I hope that y’all are doing okay as always. I’m guessing this is going to air late June, maybe early July. So, we’re still in the middle of it and everybody is looking for the right fit for their practice to get back to normal and provide services for their families. So, best of luck.

If you have not rated the podcast and spread the word about the podcast, I’m asking for a huge favor for you to do both of those things. So, quick rating in iTunes, very simple. And if you haven’t told your psychologist friends about The Testing Psychologist podcast, just tell one person. That would be incredible. Anything we can do to increase the reach of these episodes, we’ll just do more and more for folks who are trying to find resources on testing. So thank you all. I will see you next Monday for our next clinical interview. Until then, take care.

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