Cfinzrol f?~~cholo~~ Revzew. Vol. 3, pp. 41-59, 1983 0272-7358/83/010041-19$03.

00/O
Printed in the USA. All rights reserved. Copyright 0 1983 Pergamon Press Ltd.

~SYCHO~O~ICA~ASSESSM~NT
OFAUTISTICCHILDREN

University of North Carolina

ABSTRACT. Psychological ussessment qf autistic children zlsing standard tests can be a

z&uabLe tool for euuluation and treatment planning. However, such assessment can he
(~~~~~cl~Lt,
.. a& requires c~lre~~~u?lderstandin~ and management of
the handicaps ct~aracte~~~~tic
of autism. This article describes common problems that arise in testing au,tistic children, giz~es
for test se~ect~o~~and discusses the a~~l~cabi~i~ of a ~~.~?rl~~r
~~~~~~e~~~~e~~ of stun~~ard tests to
this ~~)~~~~uti~rl.
It also presents geneml principles for test administration und behavior man-
agement during testing.

Psychological assessment plays an important role in the treatment of autistic chil-

dren; yet that role has been frequently undervalued. Autistic children have often
been considered “untestable” by standard intelligence tests; in some cases an ad-
ditional assumption has been that intellectual ability at or above the average level
lay hidden beneath the autistic symptoms. More recently, behavioral approaches
have sometimes been used to teach desired skills and behaviors without assessment
of overall cognitive ability.
There now is a growing recognition that broad and thorough assessment of
autistic children is possible and is a prerequisite for fruitful treatment (Alpern,
1967; Freeman, 1976; Littler, 1966; Rutter, 1973). Hefping the child to enlarge
his perceptions of the world, change his behavior, and learn new skills must be
preceded by understanding his current perceptions, behavior, and abilities. Rutter
has discussed the importance of multidiscipIinary evaluation procedures and of a
developmental perspective in assessment. Others (Freeman & Ritvo, 1976; Marcus,
1978; Schoplcr 8c Reichler, 197 1) have described how cognitive and beha~riora~
assessment data can provide the basis for educational and behavioral programs.
In addition to their role in planning specific interventions, assessment results
are important in choosing appropriate educational and vocational placement. A
child’s success in a program will be highly dependent on how well his current skills
and predicted rate of progress are matched with the curriculum. Assessment in-
formation also is very helpful for parents, teachers, and others who are trying to
understand and deal with the child. For example, knowing that a child’s receptive
language (how well the speech of others is understood} is much better than his

Requests for reprints should be addressed to the author at the Department of Psychology,
Davie Hall 013A, University of North Carolina, Chapel Hill, N. C. 27514.

41
42 Ann F. Haker

expressive language (how well he can express himself in speech) helps to explain
wh>, he goes to get his coat on request but cannot tell you where it is. E‘inallv,
intellectual assessment can provide an estimate of long-term prognosis for autistic
individuals. Several studies indicate that the pattern of skills and deficits typical of
autistic children tends to persist in adolescence (Tymchuk, Simmons, 8c Neafsey,
1977) and that childhood IQ scores are often good predictors of performance in
adolescence and adulthood (DeMyer, Barton, Alpern, Kimberlin, Allen, Yang, &
Steele, 19’74; Lockyer 8c Kutter, 1969).
.I‘he growing recognition of the importance of assessment has led to the devel-
opment of’ several instruments designed specifically for autistic children (e.g., Fla-
harty, 1976; Schopler 8c Keichler, 1979). These tests take the special characteristics
of the autistic syndrome into account and avoid many of the problems that arise
I\-it11 standard tests. For example, they cover a wide range of skill levels to accom-
modate the scatter typical of autistic children’s profiles. They limit use of language
to tasks that measure language skills, presenting other tasks with non-verbal tech-
niques.
Holve\rer, more traditional intelligence tests still play an important role in as-
sessment (Gould. 1976). Clinicians in many settings my? not have training in the
~~dministration of specialized tests. and referral to faclhties where they are used
may be impractical. Even when specialized tests are available, standard tests can he
a useful supplement. For clinicians who see autistic children infrequently. it is
helpful to observe the child’s performance within a familiar frame of reference,
such as a standard test as well as on specialized test items. Standardized tests ma)
also provide a second evaluation, a set of results familiar to other professionals, or
an IQ score required for program placement.
This paper discusses the use of standard intelligence tests with autistic children.
It outlines the problem encountered in such assessment, describes a number of’
tests which can be used effectively, and gives guidelines for selecting the most
appropriate tests for a particular child. In addition, it provides general principles
for test administlatiorl with autistic children and brief suggestions concerning inter-
pretation of results.

COMMON PROBLEMS IN TESTINGAUTISTICCHILDREN

.l‘he handicaps that comprise the autistic syndrome lead directly to the dif‘ficulties
that arise in assessment. One of the most salient of these handicaps is a deficient
ability to establish social relationships and enjoy contact with other people. In the
testing situation, the child may show little or no desire to interact i\:ith the examiner.
He may display little motivation to follow directions or “do his best.” and little
enjo\ ment of praise, hugs, or other social reinforcement. If he does initiate contact,
it ma); have an impersonal or mechanical quality. Our familiar, automaticjudgments
of events as pleasurable or aversive may be invalid with such children. .A smile, an
in\itation to plav. or the presentation of a picture book may be unappealing or
threatening, \\hile time alone in a corner, a coat hanger to hold, or a long list of
phone numbers to copy may be enjoyed and sought out. For children with some
social a\varcness but little discriminatory ability. a pleased smile may be less re-
~varcling than a loud, stern admonition. ‘l‘hus, the system of I-einf’ol-cement the
examiner has developed with other children rn;l>; be inef‘fective.
I\ second characteristic of autism which sigmflcantly affects assessment proce-
 Psychological Assessment of Autistic Children 43

dures is impairment of’ communication skills. Most obviously, this def’icit means
that man)- autistic children cannot complete tasks that require verbal expression.
In addition, they may be handicapped on “nonlanguage” items which employ verbal
directions from the examiner. For example, a child with little or no receptive
language Mill not be able to utilize the verbal instructions for \VISC-K I’erf’ormancc
subtests. Beyond these language handicaps, however, lhe comniunication deficits
of‘autistic children affect their test performance in broader wavs. Other latlg~qe-
ll~~i~~~ic~il)~e~ichildren, such as deaf and aphasic children, of&n show high levels
of communicative ability in non-verbal chamwls, such as gesture, facial expression.
and pictorial symbols. By contrast, the deficits of autistic children usually appeal
across all f’orms of’ communication (although non-lan<guage channels may be rel-
atively better developed). ‘I’heref‘ore. the examiner’s LW of’ gestures, exaggerated
tiicial expressions, and pictures, thouSgh often helpful, may not be as successtul
\cith these children as with other language handicapped groups.
SeTera other autistic characteristics may create difficulties in testing. The child
may have sensory abnormalities that result in unusual responses to sensors stimuli.
He may become mesmerized by lights or mirrors, startle at f’aint so~lncts’ or seem
impervwus to loud ones, or explore materials ,bu smelling or tasting them. I’here
mav be attentional Cii~~cL~lties such as hyperactrvlty. extremely passive behavior, or
5tGie fluctuations in attention and concentration. A “need for sameness,” for pre-
dictable, ritualistic routines, may make it difficult for the child to sr\jtch tasks or
to relinquish a f’A\orite toy. Abnormal motor behaviors such as handflapping 01
t\virling may interfere. Finally, the scattered profile of’ skills typical of‘ autism may
be difficult to assess with a single standardized instrument. A 4-year-old child ma);
have \isrtal memory skills at the G-year level and social or language skills belotv I
year. ‘I-he assumptions of’ normal developmental progression built into most tests’
basal and ceiling criteria may be inappropriate, and the usual scoring procedures
meaningless.
FVhile this \.aried group of handicaps creates numerous dif‘f’iculties in assessment,
it is possible to avoid or minimize many of them. Awareness of’ the potential prob-
lems is the first step toward solving them. The ~ollc~~sit~g two sections give sugges-
tions for selection of’ tests and outline general principles of’test administration lvith
autistic children.

TEST SELECTION

The guiding principle in both selection and administration of’ tests should be to f’it
the test to the child rather than the child to the test. Observing how the child
perf’orms on specific test items should not be the goal of the evaluation, but rather
a means of’ exploring more general issues about the child’s functioning and of’
addressing the particular questions that led to the request for evaluation. The child’s
preferences, abilities, handicaps, and indi~rid~lal style should guide the examine1
in each aspect of’ the evaluation. The most important application of this principle
in test selection is to match the test to the child’s developmental level. Selection
should be based on all available inf’ormation about the child, combined, if’ at all
possible, with direct observation and interaction with the child bef’ore the start of’
fi)rmai testing. Because most autistic children function in the retarded range (AI-
pet-n, rY6i: Kutter, 19’78). it is usually best to select a test which extends well below
the child’s chronological age. Some children will need to be tested with instruments
 Table I. Summary of General Intelligence Tests t

Autistic Children
Age For Whom Test Is
Test Range Description Best Suited Advantages Disadvantages

Bayley Mental 2 mo. Motor, language, and Young or severely Breaks down social For children with
Scale of Infant to social skills assessed delayed children, and language skills poor language
Development 30 in tasks designed to particularly if atten- into small compo- and social skills
mo. measure small incre- tional and behavioral nents. Tasks require but good visual-
ments of ability. skills are poor. only brief attention. motor skills,
range of visual-
motor tasks may
be too low.

Merrill-Palmer 18 Wide range of visual- Children whose con- Attractive materials. Language skills
;
Test of Mental mo. motor tasks, smaller ceptual and language Language and non- not comprehen-
3
Abilities to number of language deficits make higher language items fairly sively assessed. b
6 yrs. items. tests inappropriate, well separated. Autistic children %
but who have rela- with good visual- ?
tively good visual-mo- motor skills may
tor skills. score mislead-
ingly high. No
derived IQ.

Leiter Inter- 3 yrs. Non-language test Children whose con- Little interaction with No language as-
national Per- to used with deaf chil- ceptual abilities examiner required. sessment. Very
formance 18 yrs. dren. Child demon- greatly exceed their Repetitive routine of little assessment
Scale strates understanding language or who have administration mini- of interpersonal
of concepts by difficulty with tasks mizes stress for many skills so score
matching blocks to a requiring social inter- autistic children. may not be accu-
pictorial key. action rate reflection of
ability in “real
life” situations.
Hiskey-Ne- 3 yrs. Non-language test Children whose con- Tests wide range of No language as-
braska Test of to used with deaf chil- ceptual abilities concepts and inter- sessment. Longer
Learning Ap- 16 yrs. dren. Various sub- greatly exceed their persona1 skills with no and more de-
titude tests involve imitation language, and who language demands. manding than
and memory as well can sustain attention Can be given with or Leiter. No de-
as matching. to and interaction without verbal in- rived IQ.
with examiner. structions.

McCarthy 2% Five subscales, par- Children whose lan- 2%-g% year range Language and
Scales of Chil- yrs. tially overlapping, guage skills are not better suited to many conceptual de-
dren’s Abilities to measure verbal, per- severely delayed and children than Wechs- mands too diffr-
8% ceptual-performance, who have relatively ler tests. Fewer tasks cult for many
yrs. quantitative, motor, good attentional and dependent on lan- autistic children.
and memory skills, behavioral skills. guage. Attractive ma- Comparison of
terials. Administration subtest scores
allows for repeated difficult.
demonstration, en-
couragement.

Wechsler Pre- 4 yrs. Verbal and Perfor- Higher-level autistic Well designed and Language and
school and to mance subscales. Em- children, whose lan- well standardized. conceptual de-
Primary Scale 6% phasis on language guage skills are only Several subtests assess mands too diffi-
of Intelligence yrs. skills. Several subtests mildly delayed, and skills emphasized in cult for most
(WPPSI) assess formally ac- who have good atten- school. Alternation of autistic children.
quired knowledge tional and behavioral Verbal and Perfor- Receptive lan-
Wechsler In- (e.g., Arithmetic, In- skills. mance subtests helps guage important
telligence 6 yrs. formation). reduce language de- even on Perfor-
Scale for Chil- to mands. mance subtests.
dren -Revised 17 yrs. Administration
(WISC-R) guidelines fairly
rigid.
46 Ann F. Baker

Lvhose entire age range is below their CA. Although this procedure precludes the
use of’ derived IQ scores, since the child’s CA will be outside the range of the
standardization sample, it can still provide an accurate estimate of the child’s de-
~elopmental level. This alternative is far better than administering a test which is
appropriate to the child’s a<ge but too difficult for him. Giving tests above the autistic
child’s abilities is a mistake tvhich often accounts for the familiar comment in
children’s records: “Untestable-no results obtained.”
The second way in which the test should be fitted to the child is in its language
requirements. Because of their language handicaps, autistic children need separate
assessment of‘ language and non-language skills. Assessment of non-language skills
must employ techniques that are not dependent on language. .l’he tests which meet
this criterion best, of course, are those in which language is employed minimally
or not at all on non-language tasks. Tests designed for deaf or language handi-
capped children, such as the Leiter and the Hiskey-Nebraska, are examples. In-
struments which clepend on language for almost every item, such as the Stanford-
Binet, cannot provide accurate assessment. The Wechsler tests, with their Verbal
and Performance subtests. are partially successful in separating language and non-
language assessment.
Other f’actors to be considered in test selection include the child’s social skills
and ability to relate to others, attention span and interest in task completion, and
preference for particular materials. For example, a child who avoids all interper-
sor~al contact may work best with the Leiter, which requires almost IW social in-
teraction. A very active child with a short attention span may do better on the
;2Ierrill-Palmer than the Hiskey-Nebraska.
The following list suggests standardized tests which may be appropriate fix
autistic children and describes particularly relevant characteristics. Language tests
and other specialized tests are also mentioned briefly. This is not meant to be an
exhaustive listing but should give the clinician some guidance in the selection
process. The tests are presented in approximate order of increasing difficulty.
‘Fable 1 is a summary of the characteristics of each test most relevant for autistic
children.

General Intelligence Tests

Bayley Scales oflnfant Development (Mental Scale) (Bayley, 1969). 2 months to 30

months. Because the Bayley is an infant scale, its tasks require only brief periods
of attention and its materials are visually interesting. Language is not an important
element in administering non-language items. Perhaps most important, the Bayle)
breaks clown social and language skills into very small, low level components (e.g.
“discriminates strangers; ” “vocalizes four different syllables”). Many autistic chil-
dren lvith higher visual or motor skills are unable to pass these very simple items.
-rhe Bayley thus provides a way to assess these weakest skill areas on younger or
severely impaired children, even though they may be above its upper age limit.
One disadvantage is that the range of visual-motor tasks may not extend high
enough f’or children whose best skills are in this area.
 Psychological Assessment of Autistic Children 47

Merrill-Palmer Test of Mental Abilities (Stutsman, 1948). 18 months to 6 years. A

poorly standardized test, the Merrill-Palmer still has value for many children with
skills in the 2- to 4-year range whose language and conceptual development are
too low for more complex tests. Its advantages include its relatively complete sep-
aration of language and non-language items and its brightly colored, attractive
materials. Its disadvantages are its poor standardization, frequent emphasis on
visual-motor rather than conceptual skills, and preponderance of timed items.
Scores on timed items are often difficult to evaluate accurately with autistic children,
because of poor attention and lack of understanding of the need for speed.

Leiterlntemational Performance Scde (Leiter, 1969). 3 to 18 years. ‘rhe Leiter, often

used with hearing impaired children, is another clinically useful though poorly
standardized test. Its foremost advantage is that it requires no receptive or ex-
pressive language. .I‘he child demonstrates understanding of concepts such as color,
number, and function by matching associated pictures and placing picture blocks
in correct sequences. Another advantage is the Leiter’s relatively short administra-
tion time.
J‘he Leiter does not require the child to interact with the examiner or to be
flexible in approaching new tasks. The items are completed by repetitive placement
of’ blocks, with variation only in the concept represented by the pictures. Very little
attention to the examiner is needed once the basic format is understood. ‘I‘his
design has advantages and disadvantages in testing autistic children. It is useful in
that it enables children who are indifferent or resistant to social interaction to
complete a standardized test. However, it gives little information about the child’s
ability to follow directions and gestures, imitate actions, or shift from one type of
task to another. Evaluation of these skills, typically deficient in autistic children,
needs to be included in the overall assessment. In addition, the Leiter’s materials
are difficult to alter or manipulate in order to “test the limits” outside the strict
confines of standard administration. For these reasons it is often best to use the
Leiter in conjunction with other formal or informal instruments.

Hiskey-Nebraska Test of Learning Aptitude (Hiskey, 1966). 3 to 16 years. The His-

key-Nebraska, also designed for hearing impaired children, is better standardized
than the 1,eiter; however, it provides only a mental .age equivalent, not a derived
IQ. It shares with the Leiter the advantage of reqmrmg no language for admin-
istration. Its wider variety of tasks allows assessment of the child’s ability to shift
tasks, imitate, follow gestures, and engage in social interaction. By the same token,
it is a longer test and may be too demanding for many autistic children.

McCarthy Scales of Children’s Abilities (McCarthy, 1972). 2% to 8’/~, years. Like the
Wechsler tests, the McCarthy relies heavily on language and is generally suitable
only for high level autistic children. Other disadvantages are differential weighting
of various subtests, which makes comparison of subtest scores difficult, and large
increases in the level of ability required from one task to the next in a given skill
area. However, it has several advantages over the Wechsler tests. Its developmental
range is more appropriate for many children, whose scatter of skills is often too
wide for the WPPSI and whose language is usually too low for the WISC-K. Despite
the use of language on many items, the McCarthy has several non-language motor
and memory subtests; these are often relatively high skill areas for autistic children
48 Ann F. Bukel

and can be very useful in educational programming. In addition, its administration,

designed to accommodate children as young as two years. is well suited for autistic
children. For example, it permits repeated demonstrations and frequent encour-
agement; it contains few timed items and provides for alternation of table tasks
with gross motor activities.

Wechsler Preschool and Primary Scale of Intelligence (Wechsler, 1967), Wechsler

Intelligence Scale for Children-Revised (Wechsler, 1974) 4 to 6% years; 6 to 17
years. The WPPSI and WISC-R are highly dependent on language and therefore
inappropriate for many autistic children. Even on the Performance subtests, re-
ceptive language plays a significant role. However, for higher level autistic children
who have some meaningful language, the Wechsler tests offer the advantages of
excellent standardization and well designed tasks. Their format, since it separates
and alternates Verbal and Performance tasks, gives the child frequent breaks from
expressive language demands, making these tests much less stressful than the Stan-
ford-Binet. The format also allows the option of presenting only the Performance
scale. Even when a complete administration and overall scores are not obtainable,
the Wechsler tests can provide valuable information by use of selected subtests and
testing of limits. For children of school age, the Wechsler tests offer more direct
evaluation of school related skills than the tests described above.

Specialized Tests

In addition to general cognitive tests, specialized instruments are often needed to

explore diagnostic and treatment questions. These may be tests within the reper-
toire of most psychological examiners, such as school achievement or social skill
measures, or they may involve collaboration with other disciplines such as audiol-
ogy, speech pathology, or pediatric neurology. Decisions about what evaluations
are needed should be made individually for each child. Clinicians working with
autistic children should be alert to cues that additional evaluation is needed and
aware of- the common complications of the autistic syndrome. For example, brief,
abrupt staring spells might indicate a possible seizure disorder, a relatively frequent
condition in autistic children (Schain & Yannett, 1960). Specialized tests should be
used whenever their results might significantly affect treatment planning or answer
specific referral questions. They should not be used merely to document the extent
of the child’s skills and deficits in areas which are not directly pertinent to treatment
or in lvhich there is no indication of any handicap. For example, a child who has
no history of seizures and displays no behaviors suggestive of neurological problems
does not need an EEG simply to make the assessment more complete.
The specialized tests most likely to be useful adjuncts to general cognitive as-
sessment are measures of language and of social and behavioral skills. The following
discussion of tests in these areas is not meant to be comprehensive, but will give
suggestions of specific tests and how they may be useful with autistic children.

bnguage. There are currently no comprehensive language assessment instruments

designed specifically for the language disorders of autistic children. The unusual
nature of these disorders means that the theories of the developmental process of
 Psychological Assessment of Autistic Children 49

language acquisition on which most language tests are based may not be valid for
these children. Tests must be administered with considerable flexibility and clinical
judgment and should be accompanied by evaluation of spontaneous language sam-
ples and other “real life” language. Particular attention should be paid to the child’s
ability to generalize language skills to many situations, to use meaningful, creative
language rather than rote, memorized phrases, and to initiate language without
pr~)n~ptin~. Interpretation of results should consider the child’s performarlce on
specific items as well as the overall score.
The Zimmerman Preschool Language Scale (Zimmerman, Steiner. 8c Evatt, 1969),
the Sequenced Inventory of Communication Development (Hedrick, Prather, 8c
‘I‘obin, 1975), and the Test of- Language Development (Newcomer & Han~mill,
1977) evaluate both receptive and expressive language. The Zimmerman and the
SICD are relatively low level tests which employ simple objects and actions to
demonstrate the child’s understanding and use of language. The Zimmerman starts
at the l&month level; the SICD begins at 4 months, and is thus more useful for
children with severely delayed language. This test relies on parent reports for some
items. It also includes a rudimentary analysis of a language sample, a particularly
valuable component of language assessment. The TOLD is useful for children with
more advanced language, since it covers skills in the 4- to g-year range.
Tests of receptive language include the Carrow Test for Auditory Comprehen-
sion of Language (Carrow, 1973) and the Peabody Picture Vocabulary Test (Dunn,
I9t;:S). Both measure receptive understanding of nouns and verbs; the Carrow afso
tests adjectives, prepositions, similarities, and other concepts. Both these tests use
pictures rather than objects, which precludes their use with children who do not
understand pictures as‘symbols. Care must be taken in interpreting the results of
these tests, ~~rticLllarly the PPVT, since they measure only receptive unders~nding
of single words or sentences and only in the structured, repetitive format of pointing
to successive pictures. An autistic child’s skills on these tasks may be higher than
in the less structured context of conversation or stories. In addition, receptive skills
should not be used to estimate expressive language ability, since the two may vary
greatly.
Yrllere are also several language questionnaires designed to be completed by
parents or parents and clinicians together. These include the Keceptive-ExpressiVe
Enlergent Language Scale (Bzoch & League, 1970) and the Oliver Parent-Admin-
&red Communication Inventory (McDonald, 1978). Both of these scales focus on
receptive and expressive language below the three year level. The REEL provides
a more structured and detailed format for language assessment; the Oliver covers
a broader range of skills related to communication such as attention, imitation,
and symbolic play. These scales can be a useful guideline for investigating the
child’s language in everyday situations. However, because of the extremely con_
fusing and often misleading nature of‘ autistic language, each item should be dis_
cussed with parents in careful detail.

Behavioral and Social Skills. Measurement of adaptive behavior and social skills of‘
autistic children is a puorly explored area. Issues of standardization, reliability, and
applicability of existing scales for an autistic population are not yet well resolved.
However, such instruments as the Vineland Social Maturity Scale (Doll, 1965), the
Adaptive Behavior Scale of the American Association on Mental Deficiency (1974),
50 Ann F. Baku

and the Progress Assessment Chart (Gunzberg, 1976) can be useful if interpretation
focuses on specific skills rather than a global score. The scattered profiles of autistic
children often result in some items passed near or even above age level while others
are failed well below age level. A 5-year-old child with a good visual memory and
poor social skills may be able to tell time but unable to play simple cooperative
games; his overall “social age equivalent” will mean very little. In addition, the
autistic child’s performance is often very erratic. He may learn new words and then
lose them, or may imitate some adult actions but not others. It may be difficult to
score items unequivocally in many cases. With these cautions, however, behavioral
and social scales can provide important information about a child’s non-academic
skills. They can also help parents and teachers interpret the child’s everyday be-
havior within a developmental framework. For example, it is much easier to un-
derstand and deal with an eight year old’s disobedience if it is clear that his defiance
is like that of a 2-year old experimenting with adults’ reactions to his behavior.
The Vineland is primarily a measure of home skills, and is often completed with
help from parents. It gives an overall social age equivalent. It is a quick, easily
calculated scale; however, it has few items at each age level and so does not provide
detailed information about a wide range of skills. The ABS and the PAC. longer
and more detailed than the Vineland, assess classroom skills and behavior. ‘l‘he
ABS gives a percentile score, based on norms from special education classrooms,
~vhich is useful as a global estimate of skills and as a research tool; however, its
specific items are not easily applicable in designing a training program for an
individual child. The PAC’s Items are better for this purpose. In addition, the PAC
provides a visuallv clear chart of the child’s skills in various areas which clinicians
may find helpful. A disadvantage of the PAC is its system of separate forms for
scoring skills at increasing levels of difficulty; for autistic children this system often
results in having to use more than one form for one child.

PRINCIPLES OF TEST ADMINISTRATION

1. Flexibility in Aciminis tra tion

Perhaps the most complex, and most critical, issue in using traditional tests with
autistic children is the alteration of standard administration procedures to accom-
modate the child’s unusual handicaps. If a child is not tested under “standard
conditions,” of what value are the test results, whose validity depends on uniformity
of administration? Clearly, this question has no simple answers. Deviation from
standard procedure can range from subtle changes, such as unusually frequent
praise and encouragement, to obvious major alterations, such as using sign language
to explain tasks. .l‘he effect on test results will depend on both the nature and the
frequency of such deviations.
W’henever possible, standard administration procedure should be followed. If
testing appears to be impossible under these conditions, it is likely that an inap-
propriate test is being attempted. The majority of autistic children can attend to
test items without extreme distortion of standard procedures if the test is appro-
priate to their abilities (Alpern, 1967; Freeman 8c Kitvo, 1976). ‘l‘he most frequent
problem is that either the test items themselves or the test’s language demands are
 Psychological Assessment of Autistic Children 51

too difficult for the child. If needed, many accommodations to the needs of the
child can be made without significant violation of standard procedures. Verbal
instructions can be given very slowly and clearly. Gestures can be emphasized. On
many tests, such as the Bayley and the Merrill-Palmer, the examiner can administer
items in any order, so that stressful tasks are followed by more enjoyable ones.
When the child’s performance on a particular subtest has been observed with
standard aclministl-ation, the examiner on a particular subtest has been observed
with standard administration, the examiner can begin to alter items to investigate
skills and deficits more closely. J‘his “testing of limits” is often the most informative
aspect of testing with autistic children. It allows the examiner to move beyond what
the child cannot do, breaking down and simplifying tasks until it becomes clear
izhat the child CNT~do and what he shows a beginning ability to do. It is at this level
that educational and behavioral programming must start. If the child cannot solve
verbal arithmetic problems, can he solve written ones? If he becomes disoriented
rvhen asked to throw or catch a ball, does a line drawn on the floor help him to
position himself more accurately? If a timed item is failed (a frequent problem
\\~ith autistic children), could the child complete it with more time? The child’s
performance should be recorded and evaluated under both standard and non-
standard administration. The changes that the examiner has to make in order for
the child to be successful will be valuable guidelines in making treatment plans.
I‘his quality of flexibility, important in all assessment, is essential in evaluating
autistic children. Even more than most individuals, these children do not fit the
preconceived expectations with which we may approach them. Our ability to main-
tain an open, investigative attitude will in large measure determine the quality of
our assessment.

2. Appropriate Methods of Communication

The communication handicaps exhibited to a greater or lesser degree by all autistic

children make this issue a relevant one for every child. Detailed discussions of
autistic language and suggestions for communication techniques are available (Baker,
I,., Cantwell, Kutter, 8c Bartak, 1976; Lord & Baker, A. F., 1977; Menyuk, 1978).
Willis article will briefly discuss several general points to be considered in using
language in cognitive assessment and will describe non-verbal alternatives.
In using verbal language to administer assessment instruments, there are several
principles to remember. The first is that the child’s language may vary widely
between the receptive mode and the expressive. Usually, though not always, re-
cepti\re skills are higher than expressive. ‘The child may understand and comply
\vith a request such as “Give me the ball” but not be able to say “Ball” when he
wants it back. A second principle is that the child’s language may contain rote,
mechanical phrases or repetitive delayed echolalia that can easily be misinterpreted
as meaningful language. A child may be able to sing long songs but not give one
\vord ans\vers to simple questions; he may always say “Time to go in the car” when
he leaves a building but not understand the verb “go” in any other context. A third
consideration is that the child may have language skills in one setting that he cannot
generalize to other situations. He may understand the phrase “Put them together”
about puzzle pieces but not blocks; he may correctly identify a ball only if it is red
like his ball at home. Finally, the child’s language, like many of his skills, may not
f~~llow normal developmental patterns. A child who does not talk may be able to
52 Ann F. Baker

read, particularly if he has good visual and poor auditory abilities. These complex
attributes of autistic children’s language demonstrate the difficulties both in lan-
guage evaluation itself and in using verbal language to communicate with the child
during all aspects of cognitive assessment.
Many of these difficulties can be avoided by using alternative methods of com-
munication. While this idea may immediately conjure up notions of complex sys-
tems of signs, pictures, or symbols, alternative communication in most cases may
be quite simple. In many cases, using materials that are visually clear and self-
explanatory is all that is needed. For example, a task of sorting squares and circles
becomes visually clear if small trays are provided for each group, with an initial
square in one and circle in the other. Gestures and direct physical guidance can
also be very helpful.
For some children, more complex alternative methods of communication can
be useful. *l‘hese may include pictures, sign language, written words, or other
symbols. For example, the child who cannot ask for the ball verbally may be able
to convey his request by picking a picture of a ball out of several choices. ‘l‘hese
methods require considerable practice. The examiner should find out in advance
if the child uses such a method and how extensive his skills are. If the child does
not know of any of these methods, it will probably not be helpful to use them
extensively during testing. However, it may be possible during the session to explore
the possibility of teaching him one of these methods by investigating such areas as
his understanding of pictures or ability to imitate a simple sign.

3. Use of Free and Structured Time

-l‘he evaluation session should combine the structured time needed for completion
of test items with periods of f‘ree, unstructured time in which the child can decide
on materials, choose whether or not to interact with the examiner, and set the style
and pace of activities. This combination allows the examiner to discover the child’s
own interests, which are often difficult to discern in severely impaired, aloof, or
passive autistic children. The child’s spontaneous likes and dislikes can then be
used to create a system of reinforcement. This technique also shows how the child’s
behavior varies depending on the degree of structure and how he reacts during
changes in structure.

4. Assessing Motivation and Choosing Reinforcers

~l‘he issue of the respective roles of ability and motivation, often described as the
question of “can’t vs. won’t,” arises frequently in testing autistic children. When a
child does not complete a task, is it that he will not do it because of insufficient
desire or motivation or that he cannot because of deficient skills? It is easy to make
assumptions in either direction, but important to avoid them. The assumption that
the child ccl?z do the task but is not motivated to do so may stem from an overes-
timation of skills. This mistake is particularly easy to make when the child’s skills
show wide scatter across various areas. We usually assume that if a child can speak
complete sentences he can understand simple directions; that if he can assemble
‘LOOpiece jigsaw puzzles, he can put together a five piece manikin. Such assump-
tions, based on the normal sequential pattern of child development, are often wrong
for autistic children. A child may recite memorized sentences at appropriate times
 PsychologicaE Assessment of Autistic Children 53

but have poor receptive language. He may complete intricate jigsaw puzzles using
unusually high visual discrimination and matching skills but fail to grasp the more
abstract concept of body image needed to assemble the manikin. Therefore, when
a child does not complete a task, bef-ore assuming that the problem is motivation
we need to be sure the child has the necessary skills.
Conversely, it may appear that the child cannot do the task when the truth is
that he has the necessary skills but is insufficiently motivated. Assuming the child
cannot do the task may be an ?&rrestimation of skills, which, like overestimation,
can result from an unusual profile of skills. In this case, if the child does not
complete the task, we must be sure motivation is adequate before assuming insuf-
ficient ski&. Perhaps the reinforcers being used are ineffective. Some autistic chil-
dren are severely deficient in the ability to enjoy either sensory stimuli such as food
or music or interpersonal rewards such as smiles or praise. (A discussion ofchoosing
reinforcers follows belo\+,.)
Before attributing the child’s performance to volition, cognitive and interper-
sonal deficits should be considered. The handicaps of many children are so per-
vasive that very little of their behavior is truly “volitional” in our usual sense of the
term. Understanding this point is extremely important; it helps explain the dis-
appointing, unrewarding, and frustrating behavior often shown by autistic children
cluring evaluations. The examiner, instead of feeling a sense of failure and frus-
tration, can become the child’s ally and investigative companion, searching out tasks
the child can do and reinforcers the child likes.
The use of reinforcement and other behavior techniques in standardized testing
is a controversial topic. Advocates of behavioral techniques hold that their use
allows the examiner to obtain information about what rhe child can do at his best,
under specific favorable conditions. This information is very useful in planning
treatment. Critics argue that special reinforcements and other behavioral tech-
niques violate guidelines for standard admirlistration, producing results lvhich are
at best difficult to interpret and at worst invalid. X/Iore detailed presentations of
the arguments are available (e.g. Freeman, 1976). The cliscussion here is based on
the premise that behavioral techniques in general, and positive reinforcement in
particular, can be used appropriately in assessment of autistic children with stand-
ardized tests and that they often greatly increase the amount of usefut information
gathered in such assessment. The examiner should first attempt standard admin-
istration of at least a few items with no special behavioral conditions. Any use of
reinforcers or other special interventions should be noted in the assessment report,
along with the child’s response. It is important to understand both how the child
can perform when most highly motivated, and how differently he may perform
without special reinforcers or other behavioral constraints.
In choosing reinforcers, it is important to avoid assui~pti(~ns about what the
child will find rewarding or aversive. Instead, choice of reinforcement should be
based on information from parents and others who know the child well and on
careful direct observation. Before starting the evaluation, ask parents or teachers
what the child likes. If possible, have ready a variety of activities and treats, since
many children maintain only brief interest in any one reward. If a child seems to
enjoy only a few familiar items at home, such as drinking from a favorite cup or
listening to a special record, ask his parents to bring it to the session. When no
advance information is available, it is still possible to have several rewards ready
that are en,joyable for many autistic children. These include visually stimulating
54 Ann F. Baker

materials such as soap bubbles and kaleidoscopes; auditory toys such as bells, xy-
lophones, and drums; visual-motor tasks such as simple puzzles and blocks; cars,
trucks, and other wheeled toys; physically stimulating activities such as a rocking
boat, stroller, or “swing” game with the examiner; sweet or salty foods such as
cand!,, raisins, chips, or nuts.
Perhaps e\‘en more helpful than obtaining advance information is watching the
child cluring the session to discover what he likes. Such observation is particularly
important when one of‘ the concerns reported by parents or teachers is that the
child does not seem to like anything and that they are at a loss for et‘fective rewards.
\Vhile there are a f’ew children \vho truly appear co feel little or no pleasure under
any conditions. the majority have some set of preferred aclivities or materials. Often
rvhat is needed to discover them is a very open mind, able to conceive of “rein-
f’orcement” in the broadest sense and to’experiment freely. All sorts of sensory
sCmuli should be explored; examples are rubbing a piece of’ furry cloth, eating ice,
watching a flashlight blink on and off, hiding away in a dark corner or under a
blanket. Social contact may be erljoyable if conducted on the level of‘ very simple
games such as peekaboo, tickling, or pat-a-cake. Kelease f‘rom social contact may
also be reIvarcling. The child may enjoy playing alone after each task, with the
examiner at the other side of the room. A predictable or familiar ritual, such as a
token in a cup af’ter each test item or a task that is just like one at home or school,
may also serve as a reivard.

5. “Sameness “: Using Predictable Routines

.l‘he autistic “need for sameness”-a strong preference for the familiar, the routine,
the predictable-may be mild or extreme, and may appear in many ditterent fortns.
In testing, a child mav qo to the same activitv during each break, or may insist on
putting away all mate&ls slowlv and methodically, becoming upset if interrupted.
Because of this characteristic, it’ is helpful during testing to establish and maintain
predictable, repetitive routines which orient and reassure the child. -1‘hese may
inclucle using the same chair and location for all tasks, finishing each task by helping
the child put the materials in the same large box, signalling the end of each break
period \vith the s;mle brief’ ball game. or using exactly the same \vorcls each time
a direction is repeated. Koutines that are visually clear are particularly useful. I‘he
child learns that the appearance of the ball means that break time is almost over,
that five tokens in their five slots means that the task is finished.
The use of routines thus provicles a way to communicate the schedule and
structure of‘ the session to the child in a simple, reassuring fashion.

6. Choice of Materials

Autistic children’s f‘requently abnormal responses to sensory stimuli should be

considered in choosing materials both f‘or formal testing and for f’ree play. Perhaps
because of‘their language handicaps, many children rely heavily on the visual mode.
In addition, some children make extensive use of the proximal receptors-taste,
touch, ancl smell. Therefore materials which are interesting to look at, touch, and
manipulate may increase the child’s interest. -l‘he brightly colored boxes of the
Merrill-Palmer and the attractive items of the McCarthy are examples. However,
for some chilclren these sensory sensitivities may create testing problems. Chilclren
\\,ho are overstimulated by bright colors, varied textures, or intricate materials mav
 Psychological ilssessment of Autistic Children 55

become overly active, distracted, or fixated on one material. For example, they may
spin materials, gaze at the edges of blocks or cards, or use shiny materials as mirrors.
Such children may work better with plainer materials.
A second consideration in choosing materials is that autistic children often have
difficulty generalizing skills from one situation to another and lvork best with
familiar materials. I‘ests whose items are similar to objects seen at school or home
may be most successful. However. it is also important to evaluate how well the child
can generalize skills to new situations. Often the best solution is to test the child
on both familiar and unfamiliar materials. This is particularly important when a
task is being broken clown to easier steps to “test the limits” of the child’s skill. If
he cannot sort the colored plastic shapes provided in the test materials, can he do
the same task using blocks like those he has at home?

7. Managing Problems of Relatedness

-I‘he impairments in social interaction and relatedness always present in autism

\rary greatly in type and degree. A minority of children actively withdraw from
interaction with others; many other youngsters are passively indifferent. Yet an-
other group may interact spontaneously but their overtures are mechanical and
emotionless or have an “empty clingin$” quality that is directed indiscriminately
toivard parents, acquaintances, and strangers. It is important to evaluate these
deficits both to minimize the problems they may create in testing and to make
l.ecomnlendations for treatment. The child’s interaction with the examiner during
testing is a valuable indicator of his social skills and deficits. The examiner should
remember that his or her own presence may be a strong rewarding or aversive
force for the child, and should monitor attention, physical contact, voice quality,
and gestures accordingly.
The impaired relating skills of autistic children can easily produce discouraged,
angry, or self-critical feelings in the examiner. It is difficult to continue to work
intensely and sensitively with a child who seems to be indifferent, rejecting, or
deliberately provocative. Perhaps the most positive approach for the examiner is
to think of the child‘s behavior in developmental terms. The autistic child’s hand-
icaps in social relatedness may be so severe that he is more passive than a very
)oung baby who waits for the environment to provide stimulation. Or the child
may have some awareness of others as separate from himself and of the fact that
he can produce a response in them by his actions, but with the toddler’s lack of
real understanding of how his actions make the other person feel. He may have
learned to evoke angry voices and dramatic gestures rather than smiles and gentle
praise because the former are more stimulating. Thus the six vear old autistic
child’s behavior, which may look like deliberate defiance or manipulation, is fre-
quently merely experimentation at a much younger level of social development.
Keeping this concept in mind may help us as examiners dispel angry or frustrated
feelings and find ways to interact with the child at an appropriate level.

8. Managing Problems of Attention

The autistic child may have difficulties in attention and concentration, ranging
from distractible, hyperactive behavior to hypoactive passivity and lack of respon-
siveness. Testing techniques that are successful with other children with such prob-
56 Ann F. Baker

lems will often be helpful. -These may include establishing a routine of’ very short
tasks followed by a brief break, or alternation of’ difficult items with easier ones.
‘l‘he testing room’s t‘urnishings sl~oulcl be arranged so that the child’s attention is
channeled toward the test materials and not distracted by large open spaces or by
toys, pictures, and other materials. It may be helpf’ul to have a very active child
seated against a wall or in a corner during work times. With very passive children
it may help to find one or more test materials, toys, or f’oocls which can be used to
engage their interest. Many autistic children have poor eye contact. In the testing
situation, it is best not to attempt to improve eye contact PPT .SP,since the primary
objective is to have the child complete the test. Directing the child’s attention to
the task should be the goal; most children will look at materials they find interesting
e\‘en if they al&l human faces.

9. Managing Disruptive Body Movements

Many autistic children display unusual movements such as hand flapping, finger
posturing, or repetitive manipulation ot‘a fetish object. If’ frequent or severe. these
behaviors may interf’ere with testing. With some children, the behaviors appear to
be under considerable voluntary control, and may be handled like other disruptive
behaviors such as tantrums or throwing materials. Many can be entirely avoided
with careful test selection and administration. Others can be controlled by behav-
ioral techniclues such as simply ignoring the behavior or turning your head awa)
for a brief period.
However, the motor behaviors of’ some autistic children have a compulsive,
driven quality and appear not to be completely under the child’s control. In these
cases, other means are needed to handle them. Briefly holding the child’s hands
on the table or in his lap, especially when giving directions, may interrupt the
behavior long enough for the child to attend to instructions and materials. Using
materials in a way that is incompatible with the movement is also helpful; f’or
example. guicling the child to hold a pencil in one hand and the paper on the table
\vith the other, thus leaving no hand fi-ee to flap. No attempt should be made to
eliminate the behavior entirely during testing. For some children the movernents
seem to be a means of’ relaxing and reducing stress. Many children are able to
engage in these movements during breaks, then return to tasks when their attention
is redirected.

INTERPRETATION OF RESULTS

This paper will only briefly discuss the interpretation of’ evaluation data. In large
measure the principles of’ test interpretation for autistic children are the same as
for- any assessment and include addressing particular ref’erral questions, noting
strengths as well as deficits, and giving specific, concrete recommendations. Flaharty
(1976) and hlarcus (1978). among others, have presented detailed descriptions of
programming recommendations for autistic children based on assessment results.
‘I‘here are, holvever, several additional principles which follow from the ap-
proach to testing described in this paper. The first of these is the need tar careful
interpretation of’the IQ score. Our- awareness of the limited usefulness of the single
score, and our communication of’ its limits to others, must be even clearer for
 Psychological Assessment of Autistic Children 57

autistic children than for other clients. IQ scores do provide a rough estimate of
the child’s skills and do have some predictive value for the course of later devel-
opment. However, the atypical performance of most autistic children greatly re-
duces the significance of the scores by themselves. The reporting of results should
include a detailed description of the child’s performance and a caution against
placing too much emphasis on specific scores. It is important for both professionals
and parents to be able to use IQ scores and test results constructively to contribute
to a realistic picture of a child’s abilities, needs, and prognosis. However, it is also
important to avoid rigid conclusions and expectations and to maintain a positive
and flexible approach to the child.
In some cases, when more than one test is administered or when current scores
are compared to earlier scores on a different test, it may be important to discuss
how and why the IQ may vary with different instruments. For example, a child
vvho is given the Leiter and the WPPSI may obtain a much lower IQ on the WPPSI
because of its greater language and social demands.
Another guideline in interpretation of test results is the importance of thinking
of the child’s performance from a developmental perspective. Awareness of the
child’s developmental level in different skill areas can be valuable in understanding
and explaining his current behavior and in making treatment recommendations.
One common test result which a developmental approach can help clarify is the
profile with a wide scatter of skills. When a child has very uneven skills, overesti-
mation or underestimation of his ability by parents, teachers, or others often occurs
as the result of focusing on a particular peak skill or severe deficit as indicative of
overall ability. An explanation of scatter as a pattern of different skills at different
developmental levels can help correct these misconceptions.
Other factors which should be considered in test interpretation and formulation
of recommendations are the child’s ability to generalize skills from one task to
another; his interest in task completion and ability to work independently; and his
responses to social and behavioral interventions. Finally, it is particularly important
to stress the child’s strengths and potential for further development. Autism is
among the most confusing and discouraging of handicaps. For parents and others
involved with autistic children, it is heartening to be assured that their child does
have some skills, however limited, and can learn new ones, however slowly.

CONCLUSION

Thorough assessment is fundamental to the treatment of autistic children. Such

assessment is difficult, since the complex and varied handicaps these children dis-
play make them the exceptions to many of the rules by which psychological tests
are designed and administered. However, with careful selection and administration,
standard psychological tests can be used successfully with autistic children and can
provide valuable information about the child’s cognitive, social, and behavioral
development. Such information can then become the basis for planning a treatment
program.

Acknowledgement-l would like to thank Lee Marcus and the staff of the Piedmont TEACCH
Center, University of North Carolina, for their help with this article.
58 Ann F. Baker

REFERENCES
Psychological Assessment of Autistic Children 59