Diagnostic considerations for youth with mild autism presentations

The world-wide incidence of autism spectrum disorders (ASD) has been steadily increasing over the past 60 years. Current estimates indicate that approximately three percent of the population (i.e. 1 in 31 children) would meet diagnostic criteria for an ASD (Shaw, et. al., 2025). Early identification and treatment for ASD has been clearly shown to increase the quality of life and lead to a better prognosis for autistic individuals (Gómez-Cotilla, et. al., 2024; Zwaigenbaum, et. al., 2015).  However, despite the sharp increase in the number of children being diagnosed with autism, there are many individuals that do not meet specific criteria and/or are misdiagnosed with other forms of developmental disabilities or mental health challenges. The costs associated with these ‘missed’ children and youth has been clearly established and can include economic variables (increased health costs for later interventions), educational issues (missed educational opportunities/support), occupational opportunities (lost training and vocational support), mental health (misaligned treatment protocols, poor self-esteem), and health resources (draw on system for unnecessary tests/exams/treatments) (Vu, et. al., 2023).

Diagnosis of autism in children and youth has traditionally focused on a combination of behavioural observation along with parent/teacher reports. Given the ever-expanding clinical presentation of autism, the need for youth-directed interview data can assist in identifying those individuals who have a ‘milder’ presentation and better separate out potential comorbid mental health conditions. The ‘gold standard’ tools for assessing autism continue to be the Autism Diagnostic Observation Schedule – Second Edition (ref) and the Autism Diagnostic Interview-Revised Edition (ref). While both of these tools have demonstrated strong reliability and predictive validity for preschoolers, they become less accurate with older children and adults as many of the behavioural traits and diagnostic features can become more muted as individuals age due to availability of treatments/supports, maturity, social conformity, and masking (Adamou, et. al. 2021).

In an effort to address the changing landscape of ‘milder’ forms of autism, this presentation will centre on a number of domain-specific interview questions and additional questionnaires that can support the accurate diagnoses of those youth who present with less visible traits of autism. Consideration will be paid to clinical interview formats that align with the ADOS and ADI along with additional psychometric data (e.g., executive functioning, adaptive functioning) and potential comorbid mental health issues).

Dr. Worling has been a registered psychologist in Vancouver, British Columbia, BC for 27 years. He has worked extensively with children, youth, and adults who present with a variety of mental health challenges. He has worked in in-patient and out-patient psychiatric hospital settings and co-founded the Westcoast Child Development Group (2003) and Spectrum Works Consulting Group (2015). He has been providing evidence-based treatments and diagnostic assessments for autistic individuals since 2004. Dr. Worling created a course on autism was a sessional instructor at the University of British Columbia from 2017-2019 and has been providing consultation and training.