Autism assessment report: structure and template for psychologists

An autism assessment report is the document in which a psychologist or neuropsychologist sets out their part of the evaluation in a diagnostic process for autism spectrum disorder (ASD). It covers the referral question, developmental history, observations, the tools used, the person's profile and recommendations. In France, according to the HAS (the French National Authority for Health), an ASD diagnosis is a medical diagnosis based on a synthesis of the assessments made by several professionals, psychologists among them.

Who writes what in an autism assessment?

The 2018 HAS press release states that autism cannot be diagnosed by a single professional in a single consultation, and it requires the cross-observation of several specialised professionals.

For children and adolescents, according to the HAS, the process falls to a specialised multidisciplinary team at what it calls the second level of care. In France this can be a child psychiatry outpatient centre (CMP), a paediatric department, an early medical and social care centre (CAMSP), a CMPP, a specialised network, or private practitioners coordinated by a physician. The team includes in particular child psychiatrists, paediatricians, psychologists and rehabilitation professionals.

Your report is therefore one piece of the file. It covers your own field (intellectual functioning, cognitive profile, observation of social communication, adaptive skills, depending on what you were asked to assess). The diagnosis is a medical one, based on a synthesis of these assessments, and the physician who coordinates the process discloses it.

The general logic is the same as in our psychological assessment report template.

Which HAS guidelines frame this report?

For children and adolescents under 18, the reference is the February 2018 guideline on the diagnosis and assessment of ASD. It recommends a minimum set of elements for the initial assessment, which makes it the most useful basis for your outline.

For adults, the HAS approved a guideline on the diagnosis and assessment of autism and other pervasive developmental disorders in July 2011. It is old and refers to the classifications of the time (ICD-10, DSM-IV-TR). We recommend citing it with its date. A December 2017 guideline by Anesm and the HAS covers interventions and life pathways for autistic adults.

These are French texts. In Belgium, Switzerland or elsewhere, the structure below is still useful, but the MDPH (the French disability office) only exists in France.

How should the report be structured, section by section?

Here is the order we recommend. It uses the elements the HAS lists for the initial assessment.

Identification and referral

Name, date of birth, age at assessment, dates of the sessions, who referred and why. State your role in the process, for example "psychological assessment carried out as part of a diagnostic process coordinated by Dr X".

Background and developmental history

The HAS recommends a detailed developmental history. It includes when and why the parents first became concerned, the history of development (motor skills, language, social interaction and communication, play, specific interests, behaviour), personal and family history, and the child's socialisation, care and support arrangements.

Observations

According to the HAS, the assessment relies on direct and indirect observations gathered from people close to the child, especially the parents, and from professionals in childcare settings and at school. We recommend describing what you saw in session, under which conditions, and what the parents and the teacher report, with observable facts rather than labels. "He does not respond to his name while lining up his cars" says more than "limited social response".

Tools used

We recommend listing each tool with its date and conditions of administration. To structure the observation of social communication, the HAS gives the CARS, the ADOS or the ECA-R as examples. It also mentions standardised psychometric tests for intellectual functioning and the cognitive profile, and, for adaptive skills, the Vineland scale in particular, based on parents' observations. It adds that these instruments are only an aid to clinical judgement. We therefore recommend linking each result to what you observed.

For presenting the indices of an intelligence scale, see our WAIS-IV and WISC-V report template.

Results and profile

The HAS recommends that the cognitive profile be described in terms of difficulties but also of strengths and potential. We recommend organising the profile by domain (communication, cognition, everyday adaptive skills, sensory processing if it was assessed).

Co-occurring conditions and differential diagnosis

The HAS recommends looking for co-occurring conditions systematically and lists several differential diagnoses, such as a language disorder or social (pragmatic) communication disorder, intellectual developmental disorder without ASD, ADHD, social anxiety or selective mutism. In your report, note what your observations bring to these questions, without deciding alone. If another assessment would help, say so.

Conclusion

The diagnostic conclusion belongs to the multidisciplinary synthesis and to the coordinating physician. We recommend cautious wording, such as "the findings of this assessment are consistent with a profile suggestive of ASD" or "these observations are passed on for the multidisciplinary synthesis". In its text on disclosing the diagnosis, which is the physician's role, the HAS also says that before ASD is confirmed, it is advisable to give a provisional diagnosis of neurodevelopmental disorder, with a functional diagnosis, so that interventions can be put in place.

Recommendations

Recommendations cover educational and therapeutic interventions and adjustments at school. The HAS states that interventions can start before all assessments are finished, as soon as a developmental disorder is observed, and that a provisional diagnosis allows rights to be opened through the MDPH and national health insurance in France. For next steps, see our page on school accommodations after an assessment.

Sharing the report

The HAS recommends that the report on the functional assessment be sent, with the parents' agreement, to the professionals who carry out the interventions. For school adjustments, the parents pass it on themselves, if they wish. For the medical report sent to the physicians and professionals involved, the HAS refers to the information strictly necessary for coordination and continuity of care, within the legal framework for sharing information. We explain this framework in our article on shared confidentiality with the care team.

Reassessment

The HAS reminds readers that an ASD diagnosis should be re-examined, and its care pathway diagram mentions a reassessment at 6 months or 1 year. We recommend giving a time frame in your report. It helps the family and the team plan ahead.

What does an autism assessment report template look like?

Here is an outline to adapt. Fictional example, the patient and clinical details are invented and no scores are given.

• Identification. Leo M. (fictional), 6 years 4 months, final year of preschool. Seen on the 3rd, 10th and 17th of the month. Referred by Dr X, child psychiatrist, who coordinates the diagnostic process.
• Referral question. Psychological assessment of intellectual functioning, cognitive profile and adaptive skills, as part of an ASD diagnostic process.
• History. Parents first worried around age 2 (little pointing, late language). Strong interest in train timetables. No family history reported.
• Observations. In session, Leo engages easily with visual tasks. He rarely looks at the adult to share his enjoyment. His teacher reports difficulties in playground games and strong reactions to noise in the canteen.
• Tools. [Age-appropriate psychometric test, date]. [Observation tool, for example ADOS or CARS, if you administered it, date]. [Vineland, interview with the mother, date].
• Results. [Indices and scores, as you scored them, with their clinical reading].
• Strengths. Good visual memory, perseverance in tasks that interest him, enjoys puzzles.
• Difficulties. Reciprocal social communication, flexibility when activities change, independence when dressing.
• Co-occurring conditions and differential. No evidence in this assessment for an intellectual developmental disorder. Speech and language assessment of pragmatics suggested.
• Conclusion. The findings are consistent with a profile suggestive of ASD. Passed on to Dr X for the synthesis.
• Recommendations. Support for social communication, quiet time during transitions, discussion with the school about adjustments, subject to the synthesis.
• Sharing. Report given to the parents. Sent to the care team with their agreement.
• Reassessment. Review suggested in one year.

More clinical document outlines are gathered on our clinical document templates page. To prepare the feedback session with the family, see our assessment feedback template.

What changes for an adult autism assessment?

The 2011 HAS guideline describes two sides, a medical diagnosis and functional assessments that look at the person's resources for their personal plan. It notes that in adults, the warning signs are not specific. Three things change in the writing.

First, the history. According to the HAS, it covers childhood and how the signs have changed at different ages. We recommend noting where the information comes from (the person's memories, a parent's account, school reports) and saying when it is missing.

Second, the observations. According to the HAS, the gathering of clinical information takes behaviour in different settings into account, with direct observations or observations reported by the various people involved. Standardised tools are chosen according to what the person is able to do.

Third, the environment. According to the HAS, functioning is assessed in light of the resources and limits of the environment. Describe, for example, work or studies, housing and the people around the person. For reassessment, the 2017 Anesm and HAS guideline recommends reassessing the functioning of autistic adults at least every 5 years, and more often depending on their needs.

How can Delta help you write this report?

Delta is the clinical assistant for mental health and allied health professionals. During the interview with the parents or with the person, Delta can transcribe what is said. After the assessment, you can also dictate your observations and the results you scored.

From there, Delta drafts the assessment report, adapted to your profession, and updates the patient record. You can find the whole follow-up and how it has changed in one place, for example on the day of the reassessment.

Delta does not administer tests, does not score them and does not calculate any score. It does not make a diagnosis. We recommend reviewing and adjusting the text before sharing it. Data is hosted in France by an HDS-certified host, and the patient's name is pseudonymised before AI processing.

To find out more, read what is Delta.

Sources

• HAS (France), Autism spectrum disorder. Diagnosis and assessment in children and adolescents, second-level summary (in French), February 2018.
• HAS (France), Autism spectrum disorder. Disclosing the diagnosis and informing families, summary (in French), February 2018.
• HAS (France), Autism and other PDDs. Diagnosis and assessment in adults (in French), approved July 2011 (older guideline).
• Anesm and HAS (France), Autism spectrum disorder. Interventions and life pathways for adults (in French), December 2017.