ADI-R Informed ASD Assessment

Adult ASD Diagnostic Interview – ADI-R + CAT-Q Integrated Script --- 1. Administrative & Consent [Patient’s stated reasons for seeking an autism assessment at this point in adulthood] Ms. Eleanor Vance, aged 32, is seeking an assessment due to increasing difficulties in managing social interactions at her new job and a growing feeling of 'not fitting in', despite trying hard. She recently read an article about autism in adults that resonated strongly with her experiences. [Referral source and patient’s expectations or goals for the assessment] Self-referred after online research. Hopes to understand herself better, gain clarity on lifelong struggles, and explore potential strategies for managing social and sensory challenges, particularly in the workplace. [Reports of observations or feedback from family members, partners, or others] Her partner has often commented on her 'literal interpretation' of conversations and her tendency to withdraw after social gatherings. Her mother mentioned that as a child, she preferred playing alone and was particular about routines. [Availability of informants to provide collateral developmental or behavioural history] Her partner is willing to contribute information via a separate interview. Her mother lives overseas but could potentially provide written information. [Details of any prior assessments, diagnoses, or evaluations] Diagnosed with Generalised Anxiety Disorder (GAD) at age 25. Attended cognitive behavioural therapy (CBT) for GAD, which provided some coping mechanisms but didn't fully address her underlying social difficulties. No prior neurodevelopmental assessments. --- 2. Developmental / Personal History [Patient’s account of early developmental history including pregnancy, birth, and infancy] Ms. Vance reports a full-term pregnancy and uneventful birth. Her mother told her she was a 'quiet baby' who didn't cry much but was easily startled by loud noises. [Reported developmental delays or complications in early childhood] She walked at 14 months and spoke her first words around 18 months, which was considered within the typical range. However, toilet training was delayed until age 4, and she struggled with understanding social cues related to using the toilet in public. [History of any developmental regression or loss of previously acquired skills] Denies any loss of skills. She consistently progressed through developmental milestones, albeit with some social difficulties. [Descriptions of early temperament and behavioural style] Described by her mother as a 'serious' child, preferring solitary play, and becoming distressed by unexpected changes to her schedule. She was considered 'shy' by teachers. [Early feeding, sleep, or regulation difficulties] As a baby, she was a fussy eater, disliking certain textures, particularly lumpy foods. Sleep was generally okay, but she would often lie awake replaying the day's events. She had difficulty settling down if overstimulated. [Continuity or change of early traits into adolescence and adulthood] Many early traits have continued. She still dislikes specific food textures, struggles with social spontaneity, and finds routine comforting. Her 'shyness' has evolved into a conscious effort to appear sociable, which she finds exhausting. [Patient’s comparison of current personality and behaviour with earlier life stages] Feels she has become more adept at 'performing' social interactions but reports increased internal anxiety and fatigue. She feels she is still the 'serious' person she was as a child, but now with added pressure to conform. [Relevant medical history including hospitalisations or sensory and motor coordination concerns] History of eczema as a child. No significant hospitalisations. Reports being 'clumsy' and having poor handwriting. Experiences sensitivity to certain textures in clothing and finds fluorescent lighting very irritating. --- 3. Family Background [Family structure and description of early home environment] Raised by both parents, Eleanor is an only child. Described her home environment as stable and quiet, but with limited emotional expression or overt displays of affection. Her parents were highly academic. [Emotional relationships with parents or primary carers] Felt understood by her father, who shared her logical approach to problems. Found her mother's emotional expressions somewhat confusing and overwhelming at times. [Sibling relationships and patterns of interaction] No siblings. Preferred the company of her pet cat over other children. [Family history of neurodevelopmental or mental health conditions] Paternal uncle diagnosed with ADHD. Her father exhibits some traits consistent with autism (e.g., strong routines, specific interests, preference for solitude) but has not been formally assessed. Mother has a history of mild depression. [Current family relationships and level of contact or support] Maintains regular but somewhat formal contact with parents. They are supportive in practical ways but less so emotionally. She feels understood by her partner, who has helped her explore her potential autistic traits. --- 4. Social Communication (DSM-5 A1–A3 / ICD-11 Core) [Childhood communication style and initiation of interaction] As a child, she communicated her needs directly and factually. She rarely initiated conversations, preferring to be spoken to. [Patterns of conversational initiation versus responding in childhood] Primarily responded in conversations, often providing very detailed answers to direct questions but struggling with open-ended social chit-chat. [Differences in speech prosody or feedback from others about speech] Was told she had a 'monotone' voice in her teenage years. Sometimes struggles to modulate her tone appropriately, leading to misunderstandings, especially when stressed. [Current experience of eye contact and interpreting facial expressions] Finds sustained eye contact uncomfortable and distracting; often looks at people's mouths or foreheads. Reports difficulty interpreting subtle facial expressions, particularly when tired. [Degree of effort required to maintain conversational flow] Finds conversations require significant mental effort. She often plans what to say and mentally reviews social rules. She struggles with spontaneous back-and-forth. [Feedback from others regarding conversational style or verbosity] Her partner has gently told her she sometimes 'over-explains' things or goes into too much detail about her special interests. Colleagues have noted she can be 'blunt'. [Understanding of non-literal language and implied meaning] Struggles with sarcasm and relies on context to infer humour. Indirect hints are often missed, leading her to feel confused or that she has offended someone unintentionally. [Unintentional mirroring or imitation of others’ speech or behaviour] Has noticed herself unintentionally adopting other people's mannerisms or speech patterns, particularly when she is trying hard to fit in or understand them. [Use of mental rehearsal or scripting prior to interactions] Frequently mentally rehearses conversations, especially for important meetings or new social situations. Has specific 'scripts' for common interactions, like ordering coffee. CAT-Q Integration – Compensation [Conscious observation and copying of social behaviours] Consciously observes others' social behaviours, body language, and conversational patterns in order to mimic them and appear 'normal'. This is a deliberate and effortful process. [Advance planning of speech to manage social situations] Routinely plans out what she will say in social situations to avoid awkward silences or saying something 'wrong'. This helps reduce anxiety but doesn't eliminate it. [Learned compensatory social strategies] Has learned to smile and nod even when she doesn't fully understand, to ask generic questions about others to appear interested, and to maintain a polite, neutral expression. [Reported cognitive or emotional cost of compensation] This takes immense mental effort. After social events or work meetings, she feels completely drained, often experiencing severe 'hangxiety' and needing several hours of solitary recovery time. [Discrepancy between outward social behaviour and internal experience] Often feels like she is playing a role, with her outward social behaviour not matching her internal experience of confusion, anxiety, or detachment. --- 5. Social Interaction & Imagination [Childhood play preferences and patterns] Preferred solitary play, often lining up toys or engaging in highly structured, repetitive games. Disliked unstructured group play. [Use of imagination or pretend play in childhood] Created elaborate imaginary worlds in her head but rarely externalised them through play with others. Her pretend play was often re-enactments of scenes from books or films, rather than spontaneous. [Early ability to recognise and interpret others’ emotions or intentions] Found it very difficult to understand why other children reacted in certain ways, often misinterpreting teasing or playful banter as genuine hostility. [Current understanding of others’ emotional states] Has learned to cognitively recognise some basic emotions based on verbal cues and context, but still struggles with nuanced or ambiguous expressions. Finds it hard to understand motivations behind actions if they don't seem logical. [Experience of expressing empathy or emotional responses] Finds expressing empathy effortful. She understands it intellectually but struggles to spontaneously convey it. Often feels she gives the 'wrong' response when someone is upset. [Need for recovery time following social interaction] Absolutely. Needs significant time alone to decompress after any social interaction, even with close friends. Describes it as needing to 'recharge her social battery'. [Current patterns of forming and maintaining relationships] Has a small, close circle of friends with whom she shares specific interests. Finds it difficult to initiate new friendships and often struggles to maintain casual acquaintanceships due to the effort involved. [Factors contributing to relational difficulty or fatigue] Finds small talk exhausting, struggles with unspoken social rules, and often feels misunderstood. The constant pressure to 'perform' in social settings is a major source of fatigue. CAT-Q Integration – Masking [Masking of traits or suppression of natural behaviours] Frequently hides her stims (e.g., finger tapping, foot jiggling) and suppresses her tendency to launch into detailed explanations of her interests, fearing it will make her seem 'weird'. [Feigning confidence or ease in social situations] Often pretends to be more confident and at ease in social situations than she feels. She maintains a calm outward demeanour even when internally overwhelmed. [Deliberate modification of non-verbal communication] Deliberately focuses on keeping her facial expressions neutral and making appropriate eye contact (though it feels unnatural) to avoid standing out. [Emotional and energetic impact of masking] masking leads to significant emotional exhaustion, increased anxiety, and often results in periods of irritability and withdrawal afterwards. She feels inauthentic. [Situations or relationships associated with increased masking] Masks most strongly at work, in large social gatherings, and when meeting new people. Feels she can unmask somewhat with her partner and one or two very close friends. --- 6. Restricted, Repetitive & Stereotyped Behaviours (DSM-5 B1–B4) [Childhood repetitive movements or motor behaviours] As a child, she would rock back and forth when stressed or excited and had a habit of twirling her hair. [Current repetitive movements or behaviours] Still engages in discreet finger tapping under the table during meetings and picks at the skin around her nails when anxious. Occasionally paces when deep in thought. [Rigidity, routines, and emotional response to disruption] Has highly specific daily routines (e.g., morning ritual, precise order for tasks at work). Becomes very distressed and anxious if these routines are disrupted, finding it hard to adapt. [Response to change and flexibility] Finds unexpected changes incredibly challenging. Needs advanced warning and clear explanations for any changes to her plans or environment to manage her anxiety. [Restricted or intense interests] Has an intense and lifelong interest in historical linguistics, particularly ancient Egyptian hieroglyphs. Also deeply interested in specific documentary series on complex systems. [Time investment and intensity of interests] Spends several hours daily researching and engaging with her interests, often neglecting other tasks. Can lose track of time when immersed in these activities. [Sensory sensitivities or seeking behaviours] Highly sensitive to loud or sudden noises, strong smells (e.g., perfumes, cleaning products), and certain fabric textures. Actively seeks out quiet, dimly lit environments. [Sensory-driven avoidance or preference of environments] Avoids crowded places, noisy restaurants, and environments with strong artificial scents. Prefers quiet parks, her own home, and libraries. --- 7. Education & Employment [Academic performance and social experience at school] Academically, she excelled in subjects she was interested in (history, languages) but struggled with group projects and presentations. Socially, she was often isolated and experienced bullying for being 'different'. [Labels or descriptions applied by teachers or others] Was often described as 'a gifted student but quiet', 'a bit of a loner', and sometimes 'disruptive' if her routines were interrupted or she felt overwhelmed. [Difficulties with transitions or unstructured activities] Found school transitions (e.g., moving between classes, break times) very disorienting and stressful. Unstructured playtime was a source of anxiety as she didn't know 'the rules'. [Teacher responses or accommodations] Teachers generally focused on her academic strengths but didn't address her social difficulties. No formal accommodations were made. [Preferred subjects or occupational settings] Prefers roles that allow for independent, focused work with clear instructions and minimal unexpected social interaction. Enjoys research-based tasks. Her current job in data analysis suits her well. [Workplace adjustments or accommodations] Currently has a noise-cancelling headset and a desk in a quieter part of the office. Has requested flexible working hours to avoid peak public transport times. [Executive functioning skills in daily life] Struggles with task initiation and time management for non-preferred tasks. Highly organised for tasks related to her interests but can be disorganised in other areas of life. [Triggers for stress or overload in educational or occupational contexts] Open-plan offices, unexpected meetings, sudden changes in project scope, team-building exercises, and abstract or ambiguous instructions. CAT-Q Integration – Assimilation [Efforts to assimilate socially] Actively tries to blend in by observing and mimicking colleagues, participating in brief, superficial conversations, and following social norms even when they don't make sense to her. [Concealment of difficulties or traits] Has hidden her sensory sensitivities and struggles with social cues from most colleagues. She avoids mentioning her deep, specific interests unless prompted by a trusted few. [Fear of judgement or rejection] Has a significant fear of being judged as 'odd' or 'incompetent' if her difficulties were fully visible. This fear fuels her assimilation efforts. [Social conformity to avoid attention] Agrees with popular opinions or copies others' views in team discussions to avoid standing out or being seen as contrarian, even if she internally disagrees. [Emotional impact of failed assimilation] When she feels she hasn't successfully assimilated, she experiences intense shame, self-criticism, and a desire to isolate herself. It reinforces her belief that she is fundamentally different. [Patient’s reflections on reduced masking or assimilation] States that if she didn't have to mask, she would feel more authentic and less exhausted. She imagines she would be able to openly discuss her interests, stim freely, and engage in social interactions on her own terms, which she believes would lead to greater well-being. --- 8. Health, Sleep, Appetite & Medication [Current sleep patterns and difficulties] Generally sleeps 6-7 hours. Struggles to fall asleep if she has been overstimulated during the day, often replaying social interactions. Wakes feeling unrefreshed despite adequate hours. [Childhood sleep difficulties] As a child, she often resisted bedtime, preferring to stay up reading or engaging in her special interests. Had frequent nightmares. [Appetite patterns and relationship with food] Has a restricted diet due to strong texture and taste aversions. Eats the same few meals regularly. Finds eating out stressful due to unpredictable food options. [Food-related sensory sensitivities] Cannot tolerate slimy, mushy, or stringy textures. Dislikes strong spices and certain smells associated with cooking. Prefers bland, predictable foods. [Chronic physical health conditions] Diagnosed with Irritable Bowel Syndrome (IBS), which she attributes partly to stress and her restricted diet. [Medications and supplements and their effects] Takes escitalopram 10mg daily for GAD, which helps to manage her baseline anxiety but does not alleviate her social or sensory distress. Also takes a daily multivitamin. [Substance use patterns] Drinks alcohol occasionally (1-2 units per week) socially, but finds it increases her anxiety the next day. Drinks one cup of coffee in the morning. --- 9. Mental Health & Emotional Regulation [Mental health diagnoses as stated explicitly] Generalised Anxiety Disorder (GAD). [Coping strategies for stress and emotional regulation] Manages stress by withdrawing to a quiet space, listening to specific calming music, or engaging in her special interests. Uses deep breathing exercises. [Experiences of emotional overload or shutdown] Reports frequent shutdowns where she becomes non-verbal, withdraws completely, and feels an intense inability to process any further information. Has experienced a few meltdowns in childhood, characterised by intense crying and frustration, usually triggered by unexpected changes or sensory overload. [Early warning signs of overload] Recognises increased irritability, heightened sensory sensitivities, difficulty concentrating, and a feeling of 'static' in her head as early signs of overload. [Recovery strategies and supports] Needs complete solitude, darkness, and quiet to recover. Engaging in a preferred interest (e.g., studying hieroglyphs) helps to regulate her. Her partner understands her need for space. [History of trauma or social adversity] Experienced significant social bullying throughout primary and secondary school due to her differences, which has contributed to her fear of judgment and social anxiety. [Association between masking and emotional consequences] Strongly associates masking with subsequent exhaustion, increased anxiety, and low mood. She feels that the effort of masking is a direct cause of her mental health struggles. --- 10. Risk & Safeguarding [History of self-harm or suicidal ideation] Reports periods of passive suicidal ideation during intense periods of burnout and overwhelm, particularly during her adolescence when she was bullied. Denies intent or plans. [Help-seeking or actions related to risk] Discussed these thoughts with her previous therapist for GAD, who provided coping strategies. Has a safety plan in place if these thoughts resurface, which involves contacting her partner and accessing her therapist. [Legal or behavioural risk history] No history of legal issues or physical altercations. [Experiences of vulnerability or exploitation] Reports feeling taken advantage of in group work situations in the past, where she ended up doing the majority of the work due to her discomfort with confrontation. [Current safety concerns] Currently feels safe but acknowledges her vulnerability to burnout if she continues to mask heavily in her new role. [Protective factors and supports] Her supportive partner, her understanding of her own needs, her deep interests, and her access to a quiet home environment are key protective factors. --- 11. Strengths, Interests, Values & Goals [Personal strengths and abilities] Strong analytical skills, attention to detail, logical thinking, reliability, deep capacity for focus on preferred tasks, and a strong sense of integrity. [Hobbies and interests] Historical linguistics, learning ancient languages, specific documentary series on complex historical or scientific topics, reading, and solitary nature walks. [Core values] Values authenticity, logic, fairness, knowledge, and quiet contemplation. [Short- and long-term goals] Short-term: Gain a clearer understanding of herself through this assessment and implement strategies to manage social fatigue at work. Long-term: Pursue a postgraduate degree in historical linguistics, find a job that fully accommodates her needs, and cultivate a life that prioritises her well-being over social conformity. [Patient’s definition of fulfilment or success] Defines fulfilment as living a life true to herself, engaged in her passions, with minimal social pressure and enough quiet time to recharge. Success is measured by internal peace rather than external validation. [Additional information the patient considers important] Ms. Vance emphasised that she is not seeking a 'cure' but rather understanding and validation of her experiences, along with practical strategies for a more sustainable life. --- 12. Clinician Observation & Notes (To be completed post-session) Date: 1 November 2024 Observe social reciprocity, eye contact, affect, tone, body language, and sensory behaviours. Ms. Vance maintained intermittent eye contact, often looking slightly to the side or at the clinician's mouth. Her affect was generally flat, with limited range of facial expressions, though she smiled briefly when discussing her special interests. Her tone of voice was mostly monotonic, becoming slightly more animated when describing her passions. Body language was somewhat rigid, with minimal spontaneous gestures. She subtly tapped her fingers against her leg throughout the interview and adjusted her glasses frequently. She winced at the sound of a distant ambulance siren. Note masking indicators: social rehearsing, imitation, delayed fatigue, self-conscious adjustments. Demonstrated clear evidence of social rehearsing through her well-structured and detailed answers, sometimes sounding like prepared scripts. Her responses to open-ended social questions felt somewhat imitative of typical social interactions. She appeared increasingly fatigued towards the end of the session, her responses becoming shorter and her non-verbal cues (e.g., slumped posture) indicating effort. Self-conscious adjustments were noted in her deliberate attempts at eye contact and conscious efforts to appear engaged. Rate domains (0 = Typical, 1 = Mild, 2 = Clear, 3 = Marked/Impairing). Social Communication: 3 (Marked/Impairing) Social Interaction: 3 (Marked/Impairing) Repetitive Behaviours/Restricted Interests: 2 (Clear) Sensory Sensitivities: 2 (Clear) Rigidity/Routines: 2 (Clear) Record any evidence of compensatory or camouflaging behaviour during session. Clear evidence of compensatory strategies, including careful verbal planning, conscious efforts at eye contact, and suppression of visible stims. Patient explicitly described her extensive masking efforts and their draining impact during the CAT-Q integration sections.