Autism spectrum disorder

In this chapter we set out to answer the teacher's question systematically, returning to Yousef at each stage of the decision pathway (9.5) to show how a passing observation becomes a referral, then an evaluation, and finally a decision.

Chapter objectives

After studying this chapter, the reader should be able to:

1. Match described classroom behaviors to the five criteria for autism spectrum disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), and classify the same case using the approach of the International Classification of Diseases (ICD-11).
2. Write an objective behavioral observation suitable for referral, and identify, in a given description, the red flags that call for evaluation without delay.
3. Sequence the steps of the decision pathway, and explain why hearing and vision testing comes before any diagnostic instrument.
4. Classify autism instruments as screening, rating, or diagnostic tools, and select for a described student the appropriate instrument and its form or module.
5. Interpret instrument results as they appear in a diagnostic report, and evaluate the meaning of published figures on instrument accuracy, prevalence, and the status of Arabic versions.
6. Judge whether the evidence is sufficient to make a diagnosis in a new case, distinguish autism from similar and co-occurring conditions, and justify that judgment.

Introduction

The diagnosis of autism spectrum disorder follows a long path. It usually begins with an observation from a teacher or a family, as in Yousef's kindergarten scene, and ends with a judgment by a trained specialist after evidence has been gathered from multiple sources. Each stop along the way has its own function and its own limits: red flags call for evaluation without delay; screening tools sort but do not diagnose; rating scales convey what is seen by those who know the child; and diagnostic instruments are not sufficient on their own. Precision matters all the more because the disorder may be misdiagnosed when hearing loss or a language disorder is the better explanation, and it may be overlooked when giftedness masks it or when a girl conceals her traits.

We open the chapter by defining the disorder and reading its prevalence figures (Section 9.1), then present the diagnostic criteria in DSM-5-TR (Section 9.2), support levels, specifiers, and the comparison with ICD-11 (Section 9.3), and early red flags and delayed identification in girls (Section 9.4). We then turn to the five-stage decision pathway (Section 9.5), the instrument profiles (Section 9.6), and reading the diagnostic report (Section 9.7), before applying all of this to three cases (Section 9.8). We close with differential diagnosis (Section 9.9), co-occurring conditions and medical evaluation (Section 9.10), and the Saudi and Arab context (Section 9.11).

9.1What is autism spectrum disorder?

Autism spectrum disorder is a neurodevelopmental disorder: it is tied to the way the brain develops and functions, and its first signs appear in the early years of life. It is characterized by two core features: persistent difficulty in social communication and interaction, and restricted, repetitive patterns of behavior and interests (Lord et al., 2020).

The word spectrum signals that the disorder does not take a single form. We may meet a child who never speaks and needs help with most daily tasks, and an adolescent who talks fluently and excels in mathematics yet cannot tell when a classmate is joking and when he is serious. Both are on the same spectrum, but their needs differ greatly. For this reason, a report needs more than the statement “has autism”: it must also describe the level of support the student needs and any other conditions that accompany the autism.

In 2013, the fifth edition of the Diagnostic and Statistical Manual brought together under this single label several diagnoses that had been separate in the fourth edition, among them autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified. Teachers may therefore come across a diagnosis of “Asperger's” in older student files. Today it falls within autism spectrum disorder and is usually described as autism without accompanying intellectual impairment and without accompanying language impairment.

How common is autism, and how should we read prevalence figures?

In the most recent report of the US Autism and Developmental Disabilities Monitoring Network, prevalence among 8-year-olds in 2020 was about 27.6 per 1,000, or roughly one child in 36, and it was about 3.8 times higher in boys (Maenner et al., 2023). In the Arab region, the figures vary widely:

• In a national survey in Qatar of children aged 6 to 11, prevalence was 1.14%, with a confidence interval of 0.89% to 1.46% (Alshaban et al., 2019).
• In Riyadh, the rate was 2.51% (about one child in 40) among 398 children aged 2 to 4 at five hospitals, with three boys for every girl (AlBatti et al., 2022).
• In Makkah and Jeddah, the number of children registered at 37 autism centers came to about 2.81 per 1,000 children (Sabbagh et al., 2021).
• A recent study reports that the official estimate in the Kingdom is about 0.6%, and estimates actual prevalence at between 1.7% and 1.8% (Khamees et al., 2025).

These differences do not mean that autism is ten times more common in one city than in another. Each figure answers a different question. A national survey that actively searches for children differs from a sample of hospital patients, which in turn differs from center registries that count only those who have reached services. Age, the screening instrument, and the case definition also differ. The first question to ask of any prevalence figure, then, is how these children were found. A low registry figure measures not so much prevalence as the gap between those who have the disorder and those who have reached a diagnosis.

9.2Diagnostic criteria in DSM-5-TR

Diagnosis relies on one of two manuals: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association in 2022 (American Psychiatric Association, 2022), and the International Classification of Diseases, Eleventh Revision (ICD-11), published by the World Health Organization (World Health Organization [WHO], 2024), which is used to code diagnoses in health records in most countries. We present the DSM criteria here because they are more detailed and because most assessment instruments and reports are built on them; we then compare them with ICD-11 in 9.3. The manual requires five criteria to be met together. Two describe the symptoms themselves, and three are conditions without which the diagnosis is incomplete. Figure 9.1 summarizes this rule, and we then explain each criterion with examples.

Criterion A: Persistent deficits in social communication and social interaction

This criterion requires all three of the following forms to be present, either currently or in the child's developmental history as the family reports it. The word “persistent” matters: what is meant is a stable pattern that recurs across different situations and on many days.

Form 1: Deficits in social-emotional reciprocity

That is, difficulty with the natural give-and-take between two people. Social interaction resembles a game of catch: one person throws, the other catches and throws back. An autistic child may catch the ball and not return it, or throw it without checking whether the other person is ready. Examples at school include the following:

• The child does not initiate conversation with classmates; when he does, it is usually to ask for something he wants, and rarely to share what interests him.
• He does not share his interest with others: he does not show the teacher his drawing to enjoy her praise, or point to an airplane in the sky to draw the attention of those around him. Specialists call this joint attention (Joint attention).
• In middle school, for example, he talks at length about a favorite topic without noticing that his classmate has lost interest.

Form 2: Deficits in nonverbal communicative behaviors

That is, in the body language we use without words to convey what we mean:

• Unusual eye contact: very little, an uncomfortable stare, or gaze that is not coordinated with speech.
• Limited use of gestures, such as pointing with a finger, nodding to agree, or waving goodbye.
• Facial expressions that do not fit the situation, or difficulty understanding other people's facial expressions and tone of voice.

Form 3: Deficits in developing, maintaining, and understanding relationships

• Difficulty with imaginative play with peers, such as playing “house” or “restaurant.”
• Difficulty adjusting behavior to the situation: behaving in class as on the playground, or addressing the principal as he would a classmate.
• Little interest in peers, or a wish for friendship without knowing how friendships are built and kept.

Criterion B: Restricted, repetitive patterns of behavior, interests, or activities

This criterion requires at least two of the following four forms, currently or in the developmental history:

Back to Yousef in the opening scene: lining up the cars in a straight row falls under the first form, bursting into tears when one is moved falls under the second, and repeating the commercial's line in its original intonation again belongs to the first. In other words, what the teacher saw in a single morning falls under two forms of Criterion B. Yet this alone is not enough: we still need Criterion A in full, along with the three remaining conditions.

Criterion C: Timing

Symptoms must be present in the early developmental period. The manual acknowledges, however, that they may not become fully apparent until social demands exceed the child's capacities. Some children, particularly those with good language and intellectual abilities, do not reveal their difficulties until middle school, when peer relationships grow more complex and their rules less explicit. This is why the specialist always asks the family about the early years, even when the student arrives for evaluation at age 12.

Criterion D: Functional impact

Symptoms must cause clinically significant impairment in social, academic, occupational, or other areas of functioning. Having some traits that do not interfere with the child's life is not enough for a diagnosis. Many people have deep interests or prefer routine and lead successful lives, and this is not considered a disorder.

Criterion E: Exclusion

The symptoms must not be better explained by intellectual disability or global developmental delay. To understand this criterion, remember that in a child with intellectual disability all skills develop slowly, social skills included. If the child's social skills are consistent with his overall level of intellectual development, intellectual disability alone explains them. If, however, his social skills are much weaker than his developmental level would predict, he may have both autism and intellectual disability, and the diagnosis records both.

9.3Support levels, specifiers, and comparison with ICD-11

How much support does the student need?

After diagnosis, the specialist specifies the severity level for each domain separately: social communication, and restricted, repetitive behaviors. The yardstick is how much support the student needs in daily life, regardless of the number of symptoms. The manual calls these “severity levels,” but defines each level by the amount of support required, which is why they are commonly referred to as “support levels.” We use that term in this chapter to distinguish them from the severity levels of intellectual disability, which are determined by adaptive behavior.

A student may be at Level 1 in social communication and at Level 2 in restricted behaviors, so the report states both levels. The level may also change with development and intervention: it describes the current situation and is open to revision.

Accompanying specifiers

The specialist adds to the diagnosis whatever accompanies it, because this changes the student's educational picture considerably. The report states, for example, whether the autism is:

• With or without accompanying intellectual impairment.
• With or without accompanying language impairment.
• Associated with a known medical or genetic condition or environmental factor.
• Associated with another neurodevelopmental, mental, or behavioral disorder, such as attention-deficit/hyperactivity disorder or anxiety.
• With catatonia, meaning motor freezing, holding fixed postures, extreme slowing, or purposeless movements. It is uncommon, but may emerge in adolescence as a sudden decline in movement, speech, and self-care. It calls for urgent medical referral and should not be treated as ordinary “autistic behavior.”

Two students diagnosed with autism, one with accompanying intellectual and language impairment and the other with neither, need entirely different educational plans, even though the name of the diagnosis is the same. Section 9.10 returns to the common co-occurring conditions and how they are assessed.

9.4Early red flags

The earlier autism is identified, the earlier intervention begins and the greater the chances of improvement. Since the late 1990s, medical guidelines have specified signs that, when present, call for evaluation without delay (Filipek et al., 1999), and the current guidelines of the American Academy of Pediatrics have reaffirmed them. These guidelines also recommend screening all children with an autism-specific instrument at the 18- and 24-month visits, without waiting for signs to appear, alongside developmental surveillance at every visit (Hyman et al., 2020). The presence of these signs means that waiting is no longer an appropriate option; the diagnosis itself, however, still depends on a comprehensive evaluation.

Why is autism identified later in girls?

Girls are diagnosed with autism far less often than boys. A large systematic review estimates the true ratio at about three boys to every girl, lower than the ratios found in diagnostic records (Loomes et al., 2017). Researchers believe that part of the gap arises because many girls learn to camouflage their traits (Camouflaging): they watch their female classmates, imitate the way they talk and move, and memorize ready-made phrases for social situations (Hull et al., 2017). Their intense interests may also center on topics that attract little attention, such as animals or novels, and so do not seem “odd” in the way a boy's interest in train timetables might.

As a result, a girl may appear well adjusted at school and then collapse from exhaustion at home. So when a mother says that her daughter “gets very tired after school and needs to be alone for hours,” this is information worth heeding.

9.5The decision pathway: From observation to judgment

The student passes through five stages before a decision is made, and each stage has its own question and its own instruments. The central idea of this pathway is that its stages are completed in order, so that the judgment is made only after each stage has answered its question. Hearing and vision testing comes at the second stage as a prerequisite for any instrument, because any autism measure administered to a child who does not hear well yields a doubtful result, whatever that result may be.

Stage 1: Initial indicators

The story usually begins with an observation from the family or a teacher. Here lies the teacher's most important role, because the teacher sees the student every day among peers, in situations the physician never sees in the clinic. An observation helps the team, however, only if it is documented and objective. Compare these two observations about Yousef:

The first observation is a personal judgment; it even contains a diagnosis, which lies outside the teacher's remit. The second describes a specific behavior, in a specific context, with the number of times it occurred. It also draws attention to something important: Yousef hears the biscuit packet, so his failure to respond to his name is probably not due to hearing loss, although a hearing test remains necessary. A record such as the following helps the teacher document what she sees:

The record captures what came before and after the behavior, because context is part of the evidence.

Stage 2: Hearing and vision testing

Before any autism instrument is used, the question is: Does the child hear and see well? Not turning to his name, delayed speech, and limited interaction in noisy settings can all arise from hearing loss alone. A child who is administered an observation schedule while unable to hear the specialist clearly may appear less interactive than he really is, and the result loses its validity. Passing a newborn hearing screening is not enough, since some types of hearing loss appear later or fluctuate with middle ear infections. The team therefore requests a recent, age-appropriate hearing assessment with tympanometry, together with a vision test.

The kindergarten referred Yousef for a hearing test first. His hearing proved normal in both ears, his tympanometry was normal, and his vision test was clear. Only then did screening become meaningful.

Stage 3: Screening

Screening is a sorting tool; diagnosis is a later stage that requires broader evidence. The function of screening is to determine who needs a more in-depth evaluation, so that not every quiet child is referred and no child who genuinely needs evaluation is overlooked.

The accuracy of a screening tool is measured by two concepts: sensitivity (Sensitivity), the proportion of those who actually have the disorder whom the tool detects, and specificity (Specificity), the proportion of those without the disorder whom the tool correctly rules out. Chapter 2 (Section 2.6, Table 2.5) presented a worked example showing that a tool with 85% sensitivity and 95% specificity, applied to 1,000 children among whom the disorder has a prevalence of 2%, yields positive results of which roughly three quarters are false. The lesson is that the value of a positive result depends as much on the proportion of those screened who have the disorder as on the tool itself.

Real-world data tell the same story. In the validation study of the M-CHAT-R/F, administered to more than 16,000 children at primary care visits, fewer than half of those who still screened positive after the Follow-Up interview were diagnosed with autism. Most of the rest, however, had developmental delays or other concerns warranting intervention, so their results were not “false alarms” in the full sense (Robins et al., 2014):

Yousef is 5 and thus past the age range of the M-CHAT-R/F. His mother therefore completed the Lifetime form of the Social Communication Questionnaire (see its profile in 9.6). He scored 21, above the cut-off score of 15, and was referred to a diagnostic center together with his teacher's record.

Stage 4: Comprehensive evaluation

This stage is carried out by a multidisciplinary team that may include a pediatrician or psychiatrist, a psychologist, a speech-language pathologist, and a special education specialist. The team gathers evidence from three independent sources:

1. Developmental history from the family, through a structured interview such as the Autism Diagnostic Interview–Revised, ADI-R: When did the symptoms begin? What was the child like at age four?
2. Standardized direct observation of the child, using an instrument such as the Autism Diagnostic Observation Schedule, ADOS-2: How does he interact now with an unfamiliar person in situations designed to elicit social behavior?
3. Supplementary assessments that rule out other explanations and reveal co-occurring conditions: an intelligence test to establish intellectual ability, a language assessment, and a medical evaluation that asks about seizures, sleep, feeding, and gastrointestinal problems. The American Academy of Pediatrics recommends offering genetic testing to every child diagnosed with autism, beginning with chromosomal microarray and testing for fragile X syndrome (Hyman et al., 2020).

Information from the school is added to these: the teacher's ratings on the rating scale, her observation records, and samples of the student's work.

In Yousef's case, the specialist interviewed his mother using the diagnostic interview, and his scores exceeded the cut-off scores in all three domains; his mother reported that he had not pointed or waved before the age of two. He was administered Module 1 of the observation schedule, because he does not use spontaneous phrases and most of his speech repeats what he has heard; the classification was “autism.” His nonverbal ability was 88, in the average range.

Stage 5: Matching against the criteria

The team lays out all the evidence and asks about each criterion in turn: Is it met? What is the evidence for it? From which source did that evidence come? If the sources converge on all five criteria being met, the diagnosis is made, with the support level specified. If the sources conflict, or if a better explanation such as hearing loss emerges, the judgment is suspended and that explanation is investigated.

Yousef's evidence converged: the teacher's record, his mother's report, and direct observation. He was diagnosed with autism spectrum disorder without accompanying intellectual impairment, with accompanying language impairment, at support Level 2 in social communication and Level 1 in restricted behaviors, and he was referred for genetic evaluation. In this way the first morning observation, once documented and followed by hearing testing, screening, and evaluation, became a decision grounded in evidence.

9.6Instrument profiles

In this section we present six of the most widely used instruments in the diagnosis and identification of autism. They fall into three families with different functions:

Each instrument has a profile following the book's standard template: its underlying idea, what it actually looks like, and a scene from its administration, followed by an information card with twelve fields (purpose, ages, edition and year, publisher, qualification level, administration time, score types, cut-off scores, reliability, classification accuracy, norming year, and Arabic version), then how its results are interpreted, and finally its limitations. Where we do not know a figure from a source we trust, we say so and refer the reader to the instrument's manual rather than estimating it.

9.7How do you read a diagnostic report?

What usually reaches the teacher is a report several pages long, dense with numbers and terminology. The skill required is knowing where to look and what to extract, more than memorizing cut-off scores. Here is a hypothetical excerpt from Ziyad's report, with annotations showing how to read it:

When you finish reading, ask yourself three questions: What strengths does the report mention that I can build on? What difficulties does it describe that show up in my classroom? And which recommendations can I put into practice tomorrow?

9.8When is the judgment made? Three cases

Having presented the criteria and the instruments, we are left with the hardest question: how does all of this come together in a single decision? In this section we follow three cases from the moment of referral to the decision. In the first, the judgment is reached; in the second, it is not; and in the third, autism nearly escapes notice because the student's giftedness masks it.

All three cases are hypothetical, written for teaching purposes; their figures are illustrative and do not represent real children.

9.9Differential diagnosis

The three cases have taught us that a single symptom can arise from different causes. Not responding to one’s name may stem from autism, from hearing loss, or from deep absorption in a toy. This is why the team always makes sure that the symptoms are not better explained by another condition. The following are the main conditions that can resemble autism:

9.10Co-occurrence and medical evaluation

Differential diagnosis asks: which of the two conditions? Co-occurrence, by contrast, asks: is there another condition alongside autism? In autism, co-occurrence is the rule rather than the exception. In the 2020 U.S. surveillance data, 37.9% of autistic children with available ability data had intellectual disability (Maenner et al., 2023). A meta-analysis of published studies estimated the prevalence of attention-deficit/hyperactivity disorder among autistic people at about 28%, anxiety disorders at about 20%, sleep disorders at about 13%, and depression at about 11%, with wide variation across studies depending on sample and age (Lai et al., 2019). Since its fifth edition, the diagnostic manual no longer prohibits diagnosing autism and ADHD together.

Medical and genetic evaluation is part of the comprehensive assessment, not an appendix to it. Current guidelines recommend offering genetic testing to every child diagnosed with autism, beginning with chromosomal microarray and fragile X testing, and asking about seizures, sleep, feeding and the gastrointestinal system (Hyman et al., 2020). Genetic referral becomes all the more important in communities where consanguineous marriage is common, Saudi society among them; its rate reached 56% in a national sample of mothers (El Mouzan et al., 2008). The working rule is that after every autism diagnosis, the team asks two questions: Is there anything in the file that autism alone does not explain? And has that area been measured with a tool suited to the student’s developmental level?

9.11In the Saudi and Arab context

Conclusion

The argument we have developed in this chapter centers on the idea that a judgment of autism spectrum disorder is reached when evidence from developmental history, direct observation, and information from home and school converges to show that all five criteria are met, which makes it broader than anything a single scale can say. It follows that hearing and vision testing comes before any instrument, that a screening result is treated as an invitation to comprehensive assessment, that disagreement between sources is taken as a signal to look for another explanation, and that medical and genetic evaluation forms part of the comprehensive assessment, because co-occurrence is so common. The teacher plays a pivotal role in all of this: documented, objective observation; honest completion of rating scales; and an informed reading of the diagnostic report.

Questions about the numbers and the instruments nonetheless remain open. Prevalence figures vary with the way children are sought out, so they should not be read without asking how those children were reached, and most screening and diagnostic instruments lack published Arabic norms. Caution remains essential with those who tend to be identified late, such as gifted students and girls who mask their traits: giftedness can conceal autism, and autism does not cancel out giftedness.

9.12Summary, key terms and activities

Chapter summary

Glossary of terms

Joint attention

When a child directs another person’s attention to something, or follows that person’s attention to it, so that the two share an interest in it, as when a child points to an airplane and looks at his mother.

Echolalia

Repeating words or phrases the child has heard from others, either immediately or after a delay, often in the same tone of voice.

Screening

A quick procedure applied to a large group to determine who needs a more in-depth assessment; it does not yield a diagnosis.

Rating scale

An instrument on which someone who knows the child rates the extent to which specific behaviors appear, using a graded scale.

Cut-off score

The score that separates two ranges in interpreting a scale, such as a score of 30 on the Standard Version of the CARS-2.

Scaled score

A standard score with a mean of 10 and a standard deviation of 3, used on subtests to compare a student’s performance with the norming sample.

Sensitivity

The proportion of those who actually have the disorder whom the instrument correctly identifies.

Specificity

The proportion of those who do not have the disorder whom the instrument correctly rules out.

Positive predictive value

The probability that the disorder is actually present in someone with a positive result; it depends on the prevalence of the disorder in the group being tested.

Differential diagnosis

Establishing that the symptoms are not better explained by another condition.

Co-occurrence

The presence of another disorder alongside autism at the same time, such as intellectual disability, ADHD or anxiety; each is diagnosed and planned for.

Functional language

The child’s ability to use language for everyday needs and communication; it is one of the two specifiers for classification in ICD-11.

Catatonia

Freezing in movement, holding fixed postures, extreme slowness, or purposeless movements; it may accompany autism and calls for urgent medical referral.

Camouflaging

A person’s attempt to hide their traits by imitating others and memorizing ready-made phrases for social situations; it is more common among females.

Twice-exceptional

A gifted student who at the same time has a disability or disorder, such as autism or a learning disability.

Review questions

1. Why does the manual require all three forms of Criterion A to be met, while requiring only two of the four forms in Criterion B?
2. A 22-month-old child scored 5 on the M-CHAT-R/F. What is the next step? Can we say that he has autism? Use Figure 9.4 to justify your answer.
3. A fourteen-year-old student speaks fluently and has an IQ of 115. Which version of the CARS-2 should be used with him? Which module of the ADOS-2? Why?
4. The teacher’s rating on the GARS-3 was high and the family’s was low. Give three possible explanations for this disagreement, then explain why the high internal consistency of the Arabic version is not enough to justify a judgment based on the index alone.
5. Returning to Fahd’s case: what evidence could the teacher have observed in class that might have alerted him to possible hearing loss? Why did the team place the hearing test before the observation schedule?
6. In Sara’s case, her CARS-2 score fell in the mild-to-moderate range, and her support level was set at Level 2. Is this a contradiction? Explain.
7. How would you distinguish between a gifted student with deep interests and a twice-exceptional student who is autistic?
8. Classify Sara’s and Layan’s cases using the ICD-11 approach, then explain what the description of support levels in the diagnostic manual adds and what the description of functional language in the international classification adds.
9. Compare the prevalence figures for Riyadh (2.51%) and for Makkah and Jeddah (2.81 per 1,000). Give three methodological reasons for the difference, and explain which figure is better suited to estimating an education district’s need for services, and why.
10. An autistic student’s teacher rated his attention symptoms on a rating scale, and his score came out very high. What would you examine before accepting a co-occurring diagnosis of attention-deficit/hyperactivity disorder?
11. Case for application: Hatoon is fourteen and in the eighth grade (second year of middle school). The student counselor referred her because of repeated absences, isolation at recess, and crying spells before oral presentations. Her achievement is high in science and art. Her hearing and vision were tested last year and found to be normal. Her mother completed the Social Responsiveness Scale, yielding a T-score of 72; her science teacher completed it, yielding 58. Her mother also completed the Lifetime form of the Social Communication Questionnaire, with a score of 13. The mother recalls that as a young child she was “quiet, never asking for anything,” lined up her stickers in a fixed order, became upset when the route to school changed, and has had an intense interest in horses since age six. Module 3 of the observation schedule was administered and yielded a classification of “non-spectrum,” but the specialist noted that many of her responses seemed to be “memorized phrases.” Hatoon says: “I get tired of playing the part of a normal girl all day.” (a) Which criteria in the manual does the evidence support, and from which source? (b) How do you read the observation schedule result and the questionnaire score, given that both fall below the cutoff? (c) What is the strongest alternative explanation, and what evidence would distinguish it from autism? (d) What is your decision now: diagnosis, no diagnosis, or deferring judgment? Justify your decision, and specify what you would need in order to reach it.

Learning activities

Any activity that involves observing a child or using a real student’s data is carried out with the consent of the family and the school administration, without any data that could identify the student, and under the supervision of a qualified specialist; its results are not used in any decision concerning the student and are communicated to the family only through official channels.

1. Structured observation: Observe a child in a natural setting over three sessions and record your observations in a log similar to Table 9.3, then rewrite a nonobjective observation in objective form, as in the first stage of 9.5. Product: a three-session log and a rewritten observation. Time: three 20-minute sessions, plus about an hour for writing.
2. Examining the instrument: Read the scene with Ziyad in the ADOS-2 profile and the description of Module 3, then design a table listing the activities it mentions, the behavior each activity elicits, and the criterion it serves. If you have access to publisher-licensed training materials as part of official training, compare your table with them. Product: a three-column table. Time: about 45 minutes.
3. Conflicting sources (group activity): The group is given conflicting results from the teacher and the family and writes down what additional evidence is needed before any judgment, where it should be gathered, and in what order. Product: an ordered list of evidence with a rationale for the order. Time: about an hour.
4. Reading a report: Analyze the excerpt from Ziyad’s report in Figure 9.12, or a real report with all student-identifying data removed, identify where each criterion was met, and then turn the recommendations into three measurable classroom goals. Product: a criteria table and three goals. Time: about an hour.
5. A local instrument profile: Choose an autism scale used in diagnostic centers in your region whose booklet and manual are available to you, and prepare a profile of it using the standard template in 9.6, with its twelve fields, including a statement of its licensing status and local norms. Product: a completed profile. Time: about two hours.
6. The pathway in your school: Consult the Special Education Organizational Guide and your education directorate’s procedures, map the decision pathway as it actually operates, and then compare it with Figure 9.3: Who refers? When are hearing and vision tested? Who diagnoses? Which tools are approved? How long does it take from referral to decision? Product: a comparison diagram and a critical paragraph. Time: about two hours.

Chapter references

1. Akoury-Dirani, L., & Alameddine, M. (2016). [Arabic edition of the Childhood Autism Rating Scale, Second Edition] [In Arabic]. American University of Beirut Press. https://www.aub.edu.lb/aubpress/pages/cars.aspx
2. Law on the Rights of Persons with Disabilities, Royal Decree No. (M/27) (11/2/1445 AH) [In Arabic]. https://ymplatform.com/sdys/
3. Ministry of Education. (1436 AH). [Special education organizational guide] [In Arabic] (1st ed., academic year 1436–1437 AH). https://moe.gov.sa/en/aboutus/aboutministry/RPRLibrary/الدليل%20التنظيمي%20للتربية%20الخاصة.pdf
4. Ministry of Education [Al-Ma'arif]. (1422 AH). [Regulations for Special Education Institutes and Programs] [In Arabic]. https://moe.gov.sa/en/aboutus/aboutministry/RPRLibrary/القواعد%20التنظيمية%20لمعاهد%20وبرامج%20التربية%20الخاصة%201422%20هـ.pdf
5. Alasmari, M., Alduais, A., Qasem, F., Almaghlouth, S., & AlAmri, L. (2024a). Examining language, speech and behaviour characteristics: A cross-sectional study in Saudi Arabia using the Arabic version of Gilliam Autism Rating Scale–Third Edition. Children, 11(4), Article 472. https://doi.org/10.3390/children11040472
6. Alasmari, M., Alduais, A., Qasem, F., Almaghlouth, S., & AlAmri, L. (2024b). Predicting language, cognition, and social skills in individuals with autism spectrum disorder using the Arabic validation of Gilliam Autism Rating Scale–Third Edition. Applied Neuropsychology: Child. Advance online publication. https://doi.org/10.1080/21622965.2024.2417812
7. AlBatti, T. H., Alsaghan, L. B., Alsharif, M. F., Alharbi, J. S., BinOmair, A. I., Alghurair, H. A., Aleissa, G. A., & Bashiri, F. A. (2022). Prevalence of autism spectrum disorder among Saudi children between 2 and 4 years old in Riyadh. Asian Journal of Psychiatry, 71, Article 103054. https://doi.org/10.1016/j.ajp.2022.103054
8. Alotaibi, B. M., & Alotaibi, A. A. (2021). Exploratory and confirmatory factor analyses of the Arabic version of the Childhood Autism Rating Scale. Research in Autism Spectrum Disorders, 86, Article 101827. https://doi.org/10.1016/j.rasd.2021.101827
9. Alshaban, F., Aldosari, M., Al-Shammari, H., El-Hag, S., Ghazal, I., Tolefat, M., Ali, M., Kamal, M., Abdel Aati, N., Abeidah, M., Saad, A. H., Dekair, L., Al Khasawneh, M., Ramsay, K., & Fombonne, E. (2019). Prevalence and correlates of autism spectrum disorder in Qatar: A national study. Journal of Child Psychology and Psychiatry, 60(12), 1254–1268. https://doi.org/10.1111/jcpp.13066
10. Al-Shibly, M. N. R., AlHusseiny, A. H., Lami, F., Jasim, S. M., Jaber, O. A., Nayeri, N. D., Sabet, M. S., & Al-Gburi, G. (2025). Psychometric properties of an Arabic modified Childhood Autism Rating Scale 2 Standard Form. International Journal of Methods in Psychiatric Research, 34(4), Article e70047. https://doi.org/10.1002/mpr.70047
11. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
12. Assistance to States for the Education of Children With Disabilities, 34 C.F.R. pt. 300 (2006) (§300.8(c)(1), §300.301, §300.304).
13. Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale (2nd ed.). WPS.
14. El Mouzan, M. I., Al Salloum, A. A., Al Herbish, A. S., Qurachi, M. M., & Al Omar, A. A. (2008). Consanguinity and major genetic disorders in Saudi children: A community-based cross-sectional study. Annals of Saudi Medicine, 28(3), 169–173. https://doi.org/10.5144/0256-4947.2008.169
15. Filipek, P. A., Accardo, P. J., Baranek, G. T., Cook, E. H., Jr., Dawson, G., Gordon, B., Gravel, J. S., Johnson, C. P., Kallen, R. J., Levy, S. E., Minshew, N. J., Prizant, B. M., Rapin, I., Rogers, S. J., Stone, W. L., Teplin, S., Tuchman, R. F., & Volkmar, F. R. (1999). The screening and diagnosis of autistic spectrum disorders. Journal of Autism and Developmental Disorders, 29(6), 439–484. https://doi.org/10.1023/A:1021943802493
16. Gilliam, J. E. (2014). Gilliam Autism Rating Scale (3rd ed.). PRO-ED.
17. Hull, L., Petrides, K. V., Allison, C., Smith, P., Baron-Cohen, S., Lai, M.-C., & Mandy, W. (2017). "Putting on my best normal": Social camouflaging in adults with autism spectrum conditions. Journal of Autism and Developmental Disorders, 47(8), 2519–2534. https://doi.org/10.1007/s10803-017-3166-5
18. Hyman, S. L., Levy, S. E., Myers, S. M., & Council on Children with Disabilities, Section on Developmental and Behavioral Pediatrics. (2020). Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics, 145(1), Article e20193447.
19. Khamees, H., Gulati, A., Vatsa, A., Aldosari, M., & Hoque, E. (2025). Estimating autism prevalence among children in the Kingdom of Saudi Arabia: A comprehensive multisource benchmarking approach. Saudi Medical Journal, 46(11), 1276–1279. https://doi.org/10.15537/smj.2025.46.11.20250781
20. Lai, M.-C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet Psychiatry, 6(10), 819–829.
21. Loomes, R., Hull, L., & Mandy, W. P. L. (2017). What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 56(6), 466–474.
22. Lord, C., Brugha, T. S., Charman, T., Cusack, J., Dumas, G., Frazier, T., Jones, E. J. H., Jones, R. M., Pickles, A., State, M. W., Taylor, J. L., & Veenstra-VanderWeele, J. (2020). Autism spectrum disorder. Nature Reviews Disease Primers, 6, Article 5. https://doi.org/10.1038/s41572-019-0138-4
23. Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. L. (2012). Autism Diagnostic Observation Schedule (2nd ed.). WPS.
24. Maenner, M. J., Warren, Z., Williams, A. R., Amoakohene, E., Bakian, A. V., Bilder, D. A., Durkin, M. S., Fitzgerald, R. T., Furnier, S. M., Hughes, M. M., Ladd-Acosta, C. M., McArthur, D., Pas, E. T., Salinas, A., Vehorn, A., Williams, S., Esler, A., Grzybowski, A., Hall-Lande, J., . . . Shaw, K. A. (2023). Prevalence and characteristics of autism spectrum disorder among children aged 8 years — Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. MMWR Surveillance Summaries, 72(2), 1–14. https://doi.org/10.15585/mmwr.ss7202a1
25. Robins, D. L., Casagrande, K., Barton, M., Chen, C. M. A., Dumont-Mathieu, T., & Fein, D. (2014). Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics, 133(1), 37–45. https://doi.org/10.1542/peds.2013-1813
26. Rutter, M., Bailey, A., & Lord, C. (2003). Social Communication Questionnaire. WPS.
27. Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism Diagnostic Interview–Revised. WPS.
28. Sabbagh, H. J., Al-Jabri, B. A., Alsulami, M. A., Hashem, L. A., Aljubour, A. A., & Alamoudi, R. A. (2021). Prevalence and characteristics of autistic children attending autism centres in 2 major cities in Saudi Arabia: A cross-sectional study. Saudi Medical Journal, 42(4), 419–427. https://doi.org/10.15537/smj.2021.42.4.20200630
29. Schopler, E., Van Bourgondien, M. E., Wellman, G. J., & Love, S. R. (2010). Childhood Autism Rating Scale (2nd ed.). WPS.
30. Seif Eldin, A., Habib, D., Noufal, A., Farrag, S., Bazaid, K., Al-Sharbati, M., Badr, H., Moussa, S., Essali, A., & Gaddour, N. (2008). Use of M-CHAT for a multinational screening of young children with autism in the Arab countries. International Review of Psychiatry, 20(3), 281–289. https://doi.org/10.1080/09540260801990324
31. South, M., Williams, B. J., McMahon, W. M., Owley, T., Filipek, P. A., Shernoff, E., Corsello, C., Lainhart, J. E., Landa, R., & Ozonoff, S. (2002). Utility of the Gilliam Autism Rating Scale in research and clinical populations. Journal of Autism and Developmental Disorders, 32(6), 593–599. https://doi.org/10.1023/A:1021211232023
32. Taylor, L. E., Swerdfeger, A. L., & Eslick, G. D. (2014). Vaccines are not associated with autism: An evidence-based meta-analysis of case-control and cohort studies. Vaccine, 32(29), 3623–3629.
33. World Health Organization. (2024). Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural or neurodevelopmental disorders.