Autism Evaluations in North Carolina
Who Does Them, What Should They Look Like, and What Could a Diagnosis Do for My Child?
To us, one of the most important things to realize about evaluations with children is that the intent should not be simply to say whether a child does or does not have a condition.
A good evaluation helps us understand how a child sees the world, how they learn, and what strengths and existing skills we can build on as we address areas of need. Our purpose should be to identify what skills the child needs help developing relative to same-age peers, and what supports may help them acquire those skills and live a safe, happy, and increasingly independent life.
Because different systems are looking at different needs, families may see several different types of evaluations as their child grows. The evaluation used for school services may be different from one used for ABA, Medicaid, TRICARE, Social Security, or another support.
Sometimes a group may be able to look at an evaluation a child has already had and say, essentially, “That is a test we recognize, it was completed by someone whose credentials we recognize, so it counts toward part—or, more rarely, all—of what we need.”
Other times, families may hear: “We need a new or different evaluation before we can consider services here.”
1. Early Intervention and Public School Evaluations
Birth to Age 3: Early Intervention
Parents, doctors, or other providers can refer children to North Carolina’s early-intervention system to see whether they qualify for services through the Children’s Developmental Services Agency (CDSA).
Young children may qualify based on Developmental Delay without needing a specific diagnosis. If a child already has an outside Autism diagnosis, families should share it with the CDSA, since Autism is an established condition that can itself support eligibility.
Services may include speech therapy, occupational therapy, physical therapy, early-intervention teaching, and family support, depending on the child’s individual needs. Services are usually provided in the child’s home or daycare setting.
Ages 3 and Up: Public School Services
Public-school evaluations are also used by North Carolina charter schools. Private schools often ask to see evaluations a child has already completed, although those evaluations do not guarantee services in a private school.
Beginning at age 3, parents can contact the Exceptional Children (EC) office in their local public-school district—Lee County, Moore County, Harnett County, Chatham County, etc.—if they believe their child may need special education services, even if the child has not started school yet.
Public-school staff complete the evaluation process. In North Carolina, the school has 90 days from the referral to complete the evaluation process, determine eligibility, and, if the child is eligible, have an IEP in place. An IEP is an Individualized Education Program—the written plan for a child receiving special education services.
For children ages 3 through 7, the school may use the eligibility category Developmental Delay rather than a more specific category such as Autism. If the child still needs special education after age 7, the school team will need to determine another appropriate eligibility category.
ACORN TIP: We recommend families start the public-school/IEP/special-education process an absolute minimum of 90 days BEFORE they plan to enroll their child in school, so that any needed special education services can be in place as soon as their child starts class.
Importantly, a child may still need a school evaluation even if they already have an Autism diagnosis from a non-school provider, although sharing the Autism diagnostic report can help with the process.
We assist our families with this process, and because our staff includes professionals with active North Carolina Special Education and School Psychology licenses, we have a real understanding of how the process works.
2. Medical, Psychological, and Other Diagnostic Evaluations
Here, the practical question for families is:
Who can make an Autism diagnosis that will be accepted for the service or benefit my child needs?
BCBAs cannot diagnose Autism. SLPs cannot diagnose Autism in North Carolina.
LCSWs (Licensed Clinical Social Workers) and LCMHCs (Licensed Clinical Mental Health Counselors) may diagnose Autism within their own professional practice when they have the appropriate training and experience, but those diagnoses may not qualify a child for other services, such as ABA.
An ADOS-2 Is Not an Autism Diagnosis
Sometimes we see individuals or groups claiming they are doing Autism Evaluations because they are in possession of a test that a licensed psychologist may use as part of an Autism evaluation, such as the ADOS-2.
The hope in some of these situations is that another professional—often the child’s pediatrician—will then “sign off” on the test and make the Autism diagnosis.
That is not good diagnostic practice.
The ADOS-2 is one assessment tool, not an Autism diagnosis. An appropriately licensed professional would not use one test as the sole determinant of a diagnosis, and a pediatrician or other professional is putting their own license behind any diagnosis they make.
Most professionals are understandably not going to simply “sign off” on testing completed by someone else for a child they have not adequately evaluated themselves.
In North Carolina, the Psychology Board has also specifically addressed the ADOS-2 as a psychological assessment that cannot simply be administered by a non-psychologist and then signed off on by a psychologist.
The professional making the diagnosis should be meaningfully involved in the evaluation and independently reach that conclusion—not simply add their signature to one test someone else administered.
Who Usually Completes a Medical Autism Evaluation?
Most often, Autism diagnoses used to access medical services are made by licensed psychologists with training in Autism or medical doctors such as developmental pediatricians and child psychiatrists.
However, these providers are not simply able to say, as may have happened more often many years ago:
“I’m a doctor and I say John Doe has Autism.”
They need to complete an appropriate assessment using tools they select based on the child in front of them.
We feel this is a very fair process and have heard ethical providers say things like:
“Why would you ever NOT do an appropriate assessment?!”
There are challenges, though. Medical providers such as pediatricians may not have the assessment tools, may not have specific training in how to administer them, or may not feel they have the time to complete a full Autism evaluation within their practices.
This is one reason medical providers so often refer children to psychologists for Autism evaluations.
Autism Evaluations by Psychologists
A referral to a licensed psychologist can add a surprising challenge.
Given how difficult it is to become a licensed psychologist, and how few licensed psychologists there are in many areas, psychology boards and insurance companies often give psychologists considerable flexibility in how they practice.
Exactly how that flexibility works differs by state. It may include whether the psychologist needs to meet the child in person and which parts of an evaluation may be completed by someone other than the psychologist.
And this is part of where things can become even more skewed.
North Carolina is part of PSYPACT, an agreement among more than 40 states that allows appropriately credentialed psychologists to practice across participating state lines, usually through telehealth.
There are very good reasons for this. In a disaster, for example, psychologists from other states can become available much more quickly to help a community.
But one seemingly unintended effect has been what this can mean for Autism evaluations.
Large ABA providers may now conduct almost nationwide searches to hire a psychologist who then has a job completing high volumes of Autism evaluations remotely, in states they may never have even visited, for children they have never met in person, to fill caseloads for literally hundreds—or even more than a thousand—BCBAs and many thousands of RBTs and BTs.
At Acorn, our psychologists complete the full Autism evaluation themselves, in person.
3. How We Do Autism Evaluations at Acorn
Acorn Autism is not, and never will be, a high-volume provider. We are a high-quality provider.
We have licensed psychologists on staff who complete in-person Autism evaluations, using assessments they personally administer as appropriate to the child.
Given that we are a small local provider, we do not need to do this to fill our own clinic. In fact, we could fill our own schedule even if we never completed a single Autism evaluation.
So why do we do Autism evaluations?
Because Time Is VERY Precious
Anyone who has worked in the field for long has met older individuals who are in crisis with their families, but have far fewer services available given their age.
The question that is always asked is:
“What happened when they were younger?”
We cannot stand by and have the answer be:
“They were on a wait list for an evaluation.”
Because Better Evaluation Can Mean Better Treatment
Doing our own evaluations enables us to TEACH and provide therapy at a much higher level.
Because our psychologists have completed literally thousands of Autism evaluations, including evaluations in major Autism specialty settings, it becomes easier to move beyond the question:
“Does this child have Autism?”
and instead answer what we believe should be the true question of any high-quality evaluation:
“How do we help and teach this individual so that they can lead their best life?”
When we are able to provide the Autism evaluation for a child who later receives ABA with us, we have substantially more time to get to know that child and their family before we need to submit an ABA treatment plan to insurance.
That means the treatment plan can be of much higher quality and, most importantly, of much better help to the child.
4. SSI and Medicaid Evaluations
In North Carolina, families may be eligible for Medicaid if they meet income requirements. Families may also be eligible for Supplemental Security Income (SSI) when they meet the financial requirements and have a child with a disability that meets Social Security’s disability criteria.
Simply having an Autism diagnosis does not automatically qualify a child. The severity of the child’s disability and how significantly it affects functioning matter.
As part of this process, records may be reviewed from the child’s doctor, preschool or school, therapists, and other providers, along with any Autism evaluation the child has already completed.
Sometimes those records are enough to determine disability eligibility, and sometimes they are not.
When more information is needed, an examination may be scheduled with a contracted provider. Depending on what needs to be evaluated, that provider may be a psychologist, pediatrician, speech-language pathologist, or another appropriate professional.
Children in North Carolina who qualify for SSI may also qualify for Medicaid, which can be especially helpful even when the family already has other insurance.
At Acorn, we are familiar with and have worked within this process, including with psychologists who complete disability evaluations, so we can help families understand where to start.
5. Other Evaluations: BCBAs, SLPs, and OTs
BCBAs complete evaluations too, when a child is looking to start ABA services and then, most often, every six months or at another interval required by the payer while the child continues to need ABA services.
When Autism is the diagnosis being used to qualify a child for ABA services, the BCBA assessment occurs after the child already has an Autism diagnosis.
The BCBA assessment has two main purposes:
· To make a clinical recommendation about how much, if any, ABA the child needs
· To determine specifically what ABA will work on during that time
These treatment plans are then submitted to insurance, Medicaid, or TRICARE. The payer can authorize the plan as requested, deny it, approve a different number of hours, or decide that it will not cover all of the goals or services the BCBA has proposed.
Similarly, SLPs and OTs complete their own evaluations to determine treatment needs, goals, and frequency of services, and those plans are also submitted to insurance for authorization.
6. Coordination of Care
When working with a child, all professionals should be participating in coordination of care when appropriate.
To us, this has always made sense.
If a child is receiving different services, those services should be working together and supporting one another for the benefit of the child—making sure we are not unnecessarily duplicating goals, teaching conflicting approaches, or giving families recommendations that work against one another.
This is also an area where Acorn brings a broader perspective than ABA alone.
Our team brings credentials and experience that include behavior analysis, psychology, school psychology, special education, and traumatic brain injury services.
Our staff hold credentials including:
· BCBA / LBA
· LPA / HSP-PA
· Licensed School Psychologist
· Licensed Special Education Teacher
· NCDPI-approved TBI Provider
Just as important, our experience has not been limited to ABA clinics.
We have provided services in schools, homes, group homes, clinics, psychological and medical settings, and community programs. That breadth of experience helps us understand how different systems approach a child’s needs—and why those systems need to communicate rather than work in isolation.
With parent permission, the professionals working with a child should understand what the other providers are working on when that information is relevant.
The goal is not for every discipline to do the same thing.
It is for each discipline to bring its own expertise while making sure everyone is working toward the same larger goal: Helping the child.
A good evaluation should leave us knowing more than whether a child meets criteria for a diagnosis.
It should help us understand how that child sees the world, how they learn, what they already do well, where they need help, and what we can do to help them live a safe, happy, independent, and fulfilled life.