*2.2. Specialistic Assessment (SA)*

The specialistic assessment phase requires a four-day commitment from the family.

During the first day,a3h commitment is requested from the parents (preferably in the morning). During this time, the psychologist carries out the anamnesis of the child (1 h) and administers the ADI-R algorithm [31] (1 h) and the Vineland/VABS [32–34] to the parent (1 h).

The Autism Diagnostic Interview—Revised (ADI-R) [31] is an interview aimed at obtaining a complete range of information for assessing autism spectrum disorders.

ADI-R is aimed at parents or educators of subjects from early childhood to adulthood with a mental age above 2 years. It focuses on the systematic and standardized observation of behaviors that are rarely found in non-clinical subjects, and mainly on the three areas of functioning: (1) language and communication, (2) mutual social interaction, and (3) stereotyped behaviors and restricted interests. The ADI-R is divided into an interview protocol and five algorithms, which can be used at various ages for diagnosis or intervention.

The Vineland Adaptive Behavior Scale—II Edition (VABS-II) [32] is a parent interview; it assesses adaptive behavior (AB). Specifically, VABS-II has the aim of measuring the AB in the domains of communication, daily living skills, socialization, and motor skills. The evaluation of AB is necessary for the diagnosis of intellectual disability disorder and, in accordance with the DSM-5, for the evaluation of the severity level of autistic disorder.

After anamnesis, ADI-R, and VABS-II administration, a team meeting (1 h) is scheduled to update everyone on the information received from the psychologist during the online meeting with the parents. After the meeting, the team, separately, watches the five videos prepared by the parents during the PSC phase and they finalize the scoring of the questionnaires that the parents completed in the PSC phase.

All clinicians watch the videos, although the global clinical evaluation of the five videos is performed by an expert clinical practitioner that is ADOS-2 certified, both for clinical and research use [10].

The ADOS-2 is widely considered a gold standard and is one of the most common behavioral instruments used to aid in the diagnosis of ASD [10]. It allows a semi-structured and standardized assessment of communication, social interaction, play, and restricted and repetitive behaviors, through a series of activities that directly elicit behaviors related to a diagnosis of autism spectrum disorder. Through the observation and coding of these behaviors, it is possible to obtain useful information for diagnosis, intervention planning, and insertion in educational contexts. The diagnostic algorithm consists of two domains, social affect and restricted, repetitive behaviors, combined into one score to which thresholds are applied [3,35]. As suggested by Fusaro and colleagues [9], the modules of the ADOS are used for the global clinical scoring of the five videos.

Following Fusaro and colleague's indications, the code is applied if the video resolutely depicts a behavior and/or contains opportunities for the child to show the inquired behavior, otherwise the behavioral item is coded as not applicable (N/A) [9]. We calculate the ADOS-2 algorithm and then the videos are marked ASD when the score is > 7 (for module 1) and > 8 (for module 2). The ADOS modules 3 and 4 are administered in a remote connection with the patient and not in the analysis of asynchronous videos [36].

During the second day we ask to the family about the possibility of carrying out three remote sessions of 25 min each with the three clinicians. In the sessions, the clinicians interact with the child and a parent.

If the child is preschool aged, we ask the parent, in advance, to prepare a setting that is ADOS-BOSCC inspired [28]. If instead the child is older and not autonomous, we ask the parent to interact with him/her in a LEGO therapy-inspired setting [30].

In the three sessions, a psychologist, a speech therapist, and a psychomotor specialist interact, separately, with the parent, requesting him/her to play with the child and suggest some tests to check the child's specific skills and competences. If possible, the clinicians may decide to give comprehension tests to the child. In the event that the child is high-functioning, it is possible to ask the family to leave the child alone to have an individual interview with the clinicians, who are able to perform a clinical interview and/or carry out ad hoc verbal tests (e.g., some items of ADOS module 3). In this case, the three sessions last for 45 min each (with psychologist and speech therapist separately).

During the third day, a 3 h team meeting is scheduled to discuss the functional profile of the child. Part of the stored videos and the output of the questionnaires and checklists are used. A checklist with Diagnostic and Statistical Manual (DSM-5) [37] criteria is used to help diagnose ASD. The family remains available for any questions from the therapists. The DSM-5 checklist includes a symptomatic dyad: (A) persistent deficits in social communication and social interaction across multiple contexts and (B) restricted, repetitive patterns of behavior, interests, or activities, which are made up of specific sub-criteria. Each of these categories includes from three to four sub-criteria. Criterion A is further divided into three sub-criteria: A1 (problems with social initiation and response), A2 (problems with nonverbal communication), and A3 (problems with social awareness and insight, as well as with the broader concept of social relationships). Criterion B is divided into four sub-criteria, including B1 (atypical speech, movements, and play), B2 (rituals and resistance to change), B3 (preoccupations with objects or topics) and B4 (atypical sensory behaviors). The DSM-5 contains specific examples and symptoms for each point [8,37].

The final preliminary diagnosis (ASD or non-ASD) is based on clinical judgement supported by the DSM-5 total checklist score, parent interviews, questionnaires/checklists, and through the analysis of both the five videos recorded by the parents (asynchronous transmission) on which the ADOS module is applied by an experienced psychologist and the direct observation of the child in live video conferencing (synchronous transmission).

During the fourth day, the team leader, together with clinicians, manage a remote meeting with the parents in order to give them clinical feedback about the functional profile and the preliminary diagnosis of their child. During the meeting, individualized psychoeducational advice is provided to parents. Overall, about 13 h are scheduled to complete the SA phase (9 h for evaluations and 4 h for meetings).
