When Are We Sure? Predictors of Clinician Certainty in the Diagnosis of Autism Spectrum Disorder

  • Christina G. McDonnellEmail author
  • Catherine C. Bradley
  • Stephen M. Kanne
  • Clara Lajonchere
  • Zachary Warren
  • Laura A. Carpenter
Original Paper


Differential diagnosis of autism spectrum disorder (ASD) is challenging, and uncertainty regarding a child’s diagnosis may result in under-identification or prolonged diagnostic pathways. The current study examined diagnostic certainty, or how sure clinicians were that their diagnosis was accurate, among 478 toddler and preschool-aged children referred for possible ASD to academic medical specialty clinics. Overall, 60 percent of diagnoses were made with complete certainty. Clinicians were more certain when positively identifying ASD than ruling it out. Children presenting with a moderate (vs high or low) level of observable ASD symptoms were less likely to have a certain diagnosis. Further, clinicians rated less diagnostic certainty for older children, those with public insurance, and those with higher IQ and adaptive behavior abilities.


Autism spectrum disorder Diagnostic certainty Differential diagnosis 



This research was supported by a Grant from Cognoa, Inc. The authors would like to thank the project coordinators, research staff, and clinicians at each site for their assistance (i.e., Rebecca Brewster, Connie Brooks, Heather Dyer, Casey Irwin, Kristy Jackson, Melissa Mahurin, Amy Nicholson, Justine Park, Madeline Santulli, Amanda Shocklee, Nicole Takahashi, and Alison Vehorn). We are very grateful to the families and participants who made this study possible.

Author Contributions

CGM conceived and drafted the manuscript and performed statistical analyses. CCB, LAC, SMK, ZW, and CL participated in the design and coordination of the study, and assisted with preparation of the draft. All authors read and approved the final manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed Consent

Informed consent was obtained from all caregivers who participated in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Christina G. McDonnell
    • 1
    Email author
  • Catherine C. Bradley
    • 2
  • Stephen M. Kanne
    • 3
  • Clara Lajonchere
    • 4
  • Zachary Warren
    • 5
  • Laura A. Carpenter
    • 2
  1. 1.University of Western OntarioLondonCanada
  2. 2.Department of PediatricsMedical University of South CarolinaCharlestonUSA
  3. 3.Department of Health Psychology and Thompson Center for Autism and Neurodevelopmental DisordersUniversity of MissouriColumbiaUSA
  4. 4.UCLA Institute for Precision HealthLos AngelesUSA
  5. 5.Department of Pediatrics, Vanderbilt Kennedy CenterVanderbilt University Medical CenterNashvilleUSA

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