How Is Autism Assessed and Diagnosed in Adults, and Why Do Hormones Change Everything?
If you have started to wonder whether you might be autistic, you are in a growing company. Adults of every age and gender are seeking autism assessment in larger numbers than at any point before. For some the prompt is a child's or sibling's diagnosis that suddenly explains their own history. For others it is a life transition, a workplace crisis, the end of a relationship, or simply the accumulated weight of decades of social exhaustion. For women in their forties and fifties the trigger is increasingly perimenopause, when strategies that held together years of work, relationships and parenting stop working as the neurobiology underneath them changes.
This article explains how autism is assessed and diagnosed in adults, what cognitive testing contributes to the process, and why the perimenopausal and menopausal transition deserves specific attention for women seeking assessment in midlife.
How is autism assessed and diagnosed in adults?
There is no single test for autism. Diagnosis rests on clinical formulation, meaning an experienced psychologist draws together evidence from several sources to decide whether a person's developmental history, lived experience and current functioning meet the criteria in the DSM-5-TR (American Psychiatric Association, 2022).
Best practice uses multiple methods and multiple informants. Guidelines from the UK's National Institute for Health and Care Excellence (NICE CG142, 2012/2021) and the Scottish Intercollegiate Guidelines Network (SIGN 145, 2016) recommend a comprehensive approach built from a detailed developmental history, structured or semi-structured clinical interview, behavioural observation, self-report and informant questionnaires, and careful consideration of differential and co-occurring conditions.
The diagnostic interview
The centre of an adult assessment is the diagnostic interview. Two widely used instruments are the ADOS-2 (Autism Diagnostic Observation Schedule, Second Edition; Lord et al., 2012) and the MIGDAS-2 (Monteiro Interview Guidelines for Diagnosing the Autism Spectrum, Second Edition; Monteiro and Stegall, 2018).
ADOS-2. Module 4 of the ADOS-2 has long been described as the gold standard observational tool for verbally fluent adults (Maddox et al., 2017; Caton et al., 2023). It uses structured activities to observe social communication under standardised conditions. It is a valuable source of data. It also has known limitations for women. Autistic females score lower than autistic males on many ADOS-2 items (Rea et al., 2023), and the instrument's sensitivity is reduced for females (Kamp-Becker et al., 2018). For a woman who has spent decades learning to perform socially, the ADOS-2 carries a real risk of a false negative if it is used as the main basis for the decision.
MIGDAS-2. The MIGDAS-2 takes a different route. It is a qualitative, sensory-based narrative interview that builds a behavioural profile across social communication, sensory processing and focused interests (Howe and O'Rourke, 2024). Its conversational format can bring out patterns that structured tasks do not, particularly in people with internalised or high-masking presentations.
Screening and self-report measures. Screening questionnaires help decide whether a full assessment is warranted and add data to the overall picture. For women, the GQ-ASC (Girls Questionnaire for Autism Spectrum Condition, modified for adult women; Brown et al., 2020) has shown good discriminative validity, correctly identifying 80 per cent of autistic women at a cut-off of 57. The CAT-Q (Camouflaging Autistic Traits Questionnaire; Hull et al., 2019) measures the extent and nature of masking, compensation and assimilation. For midlife women who appear socially capable while spending enormous cognitive effort to seem so, the CAT-Q captures what observation misses.
Adaptive functioning. One of the most consistent findings in the literature is that autistic adults without intellectual disability show a pronounced gap between cognitive ability and everyday adaptive functioning (Tillmann et al., 2019; McQuaid et al., 2021). The gap widens with age and is larger in people with higher IQ. For women who have succeeded professionally and appear to be coping, an adaptive functioning assessment with a tool such as the ABAS-3 (Adaptive Behavior Assessment System, Third Edition; Harrison and Oakland, 2015) can reveal the hidden functional cost of autism in a way cognitive testing cannot. The ABAS-3 is a rating scale completed by the individual and an informant, covering communication, social participation, daily living and self-management across home, community and work.
What does cognitive testing contribute?
Cognitive assessment does not diagnose autism. No cognitive test can confirm or rule it out. Within an autism evaluation its job is to describe the person's cognitive profile, support differential diagnosis, and inform recommendations for accommodations and support.
A meta-analysis by Velikonja, Fett and Velthorst (2019), pooling data from more than 1,800 neurodivergent individuals, found a consistent pattern on the Wechsler intelligence scales. Autistic children and adults performed in the typical range on verbal and nonverbal reasoning, with a marked weakness in processing speed (about one standard deviation below the mean) and slightly reduced working memory. The authors were explicit that this pattern is neither sensitive nor specific enough for diagnosis. Its value is in identifying strengths worth building on and difficulties that may warrant workplace or educational accommodations, such as extra time.
Executive function testing can add to the picture. Landry and Al-Taie's 2024 meta-analysis found consistent difficulties with cognitive flexibility in autistic people across the lifespan. The D-KEFS (Delis-Kaplan Executive Function System; Delis, Kaplan and Kramer, 2001) offers standardised measurement of several executive components, including flexibility, inhibition, verbal fluency and planning. Autistic adults commonly find the D-KEFS tasks that require set-shifting and switching relatively hard while performing comparably to controls on the more structured conditions within the same tests. That within-test variability is clinically informative, especially for women whose high verbal ability conceals executive difficulties in daily life.
In Australia, cognitive assessment data is also relevant to NDIS applications and workplace accommodation reports, both of which require quantified evidence of functional impact.
Why perimenopause and menopause change everything
If you are reading this as a woman in your forties or fifties, the timing of your growing awareness may have a cause beyond wider public knowledge of autism in women. The hormonal shifts of perimenopause and menopause interact with autistic neurology in ways that amplify existing difficulties, expose traits that were previously compensated for, and push people toward a crisis that prompts assessment for the first time.
The research. Moseley, Druce and Turner-Cobb (2020) conducted the first study of autism and menopause. In a focus group of seven autistic women aged 49 to 63, participants described sensory sensitivity, emotion regulation and social communication all deteriorating during the transition. For some, masking strategies that had worked for years became unsustainable. Two participants who were undiagnosed at the time linked their discovery of their autism directly to the difficulty of this period.
Brady et al. (2024) extended these findings, describing the autistic experience of menopause in the words of their title as "a perfect storm". Participants reported that late discovery of autism often followed a lifetime of struggle, with identification triggered only when perimenopause brought them to breaking point. Some reported perimenopausal symptoms from as early as 38, and several described clinicians who dismissed those symptoms because they seemed too young.
Groenman et al. (2022) provided the first quantitative evidence that autistic women experience more menopausal symptoms than non-autistic women, with higher psychological and physical symptom scores. Greater symptom severity was associated with higher autistic trait severity, which suggests a two-way relationship between hormonal change and autistic presentation.
A 2025 systematic review by Grant et al. examined all available research and grey literature on autism and menopause. It found consistent evidence of increased symptom severity, effects on work and relationships, and an interrelationship between menopausal symptoms and autistic identity. It also found that no study had yet evaluated an intervention designed for autistic people going through menopause.
What this means for assessment. The practical implications for clinicians are direct. A woman presenting in her forties or fifties with worsening anxiety, cognitive difficulty, sensory overload, social withdrawal and burnout may be experiencing perimenopausal exacerbation of lifelong, previously compensated autism. The risk of diagnostic overshadowing is real. Her symptoms may be attributed to perimenopausal mood disorder, generalised anxiety or depression while the underlying developmental pattern goes unrecognised.
The central question in assessment is whether the presenting difficulties sit on a lifelong developmental trajectory that predates the menopausal transition. Taking a menstrual and hormonal history alongside the developmental history helps establish whether the current picture is a longstanding pattern amplified by hormonal change or something new.
Jenkins et al. (2024) found that autistic people who entered menopause without knowing they were autistic reported greater difficulty overall. Earlier identification may therefore improve outcomes and coping. For women being assessed now, understanding how hormones interact with autistic neurology is part of making sense of what has been happening to them.
What to expect from an assessment
A comprehensive adult autism assessment at Behavioural Edge Psychology usually includes a detailed developmental and life history interview, a structured diagnostic interview (typically the MIGDAS-2), self-report and informant questionnaires covering autism-specific screening, camouflaging and sensory processing, adaptive functioning assessment with the ABAS-3, and cognitive assessment with the WAIS-IV or WAIS-V and D-KEFS where the referral question calls for it or where it will support an NDIS, workplace or medicolegal application. The process is collaborative, trauma-informed and neurodiversity-affirming. We are particularly experienced in assessing adults whose autism has been missed or misdiagnosed, and fees and what to bring are set out on the client information page.
You do not need to have the answers before you seek an assessment. Its purpose is to help you understand your own pattern, not to test whether you are "autistic enough".
Frequently asked questions
How is autism diagnosed in adults?
Through clinical formulation that combines structured diagnostic interview, self-report questionnaires, developmental history and behavioural observation. No single test diagnoses autism. Best practice guidelines recommend a multi-method, multi-informant approach.
Can a cognitive test diagnose autism?
No. The WAIS-IV or WAIS-V and D-KEFS describe intellectual functioning and executive function to support differential diagnosis and provide evidence for accommodations and NDIS applications. Autistic adults often show strong reasoning with reduced processing speed and difficulty with cognitive flexibility, but the pattern is not diagnostic on its own.
Why are so many women being diagnosed in their forties and fifties?
Many were missed in childhood because diagnostic tools and criteria were built largely from male presentations. Perimenopause can intensify autistic traits and wear down masking strategies that once worked, bringing women to a point of crisis that prompts a first assessment.
What is the connection between menopause and autism?
Research shows that the hormonal changes of perimenopause and menopause can worsen sensory sensitivity, emotion regulation, executive functioning and social communication in autistic women. Some discover they are autistic only during this transition, when their compensatory strategies fail.
What tools are used to assess autism in adult women?
The ADOS-2 (observation), the MIGDAS-2 (qualitative narrative interview), the GQ-ASC (a screening tool validated for adult women) and the CAT-Q (camouflaging). Cognitive testing with the WAIS-IV or WAIS-V describes the cognitive profile, the D-KEFS assesses executive function and the ABAS-3 measures adaptive functioning. Together they support diagnosis, NDIS applications and accommodation recommendations.
What is the MIGDAS-2 and why is it used for women?
A sensory-based, qualitative diagnostic interview that builds a behavioural profile through conversation rather than structured tasks. Its narrative format can bring out patterns that observation-based tools miss, particularly in adults with internalised or high-masking presentations.
Can you get an autism assessment in Melbourne?
Yes. Behavioural Edge Psychology in Caulfield South and St Kilda offers comprehensive adult autism assessments, with particular expertise in assessing women in midlife. The process is collaborative, trauma-informed and neurodiversity-affirming.
Is adaptive functioning assessment required for NDIS access with autism?
For Level 1 diagnoses the NDIS requires evidence of reduced functional capacity, and tools such as the ABAS-3 are used to demonstrate functional impact across communication, social participation, daily living and self-management. Level 2 and Level 3 diagnoses have historically met the access criteria without additional functional evidence, but it may still be requested.
About the author
Dr Sarah Fischer is the Principal Psychologist of Behavioural Edge Psychology, with consulting rooms in Caulfield South and St Kilda, Victoria. She holds a PhD and a Master of Psychology (Organisational) and is endorsed by AHPRA in organisational psychology. Her clinical work covers therapy for trauma, workplace psychological injury and neurodivergent assessment, alongside organisational consulting and medicolegal practice.
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR). Washington, DC: APA.
Brady, M. J., et al. (2024). "A perfect storm": Autistic experiences of menopause and midlife. Autism, 28(6), 1405 to 1418.
Brown, C. M., Attwood, T., Garnett, M., and Stokes, M. A. (2020). Am I autistic? Utility of the GQ-ASC as an autism assessment in adult women. Autism in Adulthood, 2(3), 216 to 226.
Caton, L., et al. (2023). Diagnostic assessment of autism in adults. Frontiers in Psychiatry, 14, 1258204.
Delis, D. C., Kaplan, E., and Kramer, J. H. (2001). Delis-Kaplan Executive Function System (D-KEFS). San Antonio, TX: Psychological Corporation.
Grant, A., et al. (2025). Autism and the menopause transition: A mixed-methods systematic review. Autism in Adulthood.
Groenman, A. P., et al. (2022). Menstruation and menopause in autistic adults: Periods of importance? Autism, 26(6), 1563 to 1572.
Harrison, P. L., and Oakland, T. (2015). Adaptive Behavior Assessment System, Third Edition (ABAS-3). Torrance, CA: Western Psychological Services.
Howe, Y. J., and O'Rourke, J. A. (2024). Diagnosing autism in adults: Clinically focused recommendations. Journal of Health Service Psychology, 50(2), 103 to 111.
Hull, L., et al. (2019). Development and validation of the CAT-Q. Journal of Autism and Developmental Disorders, 49(3), 819 to 833.
Jenkins, C. A., et al. (2024). "Struggling for years": An international survey on autistic experiences of menopause. Neurodiversity, 2.
Kamp-Becker, I., et al. (2018). Diagnostic utility of the ADOS in adolescents and adults. Research in Autism Spectrum Disorders, 52, 12 to 23.
Landry, O., and Al-Taie, M. (2024). A meta-analysis of cognitive flexibility in autism spectrum disorder. Neuroscience and Biobehavioral Reviews, 157, 105513.
Lord, C., et al. (2012). Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). Torrance, CA: WPS.
Maddox, B. B., et al. (2017). The accuracy of the ADOS-2 in identifying autism among adults with complex psychiatric conditions. Journal of Autism and Developmental Disorders, 47(9), 2703 to 2709.
McQuaid, G. A., et al. (2021). The gap between IQ and adaptive functioning in autism spectrum disorder. Autism, 25(6), 1565 to 1579.
Monteiro, M. J., and Stegall, S. (2018). MIGDAS-2. Torrance, CA: WPS.
Moseley, R. L., Druce, T., and Turner-Cobb, J. M. (2020). 'When my autism broke': A qualitative study spotlighting autistic voices on menopause. Autism, 24(6), 1423 to 1437.
NICE. (2012/2021). Autism spectrum disorder in adults: Diagnosis and management (CG142). London: NICE.
Rea, H. M., et al. (2023). Sex differences on the ADOS-2. Journal of Autism and Developmental Disorders, 53(7), 2878 to 2890.
Tillmann, J., et al. (2019). Investigating the factors underlying adaptive functioning in autism. Autism Research, 12, 645 to 657.
Velikonja, T., Fett, A.-K., and Velthorst, E. (2019). Cognitive profile in autism and ADHD: A meta-analysis. Archives of Clinical Neuropsychology, 39(4), 498 to 519.
Comments