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Table 4 Key diagnostic recommendations

From: Clinical practice guidelines for diagnosis of autism spectrum disorder in adults and children in the UK: a narrative review

CPG Recommended tools MDT recommended MDT membership Assessment targets Key features of assessment
DIAGNOSTIC CRITERIA
ICD-10 (1993) [32] N/S N/S N/S N/S Diagnose on the basis of behavioural features
DSM-5 (2013) [33] No specific tool N/S N/S N/S Careful clinical history & summary of social, psychological & biological factors. Multiple sources of information: • clinician’s observations • caregiver history • self-report (where possible) Clinical judgement
NATIONAL CLINICAL GUIDELINES
NICE CG128 (2011) [39] No specific tool recommended Autism team members should carry out assessment (short version). A diagnosis can be made by a single experienced HCP; profile of strengths & weaknesses is essential, and requires MDT [55] (full version). Autism team made up of Paediatrician &/or Child & Adolescent Psychiatrist, SLT, Clinical &/or Educational Psychologist & access to paediatrician/paediatric neurologist, Child & Adolescent Psychiatrist, Educational Psychologist, Clinical Psychologist, OT, if not in team. Also consider specialist health visitor or nurse, specialist teacher or social worker. Start the autism diagnostic assessment within 3 months of referral. Follow up appointment within 6 weeks of assessment. Seek report from the pre-school or school; gather additional health or social care information. Include in every autism diagnostic assessment: • questions about parent/carer/child’s concerns • details of the child’s experiences of home life, education and social care • developmental history, focusing on developmental and behavioural features • assessment (through interaction with and observation of the child or young person) of social and communication skills and behaviours • medical history, including prenatal, perinatal and family history, and past and current health conditions • physical examination • consideration of the differential diagnosis • systematic assessment for conditions that may coexist with autism • development of a profile of the child’s or young person’s strengths, skills, impairments and needs that can be used to create a needs-based management plan, taking into account family and educational context • communication of assessment findings to the parent/carer/child
RASDN (2011) [44] No specific tool The use of MDT approach is necessary Involving at least two disciplines: paediatrician; child psychiatrist; SLT, OT, clinical psychologist; specialist health visitor; mental health practitioner (CAMHS); social worker; nurse; ed. psych. Teacher; other trained professionals Referral screened within 5 days. Info provided within 4 weeks. 13 weeks to first appointment. Feedback within 4 weeks, report within 6 weeks of formulation. Step one: Initial directed conversation. Step two: Integrated multidisciplinary team assessment (leads to diagnosis/non-diagnosis) includes: • medical history inc: birth history, family history, & general medical concerns • developmental history focusing on developmental & behavioural concerns • observational assessment of the child/young person • further assessment/observations in another setting (school/home) • physical exam in some groups • specific assessments may be required, e.g. SLT assessment • educational assessment Step three: Integrated MDT formulation (leads to wider understanding of difficulties) Step four: family feedback and care planning
NICE CG142 (2012) [9] Identification: Consider AQ-10 (without LD); Brief assessment (with LD). Diagnosis and assessment: AAA including AQ and EQ; ADI-R; ADOS-G; ASDI; RAADS-R (without LD). ADOS-G; ADI-R (with LD); DISCO, ADOS-G, ADI-R Comprehensive assessment should be team based (short version). At a minimum by a qualified clinician usually a clinical psychologist, psychiatrist or neurologist [62] (full version). Specialist autism team made up of: Clinical Psychologists, Nurses, OTs, Psychiatrists, Social Workers, SLTs, Support Staff N/S During a comprehensive assessment, enquire about and assess the following: • core autism signs and symptoms that have been present in childhood and continuing into adulthood • early developmental history, where possible • behavioural problems • functioning at home, in education or in employment • past and current physical and mental disorders • other neurodevelopmental conditions • hyper- and/or hypo-sensory sensitivities and attention to detail. Direct observation of core autism signs and symptoms especially in social situations. Assess for possible differential diagnoses and coexisting disorders Assess risks; Develop care plan, provide health passport, consider 24 h crisis management plan; Assess challenging behaviour Consider further investigations on individual basis
RASDN (2013) [54] Screening: GADS, GARS-2, AASQ, ASAS, NAS, AQ-10 History: ADI-R, DISCO, ASDI, RAADS-R; Direct assessment: ASIT, HSST, SSQ, Observation: ADOS-G Diagnosis must be team based & draw on a range of professionals. At least two of: clinical psychology (core), psychiatry, SLT, LD/MH nursing; OT, other appropriately trained professionals. Final report to be provided within 6 weeks of assessment. As an absolute minimum, elements 2, 3 & 4 must be included in the assessment. 1. Neurodevelopmental history, corroborated via relative/family; 2. Direct autism specific assessment with individual; 3. Observational recording of assessment sessions; 4. Clinical judgement. May also include; standardized measure of adaptive functioning; assessment of language & communication skills; functional assessment of problematic behaviour; full needs assessment
SIGN 145 (2016) [10] Identification: AQ-10 Diagnosis and Assessment: E.g. ADI-R, DISCO, 3di, CARS, CARS-2, ADOS-G. NAPC and RCPsych guides. MDT … should be considered as the optimum approach Experienced professionals N/S • History taking (informant interview): prenatal, perinatal & developmental history; description of the current problems experienced; family history; description of who is in family; coexisting conditions and differential diagnoses • Clinical observation/assessment (individual assessment/interview): directly observe & assess the individual’s social & communication skills and behaviour • Contextual and functional information from a variety of settings and people • Profile of the individual’s strengths and difficulties: communication, cognitive, neuropsychological and adaptive functioning; motor and sensory skills • Biomedical investigations on an individual basis when clinically relevant • Assessment of mental health needs, wellbeing and risk should be considered
GUIDELINES FROM PROFESSIONAL BODIES
RCSLT (2005) [41] N/S Should always be multidisciplinary & multi-agency to achieve optimum benefit. This may include SLT, child psychology, child psychiatry, clinical psychology, paediatrician, EdPsych., OT & teacher N/S During assessment, consideration must be given to the triad of social impairments, as well as theories relating to the triad, for example sensory sensitivity and integration; intersubjectivity; executive functioning deficits; motivation; memory and central coherence. • Joint attention • Readiness & ability to focus & shift attention • Social interaction • Use of communicative strategies • Evaluation of child’s play • Info about learning potential • Impact of individual’s mental health
RCPsych (2014) [11] Identification: AQ, RAADS-R. RPsych Guide. Questionnaires: ASAS, GARS, GARS-2, SCQ, SRS-2, AQ, AQ-10, RAADS-R, SCDS, ABC. Diagnostic interviews: ADI-R, ADOS-2, DISCO, 3Di, AAA, RPsych Guide, PDD-MRS, ASDI, CARS-2, HBS, WADIC Assessment for associated dev disabilities: AQ, EQ, SQ, Faces test, eyes test, Faux Pas Recognition Test, SSQ, Dewey’s Social Stories, Adult/Adolescent sensory profile NICE advocates multidisciplinary exercise, but psychiatrists might be expected to diagnose straightforward cases & be alert to indications for a more specialist assessment. MDT usually includes psychology & nursing as core membership N/S • Speak with informant • Take neurodevelopmental history • Consider obtaining early health records Might include assessment for; cognitive ability, functional ability, coexistent neurodevelopmental disabilities, coexistent psychiatric disorders, mental capacity, risk of harm/offending, medical problems Wherever possible, it is essential that the clinician gets accurate accounts of relationships in different settings (e.g. at work & at home), particularly where they might be more demanding for that individual.
BPS (2016) [40] e.g. ADOS, ADI, DISCO, ADI-R It is recommended that assessment is multidisciplinary. At least one psychologist, in addition to other relevant personnel, such as OTs, mental health workers etc. It is recommended that assessment is timely. The taking of a developmental history with carers as well as observation across different settings. Information from a range of sources. Psychologists contribution to identification and assessment may include: • Assessment of protective factors, strengths and abilities • Assessment of associated mental health issues • Comprehensive developmental and family history • Assessment of learning styles • Assessment of strengths and of barriers to learning • Assessment of environmental conditions for learning • Functional behavioural assessment • Assessment of social communication style • Assessment of the needs of families. • Comprehensive cognitive assessment, which may include psychometrics if deemed necessary
BMJ (2017) [43] Screening: CHAT, M-CHAT Parental questionnaires: SCQ, CAST, CARS; for adults, the SRS, ASQ. Diagnosis and Assessment: eg ADOS-G, ADI-R; 3di; DISCO Diagnosis should be confirmed or made by an appropriately trained professional, ideally working as part of MDT Paediatricians, child psychiatrists, adult psychiatrists or psychologists, & other professionals N/S A combination of: • neurodevelopmental history • standardised interview, & • observational assessment Gather information about functioning in more than one environment; A full neurological examination including measurement of head circumference is routinely performed in all children.
JOURNAL ARTICLES
Blenner et al (2011) [47] Screening: CHAT, PDDST, STAT, CHAT-23, M-CHAT, ITC, SCQ. Diagnosis: ADOS. Paediatric neurologists, developmental & behavioural paediatricians, child psychiatrists or psychologists, or, ideally, MDT. N/S N/S Comprehensive evaluation that includes • lifetime & family history • review of medical & educational records • behavioural observation • physical examination • administration of standardised instruments such as the autism diagnostic observation schedule • cognitive & adaptive assessment • review of established DSM or ICD diagnostic criteria • Assessment of specific domains, such as communication skills, sensory and motor problems, and family stressors and coping abilities • Look for causes & co-occuring conditions (further tests)
Carpenter (2012) [48] Screening: ASDASQ, AQ and EQ, AAA. AQ-10, RAADS-R. RCPsych guide. Observation: PDD-MRS (with ID); ADOS-G. Interview: ADI-R, DISCO, 3Di. AAA to provide structure. Diagnosis can be made by one clinician. Wider assessment requires a team. A variety of professionals can diagnose. N/S Labour intensive - up to 8 h to make & document diagnosis. Three elements (judged against criteria of ICD-10 or DSM-4): • interview with person • observation • interview with an informant Some clinicians bypass the criteria & test, for example, theory of mind, central coherence. Consider possible co-morbidities Holistic assessments needs to be structured around: • Need for social support and for help with employment • Sensory and processing difficulties • Medical issues • Neuro-psychiatric conditions • Practical skills, including motor difficulties • Social interaction skills • Emotional understanding (of self and others) and personal coping strategies • Interests and preoccupations • Sexual interests and future desires • Insight and future desires and motivation • Psychiatric concerns • Other behaviours that may get person into contact with the law • Support for carers
Garland et al. (2013) [49] Screening: AQ-50, AQ-10 Diagnosis: ADI-R, ADOS = G, RCPsych Diagnostic Interview Guide When mental health difficulties also exist, the expertise of the wider MDT is likely to be engaged. Outlines psychiatrist’s role. Enough time should be set aside • History of presenting complaint • Psychiatric history • Family history • Medical history • Developmental history • Personal & social history • Mental state examination • Assess for comorbid disorders inc. neurodevelopment disorders • Physical assessment • Functional level assessment • Assess risk • Assessment of care & support needs • Consideration of need in areas of education & employment
Howlett & Richman (2011) [45] No specific tool If the local autism team does not have the skills to assess these children themselves, they should liaise with professionals who are able to do so Minimum, paediatrician &/or child & adolescent psychiatrist, SLT & clinical &/or Ed.Psych. Other professionals … specialist health visitor, nurse, specialist teacher, social worker Timely & appropriate. Follow up appointment within six weeks of assessment Should provide detailed developmental profile. Based on NICE guidance.
Lai et al....... (2013) [50] Screening: CHAT, ESAT, M-CHAT, ITC, Q-CHAT, STAT (for young children); SCQ, SRS, SRS-2, CAST, ASSQ, AQ (for older children and adolescents); AQ, RAADS-R (FOR ADULTS). Diagnosis and assessment: ADI-R, DISCO, 3Di (for structured interview); ADOS, ADOS-2, CARS, CARS-2 (observational measure). Assessment needs to be multidisciplinary N/S N/S • Interview with the parent or caregiver • Interaction with the individual • Collection of information about behaviour in community settings • Cognitive assessments • Medical examination • Co-occurring conditions
Levy et al (2009) [51] SCREENING: Q-CHAT, M-CHAT, FYI, ECI-4, CSI-4, SCQ, ASDS, KADI, AQ-Child, A (AUTISM) ABC (autism), PDDRS, PDD-MRS, DBC, DBC-ES, PDDBI, ABC (aberrant), CCC, SRS, RBS-R, SCDC. Diagnosis and assessment: PIA-CV, DISCO, ADI-R, 3Di. CHAT, STAT, AOSI, ADOS, CARS These assessments should be multidisciplinary The MDT should include clinicians skilled in speech & language therapy, occupational therapy, education, psychology, & social work.   • Use ICD or DSM criteria • Core and comorbid symptoms, cognition, language, & adaptive, sensory, & motor skills. • Review of caregiver concerns, descriptions of behaviour, medical history, & questionnaires. • Include stage 1 data. • Observations across settings • Cognitive, communication, & ASD-specific assessment • Medical assessment • Differential diagnosis
O’Hare (2009) [53] Screening: M-CHAT, NAPC Checklist Diagnosis: ADOS-G, SRS A multidisciplinary diagnostic approach is recommended Paediatricians are essential members. N/S • Direct clinical structured observations • Critical that information is gathered from different settings, outwith the clinic – there are structured questionnaires for parents/teachers • Physical exam and other specialist tests as required
Pilling et al. (2012) [58] Identification: AQ-10. N/S N/S N/S Inquire about & assess the following: • Core autism signs & symptoms • Early developmental history • Behavioural problems • Functioning at home, education, employment • Past & current physical & mental disorders • Other neurodevelopmental conditions • Neurological disorders (for example, epilepsy) • Communication difficulties • Hypersensory &/or hyposensory sensitivities & attention to detail • Carry out direct observation of core autism signs & symptoms especially in social situations • Functional analysis
Reynolds (2011) [46] No specific tool N/S N/S N/S Observed behaviours with patient presenting symptoms from ‘Triad of Impairments’: social interaction, social communication, social imagination
Wilson et al (2013) [52] Identification: AQ-10 Diagnosis and assessment: ADI-R; ADOS-G. AAA, ADI-R, ADOS-G, ASDI, RAADS-R (without ID). ADI-R and ADOS-G (with ID). DISCO, ADI-R, or ADOS-G. Should be carried out by MDT consisting of professionals who have experience in diagnosing autism (from NICE). N/S N/S A comprehensive assessment of autism should involve an assessment of • core autism signs and symptoms • early developmental history, where possible, and in the absence of an informant written information, such as school reports may be used • behavioural problems • functioning at home, in education, or in employment • past and current physical and mental disorders • other neurodevelopmental conditions • neurological disorders (e.g. epilepsy) • sensory processing and sensory sensitivity issues Assess coexisting mental health disorders. Risk assessment. Functional analysis for challenging behaviour
  1. Key OT Occupational Therapist, SLT Speech and Language Therapist, HCP Healthcare professional, MDT Multidisciplinary team, Ed.Psych Educational Psychologist