Dr Rosie Richardson Plymouth Hospitals NHS Trust May November 2013 Paediatric Clinical Assessment for a possible Autism Spectrum Disorder Clearly there is a lot of variation in how we approach diagnosis and follow up for children and young people with suspected ASD. There are a number of departments who in trying to balance the desire for a good quality service with the high numbers of referrals have developed their own approach. I am grateful to Dr Rosie Richardson for sharing the structured assessment that she has devised and her analysis of this in practice. Dr Rosie Richardson is a Community Paediatrician in the South West. This clinical assessment is devised in the belief that to rely on parental enquiry alone, as in 3Di or DISCO, is to miss the opportunity for objective and valuable direct observation of, and interaction with the child or young person for the purposes of understanding whether their difficulties could be understood in terms of an Autism Spectrum Disorder. This clinical assessment forms the paediatric (medical) component of the tripartite assessment for an Autism Spectrum Enquiry including previously diagnostic subgroups such as Autism Spectrum Disorder with learning difficulty, Autism Spectrum Disorder without learning difficulty, Asperger s Syndrome, Pathological Demand Avoidance and semantic/pragmatic language difficulty. In line with NICE guidelines this clinical assessment is just one part of a tripartite assessment for an Autism Spectrum Disorder. A specialist psychology evaluation and a specialist speech and language evaluation form the other two parts. Examples of the information that can be gained through these further assessments are included in the appendices. The three components of this assessment may not reach full consensus, but none of them can be in direct conflict with an eventual understanding and formulation. Additional information is invaluable to support the three formal assessments above:- Parental reporting which can precede the assessment School observation by any member of the team or another School reports and a measure of cognitive ability, which may be included in another full assessment Occupational Therapy and Physiotherapy reports Knowledge from other professionals involved with the young person and their family including:- o Previous hospital reports o GP o Health Visitor Observation and reports from the child/young person including diary information and drawings. Parental Enquiry during a period of free time for the child or young person. Parental reporting includes:-
a) Neurodevelopmental history this is an inclusive appointment with parents or carers and anyone else who parents bring. The format of the history depends on those giving it. An attempt is made to understand parental expectation, to know who referred the young person, who has the concerns and it includes an antenatal history, perinatal history and postnatal history. A full developmental history is undertaken documenting all milestones. A full family history is obtained of the immediate and extended family. A full social history is obtained. A full educational history is obtained including preschool experience and cognitive levels gained from school reports if possible. It is important to understand whether the perception is that the child or young person is underachieving. This perception may be different from parents and school. b) A systemic enquiry looking at general health, which includes an understanding of appetite and diet, sleep pattern/disturbance, gross and fine motor skills, self-help skills and continence. c) An Autism specific history (in line with the 3Di and DISCO) fully explores the triad of impairment through enquiry into :- Social communication (language) Social interaction (friendships) Behaviour and the range of interests and imagination including obsessive behaviour d) Specific additional information is requested around anxiety, mood, humour and anger The free time for the child or young person The free time for the child or young person, which is a specific requested drawing, includes the need for the young person to demonstrate:- Imagination Demonstration of particular interests Fine motor skills Spontaneous engagement with others in the room during the task Attention span and degree of focus. Examination and Direct Observations Which may take place at any time during the consultation includes:- The physical examination to include height, weight, head circumference and recognition of dysmorphic features and further examination as deemed appropriate following enquiry and preliminary examination. Functional understanding of visual acuity, hearing and colour vision and motor skills. Direct observation of stereotypical behaviours, mannerisms, anxiety, obsessive and repetitive behaviours and negative behaviours with the appearance of regression or withdrawal from task. Direct assessment of mood. 2
Interactive Tasks with the child or young person a) Construction tasks which look at the understanding of :- Colour Number Manual dexterity Coordination Degree of obsessive adherence to method Spatial orientation Interaction with the examiner b) Descriptive tasks around a picture or a puzzle or a book which looks at spontaneous language and communication, creativity and interests. c) Story telling which looks at :- Idiomatic and inferential understanding Quantitative language Qualitative language General understanding Shared enjoyment Joint interests Spontaneous additional information Recognition of emotions Creativity d) Literacy tasks include:- A spelling list Remembering and reproducing a complex pattern A drawing of a person e) Memory tasks Visual Verbal All these interactive tasks are in line with the, tasks and enquiry contained within the Autism Diagnostic Observation Schedule (ADOS). Conversation and Reporting with parents and child as appropriate to age and understanding looking at:- Reciprocal conversation The elaboration of initial questioning Transferring of ideas Insight into social behaviours The use of gaze, facial expression, intonation and gesture Emotional understanding around sadness, anger, happiness and anxiety Future understanding of young person s ambition re: work, money, marriage, children, travel 3
Formulation Sheet Social communication with an understanding of the level of quantitative or qualitative impairment Quantitative and qualitative understanding of the level of social interaction with friendships and the understanding of social norms. Understanding of behaviours, imagination and creativity Quantitative recognition of abnormal behaviours and the quantitative recognition of medical concerns that need further assessment Potential are: 1. Fulfils the diagnostic criteria for an Autism Spectrum Disorder. 2. Does not fulfil the diagnostic criteria for an Autism Spectrum Disorder. 3. Fulfils the diagnostic criteria for an alternative developmental disorder. 4. Does not fulfil the criteria for any disorder currently assessed using these methods. 5. Requires ongoing referral for medical, educational or mental health needs. 4
Post Assessment 1. Summarise the assessment, write a clear formulation/diagnosis. 2. Highlight any omission from NICE guidelines and suggest further lines of enquiry as necessary. 3. Refer medical concerns that may have been highlighted to other professionals as necessary. 4. Copy full report to parents/carers, GP and others as appropriate with permission. 5. Signpost to appropriate follow up and support. 5