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 |