What's New? August 2018

Paediatricians are receiving referrals for children without the appropriate supporting information for diagnosis.  This pathway ensures the work is completed in the community prior to referral.

For School age children please follow the School Age Autism Pathway

Autism Spectrum Condition (ASC) is a collective term that includes:

  • Autism
  • Atypical autism
  • Asperger’s syndrome

Autism Spectrum Condition (ASC) is a clinical diagnosis

  • diagnostic criteria are specified in the International Classification of Diseases (ICD-10) issued by the World Health Organization (WHO) and also in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and are based on the following clinical features, which may be present to varying degrees:
    • impaired social interaction
    • impaired language and communication
    • restricted, repetitive patterns of behaviour, interests or activities
    • symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).
    • symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning.
    • these disturbances are not better explained by intellectual disability (intellectual developmental disorder), or global developmental delay

Autism Spectrum Condition (ASC) is a lifelong condition

  • a sibling with autism
  • gestational age less than 35 weeks
  • intellectual disability
  • neonatal encephalopathy or epileptic encephalopathy, including infantile spasms
  • chromosomal disorders including Down’s syndrome
  • genetic disorders for example Fragile X, Neurofibromatosis, Tuberous Sclerosis, Rett Syndrome
  • metabolic disorders
Pre-school Autism Diagnostic pathway

For School age children please follow the School Age Autism Pathway

Please click the relevant flowchart box to be taken directly to textual information

                                                                                              

Presentation (pre-school children)

For School age children please follow the School Age Autism Pathway

 

Presentation may be by parents concerned with challenging behaviour and/or hyperactivity, or may present incidentally:

  • Autism Spectrum Condition (ASC) may not be the primary focus of initial referral
  • Autism Spectrum Condition (ASC) symptoms may develop over time, for example in a child with a previous diagnosis of ADHD
  • Autism Spectrum Condition (ASC) should be considered as a differential diagnosis in preschool children displaying delay in communication and language development

  • impaired social interaction
  • impaired non-verbal and verbal communication:
  • speech and language problems range from no speech to advanced vocabulary, but the use of language is always impaired
  • restricted, repetitive and stereotypic patterns of behaviours, interests and activities
  • developmental problems tend to be noticeable before the age of 3 years or as the social demand increases at preschool or primary school

  • altered sensory perception
  • unusual sleep patterns
  • seizures
  • dietary/digestive problems

 As part of the core programme of child health surveillance, healthcare professionals should be vigilant of features of Autism Spectrum Condition (ASC) to aid early detection.

Difficulties with:

  • Making eye contact or using eye contact appropriately
  • Starting conversations or keeping conversations going, e.g., taking turns to speak
  • Understanding other people’s points of view
  • Coping with change
  • Playing imaginatively or appropriately, e.g., they may be unusually focused on a specific activity
  • Taking part in group activities
  • Understanding jokes, sarcasm or non-literal language like ‘pull your socks up'
Differential Diagnosis

Common differential diagnoses include:

  • specific language impairment or developmental language delay
  • intellectual disability or global developmental delay
  • developmental coordination disorder (DCD)

  • attention deficit hyperactivity disorder (ADHD)
  • mood disorder
  • anxiety disorder
  • attachment disorders
  • oppositional defiant disorder (ODD)
  • conduct disorder
  • obsessive compulsive disorder (OCD)
  • psychosis
  • schizophrenia of unusually early onset

  • Rett syndrome
  • epileptic encephalopathy

  • severe hearing impairment
  • severe visual impairment
  • selective mutism
When to Refer

Refer any Pre-school child with suspected Autism Spectrum Condition (ASC) to the Health Visitor as Lead Practitioner for assessment and management. Ensure parents are informed.

Locality

Champions

 

Cheltenham

Louise Mackay

Cindy Pickering

Judith Cheyney

Gloucester

Laura Collingbourne

Tewkesbury

Jocelyn Broderick

Stroud

Jenny Perret

Forest of Dean

Alison Monk

Cotswolds

Denise Bach

Assessment / Ongoing Management

Click to enlarge

                                                         

 

HV will commence recognition and referral screening process:

  • Discuss pre-school communication pathway with parents/carers and obtain consent to share information with other professionals.
  • Complete Ages and Stages assessment and modified checklist for autism in toddlers (M-CHAT) if applicable
  • Refer child to audiology and SALT for initial assessment (see Services and Referrals section for further information)
  • Refer child to Advisory Teaching Service and Educational Psychology (see Services and Referrals section for further information)
  • Discuss child’s needs and referrals made with educational setting if applicable

 

Key Point

If attachment concerns are high, HV to contact 2gether Foundation Trust's Children and Young People Service practitioner advice line: Monday-Friday, 9.00am-5.00pm, 01452 894272

 

Assessments completed

If social communication difficulties not indicated, Health visitor to:

  • Discharge child from pathway and provide support with other agencies as required e.g. SALT, Advisory Teaching Service, Educational Psychology and inform GP

 

If diagnosis uncertain:

  • The team may decide to plan appropriate intervention and support for the child and family and make a clear plan for ongoing review with the local team. Refer to NICE guidance

 

If social communication difficulties indicated, Health Visitor to:

  • Add social communication flag to child’s record on SystmOne
  • Refer child in for discussion at multi agency meeting

Attendees include:

Paediatrician, Speech and Language Therapist, Advisory Teaching Service, Clinical Psychologist, Educational Psychologist, Health Visitor Champions, Pathway administrator

  • Children with social communication difficulties are discussed at the meeting
  • Education and care package developed
  • Refer for assessment when the child is ready and information has been gathered

Following the meeting:

  • HV will feedback to families

 

If diagnosis is complex:

  • Child referred to Social Communication (SCOM) clinic
  • Child referred to community paediatrician for physical examination and information on SCOM clinic

 

If diagnosis is NOT complex:

  • Child might be referred directly to community paediatrician for physical examination, assessment and diagnosis

Attendees include:

At least 2 professionals: Paediatrician, Speech and Language Therapist and/or Clinical Psychologist with Child and Parents/Carers

  • SCOM clinic consists of:
    • Speech and Language Therapy (SALT) led play observation (ADOS/POKIT)
    • Clinical Psychologist completes neuro-developmental interview with parents and observation of SALT led play session

Following the meeting:

  • Reports written and distributed to all professionals involved

Attendees include:

Health Visitor, Advisory Teaching Service, Clinical Psychologist, Educational Psychologist, Education setting (if applicable)

  • Professional discussion to reach decision on diagnosis
  • Multi-agency plan formed

  • Arrange feedback meeting with parents/carers to discuss diagnosis
  • Discharge child from pathway with support
  • Communicate to all professionals involved
Expand all