'Assessing Autism Spectrum Disorder calls for a holistic approach'

It's a big question for many of us after our Psychology degree – where next? I knew I was ready to leave the academic world and I'd enjoyed working with children in a play centre, so I was thrilled when I secured a role as an Assistant Psychologist in an Autism Spectrum Disorder Assessment service for children.

I support the assessment of children on the ASD pathway, which involves conducting observations, taking a neuro-developmental history from parents/carers and administering neuropsychological assessments. I then triage referrals to ensure that appropriate assessments are carried out. Our multidisciplinary team includes clinical psychologists, ASD specialist practitioners, speech and language therapists, occupational therapists, paediatricians, and psychiatrists. Working within such a talent pool of knowledge is an amazing learning experience for me.

Challenges in assessment

Assessing children for ASD poses several challenges as it can share similar traits and presentations to other clinical diagnoses such as attachment disorder, anxiety, OCD and, quite often, ADHD. Many children I meet on the ASD pathway already have an existing diagnosis of ADHD and their symptoms can be very apparent. It could be easy for their diagnosis to overshadow my judgement of whether they have ASD when their presentations could be clearly explained by ADHD; this is why it's important to ask children more specific questions relating to their social interactions and routines and look at any sensory differences they may have, as well as gaining more information from parents and school.

In some of these cases, it becomes apparent that there are some social communication difficulties, rigid behaviours and sensory differences that are being overshadowed by their ADHD. It's important to look at each case from all angles. In other cases, children may have been referred to our clinic presenting with some traits of ASD but after assessment we may discover their presentation is better explained by an attachment disorder. These children may have experienced a significant number of Adverse Childhood Experiences (ACE's) which better explain their rigid behaviour, sensory needs and social communication difficulties. It's important that I consider the psychologist's formulation and administer and interpret the Coventry Grid Interview (CGI) to differentiate whether the young person's behaviour is due to ASD or attachment disorder.

Observing within schools

When we're assessing for ASD, we are mindful that some children mask their difficulties at a subconscious level to conform to societal norms and 'fit in'. In our service, an ASD referral will only be accepted via GP services or school. In some cases, parents and clinician's observations of a child are indicative of an ASD diagnosis and appear to meet DSM-V criteria. However, information from their school contradicts this and highlights strengths in social communication and interaction. This is where I, along with other clinicians, are responsible for undertaking a discrete observation at school to see how these children and young people are interacting in a school environment.

How diagnosis can provide support

An accurate diagnosis of ASD can serve as an educational and supportive purpose for children and their parents/carers. When I ask them "What would a diagnosis mean to you?" and, "Would anything change if you were to receive a diagnosis?", they often hope for additional support and an understanding from an educational perspective, which is crucial for their future career aspirations. Children also often comment on how having an ASD diagnosis would support them to understand their own mind and behaviour and give them an understanding of why things may feel 'different' in comparison to others their age.

At the heart of our assessment of children on the ASD pathway is an acknowledgment of the immense value of working in an interdisciplinary team. Several diagnoses share similar traits to ASD and by working as a team you are capturing expertise from different areas which provides a holistic view of a child's presentation. Perhaps there is a need for professionals specialised within ASD to offer educational workshops or programmes to local schools, GP services and other healthcare professionals to highlight the complexity of diagnosing ASD. We know that presentations vary across children, and diagnosis can be difficult. Yet it's crucial that we get it right for individuals to understand themselves and access the appropriate support. It's our job to do everything we can to get this right and I'm proud to be a part of that.