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The assessment and diagnosis of Autism Spectrum Disorder (ASD) in children and young people: Information for Health Visitors and Nurseries

What is ASD?

Autism is a lifelong developmental condition that affects how a person communicates with, and relates to, other people and the world around them. It is thought to affect at least one per cent of the population. It is a spectrum condition, which means that, while all people with autism share certain areas of difficulty, their condition will affect them in different ways.

Using Autism-Friendly Strategies:

People with autism may:

  • be over- or under-sensitive to light, sound, and pain
  • have a very literal understanding of language
  • find open-ended questions difficult to answer
  • need more time to process information
  • respond to medication very individually
  • find it very stressful when appointments run late.

Adjustments need to be tailored to the individual but consider the following when interacting with parents who also may have ASD:

  • ensure your staff are autism trained and aware
  • explain clearly what will happen at the beginning of the meeting to reduce anxiety
  • ask clear, specific questions – be aware of how you phrase questions
  • give people time to process what you’ve said before asking more questions
  • check people understand what you’ve said – even if they appear to have understood
  • use visual aids to support your discussion if possible, e.g. pictures/diagrams
  • adjust to any sensory needs – e.g. reduce electric lighting if possible
  • minimise clutter
  • schedule appointments at the start of the day to reduce delays and time spent in the waiting room.
  • provide a written summary.

What types of difficulties might a pre-school child have?

Signs and symptoms of possible autism in preschool children (or equivalent mental age) (NICE Guidelines)

Social interaction and reciprocal communication behaviours

Spoken language

  • language delay (in babble or words, for example, less than ten words by the age of 2 years)
  • regression in or loss of use of speech.

Spoken language (if present) may include unusual:

  • non-speech like vocalisations
  • odd or flat intonation
  • frequent repetition of set words and phrases (‘echolalia’)
  • reference to self by name or ‘you’ or ‘she/he’ beyond 3 years
  • reduced and/or infrequent use of language for communication, for example, use of single words although able to speak in sentences.

Responding to others

  • absent or delayed response to name being called, despite normal hearing
  • reduced or absent responsive social smiling
  • reduced or absent responsiveness to other people’s facial expressions or feelings
  • unusually negative response to the requests of others (demand avoidant behaviour)
  • rejection of cuddles initiated by parent or carer, although may initiate cuddles themselves.

Interacting with others

  • reduced or absent awareness of personal space, or unusually intolerant of people entering their personal space
  • reduced or absent social interest in others, including children of his/her own age – may reject others; if interested in others, may approach them inappropriately, seeming to be aggressive or disruptive
  • reduced or absent imitation of others’ actions
  • reduced or absent initiation of social play with others plays alone
  • reduced or absent enjoyment of situations that most children like, for example, birthday parties
  • reduced or absent sharing of enjoyment.

Eye contact, pointing and other gestures

  • reduced or absent use of gestures and facial expressions to communicate (although may place adult’s hand on objects)
  • reduced and poorly integrated gestures, facial expressions, body orientation, eye contact (looking at people’s eyes when speaking) and speech used in social communication
  • reduced or absent social use of eye contact, assuming adequate vision
  • reduced or absent joint attention shown by lack of gaze switching

Following a point (looking where the other person points to – may look at hand)

Using pointing at or showing objects to share interest.

Ideas and imagination

  • reduced or absent imagination and variety of pretend play.

Unusual or restricted interests and/or rigid and repetitive behaviours

  • repetitive ‘stereotypical’ movements such as hand flapping, body rocking while standing, spinning, finger flicking
  • repetitive or stereotyped play, for example, opening and closing doors
  • over-focused or unusual interests
  • excessive insistence on following own agenda
  • extremes of emotional reactivity to change or new situations, insistence on things being ‘the same’
  • over or under reaction to sensory stimuli, for example, textures, sounds, smells
  • excessive reaction to taste, smell, texture or appearance of food or extreme food fads.

Further information about autism in different age groups for Primary Care Practitioners is available on the following website: asd.nes.scot.nhs.uk

How should I raise concerns?

Families may approach you with a specific concern that their child may have ASD. Alternately, concerns may be raised by another professional following developmental review or observations.

It can be difficult for professionals to raise concerns with families. Rather than talking in terms of diagnostic labels, it may be more appropriate to give descriptions of behaviours or developmental concerns. If they do not share your concerns, you may need to make this a gradual process.

How do I refer for an assessment for ASD?

The Cornwall multidisciplinary pathway for the assessment and diagnosis of Autism Spectrum Disorder (ASD) in children and young people was developed using national guidelines.

It aims to provide timely assessment and where appropriate, diagnosis close to home if possible.

The process is initiated by a referral to the most appropriate members of the multidisciplinary team.

For children under 5 years 6 months, they can only be referred through a joint agreement with a Speech and Language Therapist (SLT) and Community Paediatrician with those specific professionals making the referral. If the child is not already known to both of these teams then a referral should be made to these specialists who will then decide with the family about an autism assessment.

To refer to SLT please complete the referral form on the Early Help Hub. To refer to Community Paediatrics please write or email them (contact details can be found at the end of this leaflet).

What information will be gathered for the assessment?

  • surveillance tools such as e.g. M-CHAT, ASQ and NICE red flag guidance can be helpful to ensure relevant observations are collected
  • the assessment process involves gathering information about the child and young person in the form of a developmental assessment, as well as clinical and contextual observations
  • you may be asked to complete a questionnaire to contribute to contextual information
  • information from nursery staff about the child’s progress at nursery, social communication, friendships and peer interaction, play and imagination and strategies used to support positive behaviour is extremely important for the assessment.

Where can I signpost families for support whilst they are waiting?

Cornwall Autism and Wellbeing Wheel provides information about various aspects of ASD.

www.supportincornwall.org.uk/kb5/cornwall/directory/autismwheel.page

The Early Help Hub can provide advice and information about local services:

www.cornwall.gov.uk/earlyhelphub

01872 322277

The National Autism Society has lots of useful information about specific difficulties and also have a help-line:

www.autism.org.uk

0808 800 4104

Spectrum provides a telephone helpline and advice about local support etc. They can be contacted on the following link/telephone number

01326 371000

www.spectrumasd.org

Links to referral forms:

Contact the Early Help Hub on:

Tel: 01872 322277

Email: earlyhelphub@cornwall.gov.uk

The website for professionals is

www.cornwall.gov.uk/earlyhelphub

Community Paediatricians:

Community Child Health Department, Pendragon House, RCHT, Truro TR1 3XQ

Tel: 01872 254518

Email: rch-tr.CommunityPaediatricTeam@nhs.net

Information for Health Visitors and nurseries in accordance with NICE guidelines.

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