ASD Consults

[MedMan80]

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Hey all,

Im still struggling with comfortably diagnosing ASD, in kids that aren't obviously meeting criteria. My fellowship wasn't extremely oriented towards developmental disorders, so the exposure I got was mostly extant patient's with ASD diagnosis that I followed on an outpatient basis. What sort of things do the CAP attending's (and fellows) look for in children/adolescents, especially for higher functioning kids? So far I do screen for speech delay, developmental delays, lack of social/emotional reciprocity, restricted interests, lack of eye contact/emotional warmth, deficits in social play..

 

[calvnandhobbs68]

Are these kids being sent to you for ASD diagnosis referrals or are you just asking in the cases of kids that you suspect have ASD, how do you go about diagnosing it?

Technically you can diagnose ASD just using the DSM V criteria:

https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_AutismSpectrumDisorder.pdf

However, as you've probably found out, most of the criteria require you to have run into enough developmentally normal kids for various ages to recognize abnormal behavior in these areas (which is a bit of an art form all of its own).

In practice, most patients are referred to people/centers who specialize in ASD or ASD diagnosis (the types of specialities who staff these centers can vary but typically one or a combo of developmental pediatrics, peds neurologists, child psychiatrists, child psychologists) for long, formal evaluations (which can be fairly expensive and not covered by insurance). The kind of "gold standard" observational tests (the ADOS-2 and ADI-R) are long, in depth diagnostic assessments that you have to be specially trained on. There are also other, more brief tests that include info from parents/teachers (SRS-2, CARS-2, SCQ, ABC) and less commonly used ones (ASRS). To make things more complicated, some of these are more screening tests than diagnostic tests (SCQ and ABC are better at screening, MCHAT is used in primary care a lot to screen for autism). There's probably other instruments that I'm not including right now that I can't remember. Downside is that you have to pay for all of these (they're all copyrighted except maybe the MCHAT?). Upside is that many of these assessments (especially the CARS-2) are very detailed in terms of what they're looking for with scoring and can be very helpful in guiding you on what to look for in an assessment. Using assessments from multiple sources is helpful as well (ex. having parents/teachers fill out the SRS-2 along with your own evaluation) to help weed out if what you're seeing is constant over environments.

Do you have any access to a developmental peds department or peds psychologists? Many of them pay for at least a few of these because they use them in their assessments, so they can at least let you know what the different scoring rubrics look like (I don't think you yourself are allowed to use them officially unless you pay for them).

 

[Merovinge]

I essentially never clinically diagnose ASD, even when it is painfully obvious (and I went to a very strong ASD fellowship), because I feel that having supporting ADOS or ADI-R is very important for schools, legal system, and just general knowledge from the family/patient. If you have time/training to do those tests, it's very reasonable to do so, but I feel like psychologists are generally the testing guru's and we have too much business as is, so I defer all my testing to them.

If children are wildly aggressive and have histories that strongly support ASD, I will still treat them with medication while we get on a waitlist for testing, so that no one is neglected while we wait. I have yet to "call" an ASD diagnosis that was not reinforced by extensive followup psychologic testing but I am sure the day will come.

Also, my staff make sure to clarify for any ASD referrals that the families are worried about behaviors and not presenting just for diagnosis so most of these get screened out. I still get referrals from PCPs for ASD diagnosis but many have figured out to refer these to various ASD centers in the area rather than me after getting rejected from the office.

 

[MedMan80]

I essentially never clinically diagnose ASD, even when it is painfully obvious (and I went to a very strong ASD fellowship), because I feel that having supporting ADOS or ADI-R is very important for schools, legal system, and just general knowledge from the family/patient. If you have time/training to do those tests, it's very reasonable to do so, but I feel like psychologists are generally the testing guru's and we have too much business as is, so I defer all my testing to them.

If children are wildly aggressive and have histories that strongly support ASD, I will still treat them with medication while we get on a waitlist for testing, so that no one is neglected while we wait. I have yet to "call" an ASD diagnosis that was not reinforced by extensive followup psychologic testing but I am sure the day will come.

Also, my staff make sure to clarify for any ASD referrals that the families are worried about behaviors and not presenting just for diagnosis so most of these get screened out. I still get referrals from PCPs for ASD diagnosis but many have figured out to refer these to various ASD centers in the area rather than me after getting rejected from the office.

thank you for sharing, just recently had a kid who was an ADHD r/o, which i noticed to have some features of ASD, however not an obvious diagnosis. Just wanted to check how often this was being diagnosed/screened in the community. In training we had a similar practice of screening out pure ASD referrals in the absence of ADHD or other anx/depression..good to know i'm not alone in not wanting to diagnose these kids without formal testing or obvious clinical signs..

 

[WisNeuro]

Especially for the ASD/ADHD/LD stuff, best to refer out for an evaluation or encourage the parents to see what is available through their school system. As was mentioned, if they are eventually going to get some kind of accommodation/IEP/etc, they'll need this anyway. And, for these things, best to send to someone who knows it backwards and forwards and has the leeway to do a lengthy exam. It's just way too hard to diagnose in a standard psychiatric interview, I've seen way too many misdiagnoses this way. Additionally, even if someone does have ASD, it's more important to have an extensive eval to identify the severity and impairment the diagnosis causes, rather than just finding out of the diagnosis applies or not. Heck, I can do these, but still refer them out. Though, mostly because I focus my billing on the med side vs MH side for most things.

 

[Merovinge]

thank you for sharing, just recently had a kid who was an ADHD r/o, which i noticed to have some features of ASD, however not an obvious diagnosis. Just wanted to check how often this was being diagnosed/screened in the community. In training we had a similar practice of screening out pure ASD referrals in the absence of ADHD or other anx/depression..good to know i'm not alone in not wanting to diagnose these kids without formal testing or obvious clinical signs..

You bring huge value being acutely aware of ASD and picking it up when it is not a referral question. I have had a handful of children in the past year referred for ADHD/Anxiety/Depression who are somehow getting through several peds/PCP visits, school, and life in general with moderate to severe ASD and me just getting them referred and diagnosed has made a huge difference. Families have universally been accepting of these referrals and usually quite grateful to finally understand what is actually happening.