Diagnosing autsim without a formal assessment?

[foreverbull]

On internship, I was told that psychologists at my site wouldn't diagnose autism other than provisionally without referring out to an assessment specialist for confirmation, but it was never explained why. Is it really frowned upon for psychologists to diagnose autism spectrum disorder directly from the DSM-5, especially if they've worked with people on the spectrum before?

A colleague of mine has been asked to write a letter confirming a client's diagnosis for housing reasons, and it got me thinking about this issue of "diagnostic turf" so to speak. If the housing entity doesn't require a specific formal assessment, is it appropriate for the colleague to write the letter based on their knowledge of working with the client long-term and experience working with folks on the spectrum (without conducting assessments), or is it an unspoken rule that no one diagnoses autism except assessment specialists?

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[PsyDr]

Tests don’t diagnose. People do.

 

[R. Matey]

Many of the autism assessments I've seen rely heavily on clinical observations. Don't know how common that is. I haven't personally evaluated autism, except to tell people that identifying with behaviors they've seen on TikTok doesn't automatically mean they have autism.

 

[summerbabe]

I don’t do anything in the autism space but this reminded me of personality disorder diagnoses and how some/many clinicians are often hesitant to list that without some additional testing/data.

A major benefit for a formal assessment, especially one done by another clinician unrelated to the patient’s treatment, versus purely subjective experience (‘They act so borderline’) is that a good formal assessment should engage in a more thorough, thoughtful, and hopefully objective differential diagnostic process to consider alternative possibilities and identify important factors that may influence current presentation.

 

[ClinicalABA]

In regards to access to services, a "provisional" diagnosis- if noted as such in the record- may be indistinguishable from no diagnosis, as far a some treatment funders are concerned. As to who can give an ASD diagnosis that would qualify the client for insurance (or state birth-to-three program) funded services, it is likely codified and differs from state to state. In my home state (MA), a diagnosis of ASD from a psychologist or physician is required. In CT, a diagnosis from a licensed social worker would qualify for birth-to-three services, but maybe not insurance.

As to the how, that is not as clear cut. Here's a definition from the MA Law (Act Relative to Insurance Coverage of Autism):

“Diagnosis of autism spectrum disorders”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has 1 of the autism spectrum disorders."

Pretty vague and, in the case of "genetic testing", not totally based on the science. In practice, if you are following DSM-5 criteria, the symptoms need to be present currently or by history, and must be present during the "early developmental period." The history part and early developmental period are not too much of an issue for me, as I'm only seeing really young kids and am usually getting history from multiple sources (e.g., parents, early intervention therapists, pediatricians). However, I do think it is good practice to differentially weight and give more importance diagnostically to the symptoms I actually observe. For example, if parents report an absence of pretend play skills, but the child comes to the office and spontaneously and consistently engages in multischeme play with a doll and representational toys that they have never seen before, I'm likely to conclude that they have pretend play skills. Similarly, if parent or teacher ratings on an SRS-2 indicate appropriately developed social interaction skills, yet the child does not make any eye contact, doesn't respond to his name, and doesn't use speech or communicative gestures for 2 straight hours, I'm going to more heavily weight what I saw.

You can see where this would be difficult as the clients get older and a) through therapy, maturation, etc. develop more subtle and consistent social interaction skills; and b) get farther removed from the "early developmental period" (and may not have a second source or data), self-report data may be the best you have for a lot of things. Additionally, there are many more other things that cause ASD like symptoms in adults, and differential diagnosis is much trickier than in a 2 year old (where I'm typically deciding between ASD, language disorder, global developmental delay, or intellectual disability- or a combination thereof). In practice, I use structure criterion- and norm-referenced tests to identify specific symptoms of ASD, identify/rule out pure language delays, and identify/rule out global developmental delays. Could i diagnosis accurately without these tests? Most likely I could at the extreme ends of things (e.g., high level of consistently symptoms of ASD or high level of consistent behaviors incompatible with an ASD diagnosis). It would be trickier for those kiddos in the middle. I actually get a lot of "second opinion" cases (both Dx and no-DX) from a local developmental pediatrician who meets with kids unstructured for 30 minutes and then gives (or doesn't) a dx.

 

[cara susanna]

We typically refer to neuropsych for autism assessments. But keep in mind that we're assessing adults, which is MUCH more difficult.

 

[borne_before]

Couple of thoughts:

1. A formal evaluation utilizing multiple sources, a developmental interview to establish the developmental onset, and use of multiple methods (e.g., ADOS-2, ASRS, etc.) is best practice. But, often the ADOS-2 is needed by insurances.

2. Autism is like porn. You know it when you see it.

3. Autism is extremely over diagnosed and close to becoming a meaningless diagnosis. But, if it helps the patient get housing, it would be hard to argue against it, from a helping a human out perspective.

4. If there is a documented history of autism, and the patient has had some solid evals in the past, I really don't see an issue with it, because it's not like the autism is gonna go away. Might benefit from updated adaptive measurement though.

 

[clausewitz2]

Related topic: are there any ASD-specific interventions or treatment approaches for adults that would warrant or justify a full, best-practices evaluation? I have a couple of adult patients who are fairly high-achieving but also were clearly enough impaired that I even had the suspicion of ASD, had consistent histories, but were never diagnosed formally. I do an AQ-10 and have a conversation of "I am not diagnosing you, but based on the score this might be worth your time having evaluated and it might explain x/y/z of your experiences", but I can't shake the feeling that there may not be a point to this. Probably doesn't help that finding someone to refer to for (credible) adult autism evaluations in this area is almost impossible so often this goes nowhere fast.

Not an area of my practice I feel terribly confident in, so open to any and all feedback about it.

 

[BuckeyeLove]

2. Autism is like porn. You know it when you see it.

I feel like this is something we as psychologists should all just get on board with. And I'm not saying just with ASD. I'm talking ADHD. I'm talking Bipolar. I'm talking anything where it's pretty effin clear as day and yet we try to complicate things for some reason.

 

[Therapist4Chnge]

I feel like this is something we as psychologists should all just get on board with. And I'm not saying just with ASD. I'm talking ADHD. I'm talking Bipolar. I'm talking anything where it's pretty effin clear as day and yet we try to complicate things for some reason.

Yes and no....there is a fairly large gap btw a comprehensive eval for ASD and a psychologist or psychiatrist spending <30-60min with a patient and slapping a diagnosis on the chart. Look at the same setup for ADHD.....and it becomes even more problematic. It's not that neuropsych for ADHD is required (it isn't and shouldn't be), but a thorough clinical interview, input from outside sources, and ideally school grades and reviews (or work reviews for adults) is a lot more effort than what I usually see. Too often I see a 30min intake and then diagnosis and Rx of a stimulant. Then the prescriber looks to see if there is a positive response. Well....the vast majority of patients report positive effects, but that shouldn't confirm the diagnosis. My bias is towards formal assessment, but I do see a middle ground...but it'd still take more time than many clinicians are willing to do.

 

[foreverbull]

In regards to access to services, a "provisional" diagnosis- if noted as such in the record- may be indistinguishable from no diagnosis, as far a some treatment funders are concerned. As to who can give an ASD diagnosis that would qualify the client for insurance (or state birth-to-three program) funded services, it is likely codified and differs from state to state. In my home state (MA), a diagnosis of ASD from a psychologist or physician is required. In CT, a diagnosis from a licensed social worker would qualify for birth-to-three services, but maybe not insurance.

As to the how, that is not as clear cut. Here's a definition from the MA Law (Act Relative to Insurance Coverage of Autism):

“Diagnosis of autism spectrum disorders”, medically necessary assessments, evaluations including neuropsychological evaluations, genetic testing or other tests to diagnose whether an individual has 1 of the autism spectrum disorders."

Pretty vague and, in the case of "genetic testing", not totally based on the science. In practice, if you are following DSM-5 criteria, the symptoms need to be present currently or by history, and must be present during the "early developmental period." The history part and early developmental period are not too much of an issue for me, as I'm only seeing really young kids and am usually getting history from multiple sources (e.g., parents, early intervention therapists, pediatricians). However, I do think it is good practice to differentially weight and give more importance diagnostically to the symptoms I actually observe. For example, if parents report an absence of pretend play skills, but the child comes to the office and spontaneously and consistently engages in multischeme play with a doll and representational toys that they have never seen before, I'm likely to conclude that they have pretend play skills. Similarly, if parent or teacher ratings on an SRS-2 indicate appropriately developed social interaction skills, yet the child does not make any eye contact, doesn't respond to his name, and doesn't use speech or communicative gestures for 2 straight hours, I'm going to more heavily weight what I saw.

You can see where this would be difficult as the clients get older and a) through therapy, maturation, etc. develop more subtle and consistent social interaction skills; and b) get farther removed from the "early developmental period" (and may not have a second source or data), self-report data may be the best you have for a lot of things. Additionally, there are many more other things that cause ASD like symptoms in adults, and differential diagnosis is much trickier than in a 2 year old (where I'm typically deciding between ASD, language disorder, global developmental delay, or intellectual disability- or a combination thereof). In practice, I use structure criterion- and norm-referenced tests to identify specific symptoms of ASD, identify/rule out pure language delays, and identify/rule out global developmental delays. Could i diagnosis accurately without these tests? Most likely I could at the extreme ends of things (e.g., high level of consistently symptoms of ASD or high level of consistent behaviors incompatible with an ASD diagnosis). It would be trickier for those kiddos in the middle. I actually get a lot of "second opinion" cases (both Dx and no-DX) from a local developmental pediatrician who meets with kids unstructured for 30 minutes and then gives (or doesn't) a dx.

This is helpful, and I think this is part of why there is some disagreement about who can diagnose and how. The determination for insurance purposes and for accommodations seems to necessitate “assessment” in some states , but given the unclear language, could be confusing.

Would something like a psychologist’s clinical observation over time and a self-administered AQ be considered valid “assessment” if the psychologist has worked with the client longterm (not a single session kind of thing)? It seems like it’s a gray area.

@BuckeyeLove I hear you, and I think there is something to be said for that too, but also agree that there is room for error in diagnosis, as there always is with everything. Like if a psychologist has no experience working with folks with autism and confidently thinks a person coming in has clear cut social anxiety disorder because they struggle to make eye contact and talk succinctly and don’t do well in social situations, etc. It depends on the knowledge base/experience level of the psychologist, too. But I agree to the extent that if you have a good grasp of symptoms and experience level with a certain disorder, why shouldn’t you be able to diagnose without formal assessment?

Edit: I think the crux of the issue is how to prevent misdiagnosis from folks who think they’re competent in diagnosing but aren’t, while still allowing room for folks who are competent but don’t provide formal assessments to use their clinical expertise to diagnose.

 

[ClinicalABA]

Related topic: are there any ASD-specific interventions or treatment approaches for adults that would warrant or justify a full, best-practices evaluation? I have a couple of adult patients who are fairly high-achieving but also were clearly enough impaired that I even had the suspicion of ASD, had consistent histories, but were never diagnosed formally. I do an AQ-10 and have a conversation of "I am not diagnosing you, but based on the score this might be worth your time having evaluated and it might explain x/y/z of your experiences", but I can't shake the feeling that there may not be a point to this. Probably doesn't help that finding someone to refer to for (credible) adult autism evaluations in this area is almost impossible so often this goes nowhere fast.

Not an area of my practice I feel terribly confident in, so open to any and all feedback about it.

For adults, I think criterion-based measured, tied into a structured teaching curricula (ideally with some empirical validation) are more important than norm-referenced stuff. Basically, assessing what they can do in relationship to what they need to/want to do, and then conducting some type of behavioral skills training.

 

[ClinicalABA]

Yes and no....there is a fairly large gap btw a comprehensive eval for ASD and a psychologist or psychiatrist spending <30-60min with a patient and slapping a diagnosis on the chart. Look at the same setup for ADHD.....and it becomes even more problematic. It's not that neuropsych for ADHD is required (it isn't and shouldn't be), but a thorough clinical interview, input from outside sources, and ideally school grades and reviews (or work reviews for adults) is a lot more effort than what I usually see. Too often I see a 30min intake and then diagnosis and Rx of a stimulant. Then the prescriber looks to see if there is a positive response. Well....the vast majority of patients report positive effects, but that shouldn't confirm the diagnosis. My bias is towards formal assessment, but I do see a middle ground...but it'd still take more time than many clinicians are willing to do.

I don't know about the know it when i see it approach. How do you train that in the absence of some clear heuristic? As I mentioned before, I think you'll be fine at the extremes, but you'll end up with a lot of "he makes eye contact, so he's not autistic" false negatives and "she lines up her dolls, so she's got autism" false positives in the middle range.

 

[Therapist4Chnge]

I don't know about the know it when i see it approach. How do you train that in the absence of some clear heuristic? As I mentioned before, I think you'll be fine at the extremes, but you'll end up with a lot of "he makes eye contact, so he's not autistic" false negatives and "she lines up her dolls, so she's got autism" false positives in the middle range.

I 100% agree. I know enough about ASD evaluation to not offer it bc it really is a niche area. I loathe lazy diagnosing, and it seems to happen quite often w. ASD, ADHD, "sensory processing" disorders, and bipolar v. borderline PD. There are some real cringe reports out there, which is why evals should go with the specialists...but I know in the real world the wait is often 12+ months unless you can pay $$$ out of pocket...and then it's just 3-6mon wait.

 

[cara susanna]

Yes and no....there is a fairly large gap btw a comprehensive eval for ASD and a psychologist or psychiatrist spending <30-60min with a patient and slapping a diagnosis on the chart. Look at the same setup for ADHD.....and it becomes even more problematic. It's not that neuropsych for ADHD is required (it isn't and shouldn't be), but a thorough clinical interview, input from outside sources, and ideally school grades and reviews (or work reviews for adults) is a lot more effort than what I usually see. Too often I see a 30min intake and then diagnosis and Rx of a stimulant. Then the prescriber looks to see if there is a positive response. Well....the vast majority of patients report positive effects, but that shouldn't confirm the diagnosis. My bias is towards formal assessment, but I do see a middle ground...but it'd still take more time than many clinicians are willing to do.

I feel like it's one extreme or another. In our clinic, people (namely prescribers) REFUSE to diagnose ADHD without testing. Even if someone has a prior diagnose and completed testing in the past, but we can't get records.

Couple of thoughts:

1. A formal evaluation utilizing multiple sources, a developmental interview to establish the developmental onset, and use of multiple methods (e.g., ADOS-2, ASRS, etc.) is best practice. But, often the ADOS-2 is needed by insurances.

2. Autism is like porn. You know it when you see it.

3. Autism is extremely over diagnosed and close to becoming a meaningless diagnosis. But, if it helps the patient get housing, it would be hard to argue against it, from a helping a human out perspective.

4. If there is a documented history of autism, and the patient has had some solid evals in the past, I really don't see an issue with it, because it's not like the autism is gonna go away. Might benefit from updated adaptive measurement though.

For point #3, is there any research supporting this? It makes sense from what I've seen in popular culture, but am curious.

 

[borne_before]

I feel like it's one extreme or another. In our clinic, people (namely prescribers) REFUSE to diagnose ADHD without testing. Even if someone has a prior diagnose and completed testing in the past, but we can't get records.

ADHD does not need testing to diagnose. But, I find tremendous value, and patients/their parents find it very therapeutic to do ADHD evals. There are also secondary gains from a comp psychoed with adhd (e.g., SLD?, Anxiety? Dep?, etc.).

 

[futureapppsy2]

I feel like it's one extreme or another. In our clinic, people (namely prescribers) REFUSE to diagnose ADHD without testing. Even if someone has a prior diagnose and completed testing in the past, but we can't get records.


For point #3, is there any research supporting this? It makes sense from what I've seen in popular culture, but am curious.

IMO, as someone who’s done a lot of ASD assessment, points 2 and 3 kind of contradict each other. A large part of ASD
losing a lot of clinical meaning is that people, including psychologists and physicians, anchor their diagnoses or lack of diagnoses after seeing or not seeing one or two symptoms that “look autistic “ (the examples that @ClinicalABA gave are spot-on in my experience) and don’t do an actual, thorough assessment that includes rule-outs, some sort of developmental history, and some type of formal assessment of social-communication skills. So, you get people with a few autistic traits that don’t actually meet the criteria for ASD getting diagnoses and thrown into the same category as people who do meet the criteria, and that really muddies the waters.

 

[StellaB]

With Autism, I definitely think there is a lot of "you know it when you see it," but you do still have to make sure you're getting a good look at it and not a passing glance. I do think there are cases that are clearly not autism, no testing needed. There are also people for whom I may strongly suspect the diagnosis, but would still want to test the rule-outs unless I really knew their background and developmental history. IMO, the ADOS helps by bringing about the behaviors you need to observe in an efficient manner - to make sure you're getting a good look at it, so to speak.

I actually disagree that it is generally harder to diagnose in adults than kids - it really depends on the age of the kid, because there can be far more rule-outs to consider; you don't know their developmental course yet and have to make a lot of educated guesses.

Adults who weren't evaluated as kids do tend to be higher functioning (hence why they slipped through the cracks), which can create its own challenges. But with adults, you generally know how they did throughout schooling and how they do in the work environment. People with higher intelligence typically learn to mask their presentation much better, but this is effortful and they can usually tell you about it if you ask. There are also a lot of common developmental patterns to look for (e.g., onset of awareness of social problems in less severe autism typically coincides with the age at which communication starts to depend more heavily on inference). The person being assessed won't normally have that insight, of course, but you'll notice the age at which they tell you they stopped enjoying school. Although adults can read about autism online and convince themselves they have it, it's relatively hard to fake with an experienced evaluator, and particularly so if the evaluator uses testing. I would say of my adults who self-refer for evaluation, 30-40% do not meet criteria.

 

[R. Matey]

Would something like a psychologist’s clinical observation over time and a self-administered AQ be considered valid “assessment” if the psychologist has worked with the client longterm (not a single session kind of thing)? It seems like it’s a gray area.

We've used the AQ as a screener to refer on for assessments. I'm not a fan. Many of the items capture competing phenomena. I've had folks score off the charts with the AQ, but when you review it with them, it's clearly better explained as social anxiety, depression, agoraphobia, etc.

 

[singasongofjoy]

IMO, as someone who’s done a lot of ASD assessment, points 2 and 3 kind of contradict each other. A large part of ASD losing a lot of clinical meaning is that people, including psychologists and physicians, anchor their diagnoses or lack of diagnoses after seeing or not seeing one or two symptoms that “look autistic “ (the examples that @ClinicalABA gave are spot-on in my experience) and don’t do an actual, thorough assessment that includes rule-outs, some sort of developmental history, and some type of formal assessment of social-communication skills. So, you get people with a few autistic traits that don’t actually meet the criteria for ASD getting diagnoses and thrown into the same category as people who do meet the criteria, and that really muddies the waters.

So much this re: why diagnosis can seem like it lacks meeting. There are so many meaningless/wrong diagnoses and it is a HUGE disservice- the most frustrating I see is when parents are kinda like "oh great, it's autism, and not the huge mismatch between what my kid needs and my parenting/family lifestyle/etc" so they don't get the actual intervention they need AND some parents view that as a way to absolve themselves of responsibility for their kid's learning / development and disregard any suggestion that they themselves might need to make some changes, like ASD is some kind of excuse or free pass.

Other cases that get mistakenly diagnosed by providers who don't do thorough assessment - is it ASD, or is it maybe one or some combination of: very big dose of ADHD and/or anxiety and/or intellectual disability or certain types of learning problems which affect things like pretend play or socializing. Those things can also observationally look very much like ASD- which is why thorough assessment is sometimes needed, because are those behaviors ASD, or is this a kid with intellectual disability or language disorder and a whole lot of anxiety who is coping with it in ways atypical for their chronological age? (Don't get me wrong, there are also the "waiting room diagnoses" that I'd rather NOT sit on our waitlist for an evaluation when a pediatrician or community provider with a shorter wait could have diagnosed them and me given that spot to a "trickier" case).

In my state different services are available depending on the person's age and who diagnosed them and how. For medicaid waiver and similar supports, must be medical dx by doctoral level psychologist or similar level AND include standardized assessment that includes at least one standardized based on observation (typically ADOS) AND show clear need for substantial support in at least 3 of 7 functional areas, whereas provisional from a pediatrician without any formal testing will get you early intervention and frankly I think that makes a lot of sense when I think about the length of services and amount of tax dollars. I want the threshold to be higher for things that are essentially life-time or long-term services, especially when there already aren't enough providers of those services. I'm also all for easier diagnosis and access to services for those really clear cases - but I still think an observational rating should be required. I've seen plenty of reports from one community provider in paricular who essentially seems to give ASD diagnosis based on parent report and parent filling out a rating scale only, and then the kid comes to our clinic for intervention and we're like "uh... where's the autism?"

 

[ClinicalABA]

So much this re: why diagnosis can seem like it lacks meeting. There are so many meaningless/wrong diagnoses and it is a HUGE disservice- the most frustrating I see is when parents are kinda like "oh great, it's autism, and not the huge mismatch between what my kid needs and my parenting/family lifestyle/etc" so they don't get the actual intervention they need AND some parents view that as a way to absolve themselves of responsibility for their kid's learning / development and disregard any suggestion that they themselves might need to make some changes, like ASD is some kind of excuse or free pass.

Yep. Big problem in my area is that with the piece of paper that says "autism" on it, the kiddo is now eligible for 10-30 more hours per week of covered services. With the piece of paper that says "no ASD, but kiddo would benefit from home-based behavioral therapy,' family is either a) out of luck if they are non-medicaid, as insurance is not going to pay for the appropropriate discipline; or b) if medicaid, able to access some very watered down services through a program that resulted from a class action lawsuit against state medicaid system, but the process is complicated and involves multiple new referrals, evals, and professionals. I can't (and don't) take this into consideration when making or not making the diagnosis.

I literally just had the discussion about parenting strategies, need for consistency/ appropriate inconsistency with limit setting and consequences, and how it's basically in the job description of a 3 year old to try to pull one over on the parents and get what they want when they want it. It can be a tough thing to say, especially if you are not used to saying it. I always try to demonstrate and give examples. More often than not parents will report that their child was much better behaved with me than they would have expected. I point out that this is because i limited my demands to what was necessary, offer high quality and quantity reinforcers contingent upon adaptive behaviors, and stuck to my guns whenever i presented a negative reinforcement or punishment contingency. I then point out how it's much harder when you are the parent and have other things to worry about, and throw in an anecdote or two about how i may have not always been the most consistent with my own kids, but learned to adapt.

 

[ClinicalABA]

I actually disagree that it is generally harder to diagnose in adults than kids - it really depends on the age of the kid, because there can be far more rule-outs to consider; you don't know their developmental course yet and have to make a lot of educated guesses.

I should clarify that when I say "kids", I'm generally talking toddlers up through age 3-4. I even refer to the 4 year olds as "old men." Differential diagnosis in late elementary through high school is a miserable undertaking, IMHO.

 

[StellaB]

I should clarify that when I say "kids", I'm generally talking toddlers up through age 3-4. I even refer to the 4 year olds as "old men." Differential diagnosis in late elementary through high school is a miserable undertaking, IMHO.

That makes sense. I don't see the super young kiddos because of the nature of my practice, so I only see the "old men" and "old women" by your rubric

 

[foreverbull]

We've used the AQ as a screener to refer on for assessments. I'm not a fan. Many of the items capture competing phenomena. I've had folks score off the charts with the AQ, but when you review it with them, it's clearly better explained as social anxiety, depression, agoraphobia, etc.

I wondered. I've never heard of that measure before, and am curious about self-administered measures and their utility for autism spectrum disorder in particular, where there may be self-awareness limitations in some areas (as is a pitfall of any self-report measure).

 

[Sanman]

I don't really work with autism, but this is not really about that. This is about diagnosis more generally. The truth is that we are all allowed to diagnose anything we feel like that is legally within the spectrum of psychology. This can range from a common garbage diagnosis (need to put some billing code in for that initial) to the very stringent (forensic evaluations, insurance stuff, etc for the court usually fall into this category). The question here really needs to be what purpose is the diagnosis serving. There are many times, for example, I diagnose a patient with dementia despite minimal assessment. This will usually be a screener where they think it is the year 1963, have no appropriate awareness of their surroundings, cannot independently feed or dress themselves, and cannot follow a multi-step command. Likewise with similar patients who are bedbound following a stroke with severe cognitive deficits. That said, at those later stages I really don't care for a definitive differential as much as I do that they are having their functional needs met and are in a safe environment. It is also an undo burden on them and their caregivers to get extra testing done. In instances where there are other concerns (be it milder cognitive issues, impending legal or financial issues, etc) I do refer to neuropsych despite the 3 hour round trip commute to the hospital or will assess them further myself in home (going to check out testing materials and return them is a drag, interns come in handy here). So, I think that there needs to be some allowance for a variety of situations. That said, just slapping a diagnosis on someone so that they can access a random pot of money for housing, accommodations, etc seems unethical, but there are many practices making a living doing this stuff (anyone assess for school testing accommodations?) So it really boils down to personal ethics and the level of interview and history that one is willing to complete, some with be more liberal with a dx and others more conservative with it.

 

[foreverbull]

I'm also all for easier diagnosis and access to services for those really clear cases - but I still think an observational rating should be required. I've seen plenty of reports from one community provider in paricular who essentially seems to give ASD diagnosis based on parent report and parent filling out a rating scale only, and then the kid comes to our clinic for intervention and we're like "uh... where's the autism?"

I think you capture one of the problems perfectly. I think the problem is extremes either way:

1. the people who are convinced they know how to diagnose it but are really bad at it--causing harm to clients and our field (not to mention wasting resources), and

2. not being able to diagnose ASD at all without formal assessment, not for specific services, but just in general, say with an adult who has demonstrated symptoms over time in therapy and the psychologist has worked with several adults on the higher functioning side of the spectrum and can recognize it AND knows when to refer out when it's beyond their capability to diagnose competently (i.e. knowing what they don't know).

I can see why diagnosis leading to years of resources & supports, etc. requires formal assessment in many cases. I think good psychologists who have experience but don't administer those assessments would refer out in those cases. I'm just wondering if there's some leeway on a case-by-case basis.

@Sanman I think we're getting at the same point here!

 

[borne_before]

I work in a clinic where the biggest problem I have is people coming for ASD eval because of RRB's, but their IQ also tends to be like way below 50 and they have genetic conditions, cp, etc.

 

[cara susanna]

I should clarify that when I say "kids", I'm generally talking toddlers up through age 3-4. I even refer to the 4 year olds as "old men." Differential diagnosis in late elementary through high school is a miserable undertaking, IMHO.

I've been thinking, for ADHD and autism, is it really ethical to diagnose it in adults if we don't already have a childhood diagnosis? It just seems SO muddled.

I guess that would raise the question of what do we do about treatment, but I really hate being the gatekeeper for diagnosis (again, in my clinic a psychiatrist won't even consider ADHD meds without a psychologist testing and diagnosing ADHD).

 

[AcronymAllergy]

I do think it's ethical to diagnose, assuming we do a reasonable job of attempting to assess for it. Plenty of kiddos end up without diagnoses for various reasons outside their control (e.g., parents don't "believe" in ADHD, limited resources at home and/or in the school, etc.).

I also think that while it's important for providers to know and recognize the boundaries of their competence, there are definitely psychologists who are unnecessarily averse to even attempting to assess for ADHD (i.e., as soon as patient mentions it, they auto-refer to neuropsych for testing). If that's facility policy, it's a complex case, or you for some reason think assessing for or making the diagnosis yourself would impact the therapeutic relationship, I understand. But I think most psychologists should have at least a cursory knowledge of ADHD, enough to be able to potentially rule-in or rule-out very clear and/or straightforward cases.

 

[cara susanna]

I do think it's ethical to diagnose, assuming we do a reasonable job of attempting to assess for it. Plenty of kiddos end up without diagnoses for various reasons outside their control (e.g., parents don't "believe" in ADHD, limited resources at home and/or in the school, etc.).

I also think that while it's important for providers to know and recognize the boundaries of their competence, there are definitely psychologists who are unnecessarily averse to even attempting to assess for ADHD (i.e., as soon as patient mentions it, they auto-refer to neuropsych for testing). If that's facility policy, it's a complex case, or you for some reason think assessing for or making the diagnosis yourself would impact the therapeutic relationship, I understand. But I think most psychologists should have at least a cursory knowledge of ADHD, enough to be able to potentially rule-in or rule-out very clear and/or straightforward cases.

We don't diagnose our own patients, they're referred for ADHD testing and it's assigned to a psychologist who isn't their therapist.

I hate my facility's policy but I haven't been able to do anything about it.

 

[AcronymAllergy]

We don't diagnose our own patients, they're referred for ADHD testing and it's assigned to a psychologist who isn't their therapist.

I hate my facility's policy but I haven't been able to do anything about it.

I mean, I can understand the policy, and it's fine if there's a streamlined mechanism for the evaluations (e.g., an ADHD clinic). And I can understand the prescribing provider wanting a second opinion, especially in situations where they're unsure it's ADHD. But for psychologists, I just bristle a bit when it seems like it's a knee-jerk, "sorry, I can't diagnose that" reaction. Maybe I'm being unreasonable.

 

[cara susanna]

I mean, I can understand the policy, and it's fine if there's a streamlined mechanism for the evaluations (e.g., an ADHD clinic). And I can understand the prescribing provider wanting a second opinion, especially in situations where they're unsure it's ADHD. But for psychologists, I just bristle a bit when it seems like it's a knee-jerk, "sorry, I can't diagnose that" reaction. Maybe I'm being unreasonable.

Lol, I guess I'm complaining about the opposite where (in my clinic) psychologists are the only ones who are allowed/expected to diagnose ADHD and only after testing. Even in patients where it's extremely clear cut.

 

[AcronymAllergy]

Lol, I guess I'm complaining about the opposite where (in my clinic) psychologists are the only ones who are allowed/expected to diagnose ADHD and only after testing. Even in patients where it's extremely clear cut.

That would be very frustrating. The social workers and, generally, NPs here seem to be less likely to diagnose it, but the psychiatrists typically only refer when it's a complex case or they just want someone else involved in the eval. The psychologists are generally hesitant to diagnose as well, despite no clinic policy against it.

 

[singasongofjoy]

I've been thinking, for ADHD and autism, is it really ethical to diagnose it in adults if we don't already have a childhood diagnosis? It just seems SO muddled.

I guess that would raise the question of what do we do about treatment, but I really hate being the gatekeeper for diagnosis (again, in my clinic a psychiatrist won't even consider ADHD meds without a psychologist testing and diagnosing ADHD).

As AcronymAllergy said, lots of reasons people don't get diagnoses as kids and what a disservice to deny that opportunity in adulthood if it fits, right? But I concur with needing some kind of indication that differences were apparent in earlier life. I've been able to get prettty creative with that at times- e.g., comments on school report cards, talking to neighbors or childhood friends' parents, extended family; digging through old notes in EMR to find commentary e.g., notes from well-child visits.

It's not all that unusual though to get an adult who wants assessment but doesn't want to involve family unless necessary or who are not on good terms with parents etc. So we might go ahead with the evaluation with the understanding that without childhood history corroborated by some other 3rd party, we may be able to rule ASD out in which case extra follow-up wouldn't be warranted- or if we find at that point ASD is still on the table, htey can make teh choice then if we want to dig deeper for early childhood, or if they can meet their own goals (self-insight etc) with a provisional diagnosis (won't get them ASD-specific services, but can probably access the types of services under some other diagnosis anyway given frequency of concurrent anxiety/mood/etc. concerns- or maybe they just wanted insight into learning/cognitive/etc differences and to be pointed in the direction of some helpful literature/websites etc..

 

[foreverbull]

Just an interesting update: the CA BOP publicly shamed a psychologist (sent a letter of reproval) for saying they didn’t think a minor had ASD without conducting a formal assessment. Sounds like a parent got a second opinion and then complained to the board.

“Respondent Dr. X stipulated to the issuance of a public letter of reproval against Psychologist License No. XXXXX, with cost recovery and coursework
terms, after the Board fled an Accusation alleging Respondent’s communications with a minor patient’s mother caused her to believe that Respondent had concluded that the patient was not on the Autism Spectrum Disorder scale and did not have autism based upon his clinical observations of the patient without conducting a formal assessment of such disorder. The Decision and Order took efect
August 31, 2022.”

Does anyone else find it concerning that this is worthy of reproach?

Other gems from the board: someone had to surrender their license for lack of CEs (another person was put on 3 years of probation for the same thing—not sure why the different punishments). The first person who surrendered their license was right up there with the person who had sex with a client and threatened to send client’s nude photo out to family. How are these even remotely similar in scale of ethical violations?

 

[cara susanna]

I really don't understand this idea that everything needs testing. As a provider, the observational longitudinal data that you collect over the duration of your work together is far more valuable and reliable in diagnosing than someone who meets with the patient for a few hours*. I get with autism you would want to rule out other things, but why test the person if they don't display sufficient symptoms to warrant the diagnosis (in which case rule-outs aren't really needed)?

It goes back to PsyDr's post upthread: tests don't diagnose, people do.

*this is more of a general vent about my clinic, where providers are scared to diagnose personality disorders or psychotic disorders and always insist on testing for that

 

[Sanman]

Just an interesting update: the CA BOP publicly shamed a psychologist (sent a letter of reproval) for saying they didn’t think a minor had ASD without conducting a formal assessment. Sounds like a parent got a second opinion and then complained to the board.

“Respondent Dr. X stipulated to the issuance of a public letter of reproval against Psychologist License No. XXXXX, with cost recovery and coursework
terms, after the Board fled an Accusation alleging Respondent’s communications with a minor patient’s mother caused her to believe that Respondent had concluded that the patient was not on the Autism Spectrum Disorder scale and did not have autism based upon his clinical observations of the patient without conducting a formal assessment of such disorder. The Decision and Order took efect
August 31, 2022.”

Does anyone else find it concerning that this is worthy of reproach?

Other gems from the board: someone had to surrender their license for lack of CEs (another person was put on 3 years of probation for the same thing—not sure why the different punishments). The first person who surrendered their license was right up there with the person who had sex with a client and threatened to send client’s nude photo out to family. How are these even remotely similar in scale of ethical violations?

I really do think this should have been nothing more than an educational letter unless the psychologist charged for 90791 and did a really poor job. The surrendered license in the CE case is likely voluntary and not a license revocation without agreement as may happen in other cases.

 

[Sanman]

I really don't understand this idea that everything needs testing. As a provider, the observational longitudinal data that you collect over the duration of your work together is far more valuable and reliable in diagnosing than someone who meets with the patient for a few hours*. I get with autism you would want to rule out other things, but why test the person if they don't display sufficient symptoms to warrant the diagnosis (in which case rule-outs aren't really needed)?

It goes back to PsyDr's post upthread: tests don't diagnose, people do.

*this is more of a general vent about my clinic, where providers are scared to diagnose personality disorders or psychotic disorders and always insist on testing for that

Personality disorders I get. They can be time consuming to diagnose and pointless after the diagnosis if you are not setup to treat them. Good luck getting a Cluster B to admit to something like a narcissistic injury as a cause for their actions vs bipolar. If it is Cluster B, standard outpatient therapy is not doing much anyway. Getting them tested and eventually referred to something like a DBT clinic is a time saver the referral end. But psychosis? Good psychiatry and a med review would be more useful than testing in many cases.

 

[WisNeuro]

Just an interesting update: the CA BOP publicly shamed a psychologist (sent a letter of reproval) for saying they didn’t think a minor had ASD without conducting a formal assessment. Sounds like a parent got a second opinion and then complained to the board.

“Respondent Dr. X stipulated to the issuance of a public letter of reproval against Psychologist License No. XXXXX, with cost recovery and coursework
terms, after the Board fled an Accusation alleging Respondent’s communications with a minor patient’s mother caused her to believe that Respondent had concluded that the patient was not on the Autism Spectrum Disorder scale and did not have autism based upon his clinical observations of the patient without conducting a formal assessment of such disorder. The Decision and Order took efect
August 31, 2022.”

Does anyone else find it concerning that this is worthy of reproach?

Other gems from the board: someone had to surrender their license for lack of CEs (another person was put on 3 years of probation for the same thing—not sure why the different punishments). The first person who surrendered their license was right up there with the person who had sex with a client and threatened to send client’s nude photo out to family. How are these even remotely similar in scale of ethical violations?

Depends on what they did document and bill for. If they half-assed a 90791 in 30 minutes and "ruled-out" ASD among other things, the psychologist deserves this, and probably more. If they did a thorough diagnostic interview and history and carefully laid out why they do not think the patient met certain criteria, that's a different story. Having a job where I get to review many DAs, my money is on the former, as that's what I see a great deal of the time.

 

[futureapppsy2]

Just an interesting update: the CA BOP publicly shamed a psychologist (sent a letter of reproval) for saying they didn’t think a minor had ASD without conducting a formal assessment. Sounds like a parent got a second opinion and then complained to the board.

“Respondent Dr. X stipulated to the issuance of a public letter of reproval against Psychologist License No. XXXXX, with cost recovery and coursework
terms, after the Board fled an Accusation alleging Respondent’s communications with a minor patient’s mother caused her to believe that Respondent had concluded that the patient was not on the Autism Spectrum Disorder scale and did not have autism based upon his clinical observations of the patient without conducting a formal assessment of such disorder. The Decision and Order took efect
August 31, 2022.”

Does anyone else find it concerning that this is worthy of reproach?

Other gems from the board: someone had to surrender their license for lack of CEs (another person was put on 3 years of probation for the same thing—not sure why the different punishments). The first person who surrendered their license was right up there with the person who had sex with a client and threatened to send client’s nude photo out to family. How are these even remotely similar in scale of ethical violations?

If they're publicly shaming a psychologist for this, the medical board needs to publicly shame about 25% of pediatricians for spending 15 minutes with a kid and telling the parents they have/don't have ASD in definitive terms (yes, I know time is limited, but it's as awkward as hell when we have to tell a parent "I know your pediatricians said your kid has/doesn't have autism, but after our assessment, we determined they actually do/don't, and here's why.")

 

[WisNeuro]

If they're publicly shaming a psychologist for this, the medical board needs to publicly shame about 25% of pediatricians for spending 15 minutes with a kid and telling the parents they have/don't have ASD in definitive terms (yes, I know time is limited, but it's as awkward as hell when we have to tell a parent "I know your pediatricians said your kid has/doesn't have autism, but after our assessment, we determined they actually do/don't, and here's why.")

Med boards are mostly useless. If they won't do anything about their members killing and maiming my patients with poor med regimens, they won't do anything about a little bit of misdiagnosis of MH disorders.

 

[Fan_of_Meehl]

I really don't understand this idea that everything needs testing. As a provider, the observational longitudinal data that you collect over the duration of your work together is far more valuable and reliable in diagnosing than someone who meets with the patient for a few hours*. I get with autism you would want to rule out other things, but why test the person if they don't display sufficient symptoms to warrant the diagnosis (in which case rule-outs aren't really needed)?

It goes back to PsyDr's post upthread: tests don't diagnose, people do.

*this is more of a general vent about my clinic, where providers are scared to diagnose personality disorders or psychotic disorders and always insist on testing for that

In the cases of psychosis or ADHD (where the diagnosis at issue is tied to the decision of what med to prescribe and how), I think that there is a tremendous risk of "moral hazard" when the person with the prescription pad farms out the differential diagnostic responsibility to a third party (psychologist for a one shot yes/no assessment session) rather than doing the work themselves since they have access to longitudinal data about the patient and would be expected to titrate the med/dose in response to maximizing therapeutic benefits and minimizing adverse effects.

 

[PsyDr]

I really don't understand this idea that everything needs testing.

I can field this one. Sending someone out for testing:

1) Creates some barriers to less desirable patients. Drug seeking and the like will move on. Patients with limited resources will seek care elsewhere.

2) Pushes some of the responsibility onto the patient, and the psychologist in a way that avoids liability (e.g., "it's not me saying you don't have an Adderall deficiency, it's the psychologist"; "You didn't follow through with our treatment plan, so I will not prescribe the fun stuff).

3) Serves as a way for the physician to rapidly gain information, without slowing down their clinical pace (i.e., it's easier to read 10 pages, than ask the patient questions for 3 hours).

 

[cara susanna]

I can field this one. Sending someone out for testing:

1) Creates some barriers to less desirable patients. Drug seeking and the like will move on. Patients with limited resources will seek care elsewhere.

2) Pushes some of the responsibility onto the patient, and the psychologist in a way that avoids liability (e.g., "it's not me saying you don't have an Adderall deficiency, it's the psychologist"; "You didn't follow through with our treatment plan, so I will not prescribe the fun stuff).

3) Serves as a way for the physician to rapidly gain information, without slowing down their clinical pace (i.e., it's easier to read 10 pages, than ask the patient questions for 3 hours).

Okay, I guess I should have said I understand why there's this perception, but it's still frustrating.

 

[PikminOC]

On internship, I was told that psychologists at my site wouldn't diagnose autism other than provisionally without referring out to an assessment specialist for confirmation, but it was never explained why. Is it really frowned upon for psychologists to diagnose autism spectrum disorder directly from the DSM-5, especially if they've worked with people on the spectrum before?

A colleague of mine has been asked to write a letter confirming a client's diagnosis for housing reasons, and it got me thinking about this issue of "diagnostic turf" so to speak. If the housing entity doesn't require a specific formal assessment, is it appropriate for the colleague to write the letter based on their knowledge of working with the client long-term and experience working with folks on the spectrum (without conducting assessments), or is it an unspoken rule that no one diagnoses autism except assessment specialists?

I have a neuropsychologist who is diagnosing Asperger's in many patients. She knows it's not in the dsm and only in the icd. But she still doing that. I think she's using old tests. Also, she is diagnosing a lot of people with this. Like 80 percent! With full testing

 

[PikminOC]

I can field this one. Sending someone out for testing:

1) Creates some barriers to less desirable patients. Drug seeking and the like will move on. Patients with limited resources will seek care elsewhere.

2) Pushes some of the responsibility onto the patient, and the psychologist in a way that avoids liability (e.g., "it's not me saying you don't have an Adderall deficiency, it's the psychologist"; "You didn't follow through with our treatment plan, so I will not prescribe the fun stuff).

3) Serves as a way for the physician to rapidly gain information, without slowing down their clinical pace (i.e., it's easier to read 10 pages, than ask the patient questions for 3 hours).

I don't look at it as a liability standpoint. I want to get the correct diagnoses and as you wrote we don't have the time for that.

 

[Mojito_15]

I currently work in primary care behavioral health and our org wants us to diagnose ADHD and Autism off of what I think is not nearly enough. I've so far avoided it basically by covertly encouraging patients and their families to go elsewhere... We serve a lot of really low resource, high trauma, folks, about 1/3 of the community is refugees. So I understand the impulse to just get them a diagnosis b/c they're probably not going to go through the steps to get one elsewhere- and I would probably follow their protocol/workflow if I found someone who truly had nowhere else to go. But there are many in my org who are putting labels on people that I am not particularly confident in...