Good articles on Autism Spectrum Disorder?

[shahseh22]

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Hi all,
I'm finding in my fellowship, we are very reluctant to diagnose Autism Spectrum Disorder, mainly because of the different presentations it has. I was wondering if anyone has any good articles or a resource for where one can find one to get better with this? Before I finish my fellowship, I really want to be good at fishing this diagnosis out. It is unfortunate for me to see so many kids who aren't getting diagnosed until their 17 and thus not getting appropriate ABA therapy as well as other services in accord with what I feel is ASD until its too late.

Thanks in advance!

 

[Merovinge]

Hi all,
I'm finding in my fellowship, we are very reluctant to diagnose Autism Spectrum Disorder, mainly because of the different presentations it has. I was wondering if anyone has any good articles or a resource for where one can find one to get better with this? Before I finish my fellowship, I really want to be good at fishing this diagnosis out. It is unfortunate for me to see so many kids who aren't getting diagnosed until their 17 and thus not getting appropriate ABA therapy as well as other services in accord with what I feel is ASD until its too late.

Thanks in advance!

Are you in a CAP fellowship or something like neuropsych? If its the former that is a huge issue as ASD is likely the second most common diagnosis group past ADHD in general CAP work. I recommend finding an attending who has interest in the field and chatting with them about their approach and potentially about ways to better help your classmates learn about this (if you're in such a position at your program). I personally find that clinical interview is not sufficient for this diagnosis however you will get referrals and you have to figure out how you want to manage them. I refer the majority of my patients for testing, ADOS being the one I've seen used the most and with the best research behind it. This provides insurmountable evidence combined with your documentation to get services through schools and from ABAers.

 

[Tapepsi]

I was fortunate enough to have amazing child and adolescent attendings at my residency program and we were each required to do at least 1 ADOS (I somehow ended up doing 3 by the time I completed residency). We did them in rooms with 1 way mirrors so the attending and medical students could observe and I could get feedback following testing. Like @Merovinge said it has the best research behind it’s a tool that every child attending I met stands by. Even if they don’t end up having ASD the test can really give you some valuable information on your patient (like social anxiety) although I’d never recommend doing an ADOS without high suspicion for ASD.

 

[clausewitz2]

@shahseh22 , when you are done with fellowship and have an attending job some place can you share the name of your program? Based on your posts and the complete inability of your attendings to answer any of the questions you've brought up, I in all seriousness think you would be doing future applicants a service to warn them off it.

 

[shahseh22]

I was fortunate enough to have amazing child and adolescent attendings at my residency program and we were each required to do at least 1 ADOS (I somehow ended up doing 3 by the time I completed residency). We did them in rooms with 1 way mirrors so the attending and medical students could observe and I could get feedback following testing. Like @Merovinge said it has the best research behind it’s a tool that every child attending I met stands by. Even if they don’t end up having ASD the test can really give you some valuable information on your patient (like social anxiety) although I’d never recommend doing an ADOS without high suspicion for ASD.

That sounds like an amazing experience to be able to do ADOS evaluation. The School districts typically do this during an IEP evaluation when ASD is suspected.

 

[shahseh22]

Are you in a CAP fellowship or something like neuropsych? If its the former that is a huge issue as ASD is likely the second most common diagnosis group past ADHD in general CAP work. I recommend finding an attending who has interest in the field and chatting with them about their approach and potentially about ways to better help your classmates learn about this (if you're in such a position at your program). I personally find that clinical interview is not sufficient for this diagnosis however you will get referrals and you have to figure out how you want to manage them. I refer the majority of my patients for testing, ADOS being the one I've seen used the most and with the best research behind it. This provides insurmountable evidence combined with your documentation to get services through schools and from ABAers.

I'm in CAP fellowship. There are attendings who are interested in it but we don't do the ADOS testing it is typically done by Psychologists.

 

[Tapepsi]

That sounds like an amazing experience to be able to do ADOS evaluation. The School districts typically do this during an IEP evaluation when ASD is suspected.

Yes it was! What made it even more rewarding is that you learn a lot about your patients during the test and it really builds rapport as they view it as you playing games with them. The test takes some time to do (I remember it taking me around 40-50 min) but it is very easy to perform as the instructions are very thorough about what you ask your patient to do and how to score their performance.

 

[clozareal]

It's problematic that your CAP fellowship doesn't offer good training in how to make this diagnosis but it also sounds as though these attendings don't understand the nuances in making this diagnosis either. It sounds lazy on their part to not be able to develop enough clinical dexterity to be able to accurately diagnose ASD. It's also a huge disservice to the patients and their families in not being able to access valuable resources at critical periods of development.

In my adult residency, I've seen many ASD evaluations from psychologists, psychiatrist, social workers, and speech pathologists in a multidisciplinary setting and then have heard many arguments regarding whether to give an ASD diagnosis or not. I cannot state how valuable these debates have been on my clinical training and thinking about how to make the ASD diagnosis.

You would probably benefit from going to a training whether as a fellow or attending on how to perform an ADI-R or ADOS. We use both of them to make help make the diagnosis.

 

[shahseh22]

It's problematic that your CAP fellowship doesn't offer good training in how to make this diagnosis but it also sounds as though these attendings don't understand the nuances in making this diagnosis either. It sounds lazy on their part to not be able to develop enough clinical dexterity to be able to accurately diagnose ASD. It's also a huge disservice to the patients and their families in not being able to access valuable resources at critical periods of development.

In my adult residency, I've seen many ASD evaluations from psychologists, psychiatrist, social workers, and speech pathologists in a multidisciplinary setting and then have heard many arguments regarding whether to give an ASD diagnosis or not. I cannot state how valuable these debates have been on my clinical training and thinking about how to make the ASD diagnosis.

You would probably benefit from going to a training whether as a fellow or attending on how to perform an ADI-R or ADOS. We use both of them to make help make the diagnosis.

I wish we had the time built into the schedule to allow us to do ADI-R. We do mainly med management visits and evaluations. That's one of my gripes about my fellowship is that we don't get much exposure to psychometric testing. We usually give that responsibility to the psychologists.

 

[shahseh22]

piggy backing on the original question, any good articles explaining what exactly ABA therapy entails? what skills are being taught to these individuals way into adulthood? If someone is getting ABA for the first time at age 17 is there any utility to it? I know its not going to be the same thing as getting it at age 5.

 

[foreverbull]

I’m a psychologist, so I’d be interested in clarification on this because we are trained to immediately refer to a psychologist who conducts ASD-related assessments. We are told not to provide this diagnosis based purely on DSM criteria, nor conduct assessments we aren’t fully trained/competent in administering.

Thus, what is the perspective on diagnosing ASD in psychiatry?

 

[Merovinge]

I’m a psychologist, so I’d be interested in clarification on this because we are trained to immediately refer to a psychologist who conducts ASD-related assessments. We are told not to provide this diagnosis based purely on DSM criteria, nor conduct assessments we aren’t fully trained/competent in administering.

Thus, what is the perspective on diagnosing ASD in psychiatry?

If you look at my post above, this is exactly the same sentiment I see in a lot of younger CAP attendings. Of course either of our fields can make the diagnosis after an eval, however for numerous reasons above I think the field is shifting away from this and towards testing with specialization in this area. Even in my rural area there are several ASD specific testing/therapy locations within a few hour drive so it's rarely overly burdensome and my families come back almost universally happy when they complete the testing regardless of which direction it shows (although my referral to positive hit rate is currently clearing 90%).