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Not comfortable diagnosing Autism?

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shahseh22

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I'm currently a first year child fellow and occasionally get psych evals in my outpatient clinic, where the caregiver expects I try to diagnose autism in order to help facilitate services. I am not 100% certain at times and it is hard to take a good history (I'm also still learning how to ask parents some of these questions), but sometimes I am unclear. It is sometimes evident that the child may be on the mild end of the spectrum, but I can't definitvely say, then I have the parents unhappy that I didn't make a diagnosis. Is there any rating scale I can use in the clinic? An ADOS is too costly and we don't have the psychologists in this clinic to help with that.

Also, I don't like making such a big diagnosis on the first visit.
 
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erg923

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I'm currently a first year child fellow and I routinely get psych evals in my outpatient clinic, where there is an expectation that I try to diagnose Autism in order to help facilitate services (ABA). I am not 100% certain at times and it is hard to take a good history (I'm also still learning how to ask parents some of these questions), but sometimes I am unclear. It is sometimes evident that the child may be on the mild end of the spectrum, but I can't definitvely say, then I have the parents unhappy that I didn't make a diagnosis. Is there any rating scale I can use in the clinic? An ADOS is too costly and we don't have the psychologists in this clinic to help with that.

Also, I don't like making such a big diagnosis on the first visit.

You don't "diagnose" with preconceived notions or motives. You diagnose what is there (or not). If that is how you truly feel, the clinic/institution needs to be made aware.

Some degree of standardized assessment and observation would be best practice for diagnosing ASD. To qualify for ABA services, this is often required as well. Can you at least do an ADI-R?

Rating Scales: GARS or ASDS. BASC can be helpful too.
 
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How much time do you have for these appointments? Also it's my understanding that at least in my area people can often get services with a provisional diagnosis, but only for 2 years. But gives time to get additional info if needed.
 
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wolfvgang22

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Isn't this what your attending is supposed to be teaching you? You aren't trying to evaluate children with suspected ASD without supervision, are you? I know that my attending was always nearby in fellowship, and often in the room for these evaluations. A lot of these kids and parents can be hard to manage on your own as a first year fellow.
 
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calvnandhobbs68

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Yeah are you just flying solo for this stuff? You should have someone with more experience helping you with at least your first handful of these...

Typically these visits are pretty long and extensive too for intakes. We had two 90 minute evals with multiple rating scales to rule out other psychopathology in our referral center.

The problem is with a lot of the rating scales is your institution has to license them (CARS2, SRS, etc) but any self respecting office who is regularly diagnosing autism should have various rating scales they typically use. You’re right that an ADOS is pretty lengthy, costly and you have to be specially trained to do them anyway. Do you have ADI-Rs?
 
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shahseh22

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I only get 90 minutes for a new evaluation and 30 minutes for follow ups. Attending has limited availability as there are multiple residents. I don't know what ADI-R is, do you guys have a copy that I can use to at least guide me?

Thanks
 

calvnandhobbs68

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I only get 90 minutes for a new evaluation and 30 minutes for follow ups. Attending has limited availability as there are multiple residents. I don't know what ADI-R is, do you guys have a copy that I can use to at least guide me?

Thanks

(ADI™-R) Autism Diagnostic Interview™, Revised | WPS

We don't have copies because your institution should be licensing these things along with the instructions for you guys to use (along with basically all other psychometric tools). Are you saying you're in a child psych clinic with no standardized assessment tools?
 

clausewitz2

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(ADI™-R) Autism Diagnostic Interview™, Revised | WPS

We don't have copies because your institution should be licensing these things along with the instructions for you guys to use (along with basically all other psychometric tools). Are you saying you're in a child psych clinic with no standardized assessment tools?

I mean it also aeems to be a child psych clinic where asking random Internet strangers about basics of assessment seems like a more helpful course of action than asking an attending, so maybe they don't have validated tools.
 
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shahseh22

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I'm not 100% sure, as we have a Psychologist (there is only one in the clinic and he cannot take all our referrals, I don't think he does an ADOS), whom send the referrals for testing or we ask the parents to send their kids to the school district to do the testing (via an IEP), our job as the Psychiatrists is just do the medication management. I will check with the Pscyhologist to see if he uses any validated assessment tools. However, as far as diagnosing Autism, we have just been instructed to stick to DSM 5 criteria and ask good questions about history. But it is still quite difficult to assess.

Keep in mind that this is a county run clinic where our resources are limited.
 
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michaelrack

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I'm not 100% sure, as we have a Psychologist (there is only one in the clinic and he cannot take all our referrals, I don't think he does an ADOS), whom send the referrals for testing or we ask the parents to send their kids to the school district to do the testing (via an IEP), our job as the Psychiatrists is just do the medication management. I will check with the Pscyhologist to see if he uses any validated assessment tools. However, as far as diagnosing Autism, we have just been instructed to stick to DSM 5 criteria and ask good questions about history. But it is still quite difficult to assess.

Keep in mind that this is a county run clinic where our resources are limited.

Hopefully you will get more out of future rotations, otherwise your fellowship seems like a complete waste compared to just completing a general psych residency
 
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erg923

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we ask the parents to send their kids to the school district to do the testing (via an IEP), our job as the Psychiatrists is just do the medication management. I will check with the Pscyhologist to see if he uses any validated assessment tools. However, as far as diagnosing Autism, we have just been instructed to stick to DSM 5 criteria and ask good questions about history. But it is still quite difficult to assess.

Your fellowship training sounds like garbage.
 
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I'm not 100% sure, as we have a Psychologist (there is only one in the clinic and he cannot take all our referrals, I don't think he does an ADOS), whom send the referrals for testing or we ask the parents to send their kids to the school district to do the testing (via an IEP), our job as the Psychiatrists is just do the medication management. I will check with the Pscyhologist to see if he uses any validated assessment tools. However, as far as diagnosing Autism, we have just been instructed to stick to DSM 5 criteria and ask good questions about history. But it is still quite difficult to assess.

Keep in mind that this is a county run clinic where our resources are limited.
It sounds like you are in a really unfortunate situation and you are not getting the training that you need. This is not a position you should be in, and htat is not enough time to make a diagnosis particularly for older kids or those without really clearcut symptoms.

The ADI-R can take about 2 hours to administer (time varies significantly depending on age of the kid) but still should be used in conjunction with other rating scales (We use CARS, SCQ, & SRS most frequently) -- and DEFINITELY including other means to suss out other psych concerns. ADHD , anxiety, and mood disorders are super common in ASD-- but also on their own can cause symptoms that look like ASD, espeically with regard to the social communication items (but also perseverative thinking). That's why we typically include CBCL, Conners and/or BRIEF and sometimes anxiety and/or depression measures. And kids who have global developmental delay / ID more often have stereotyped behaiors and some of the other symptoms of ASD; you have to make sure you are considering their overall cognitive level when you are assessing their behaviors.

So in short it sounds like you're in a near impossible position for cases that aren't basically a waiting room diagnosis. We don't do 2nd opinions in my clinic but we do a lot of 3rd opinions- often because someone has rec'd a dx through their pediatrician or similar, then family asked for school assessment to get IEP under ASD category, and the school did a more thorough assessment and said no. (To be fair, it is sometimes the other way around but that is the more common scenario, and the school districts immediately surrounding me are quite good at this thankfully).

You should be aware that there is a very important difference between a SCHOOL diagnosis (from the school system, often but not always by masters-level rather than doctoral clinicians). MOST insurance companies DO NOT ACCEPT school diagnoses. If the family wants to get behavioral health services for ASD through insurance, generally they need to get a MEDICAL diagnosis (doctoral level psychologist, MD, etc).

The best way I can see for you to muddle through given your seeming constraints is that unless it's a very clear diagnosis, to learn how to do a jam-up interview getting lots of good examples of past and current behavior and deliver the appropriate measures as much as you have time for (including to screen for comorbidities). Have parents come like Then you could give a provisional diagnosis if it seems appropriate, refer them to get additional testing (through the school perhaps) and then send you the full report to include developmental / cognitive testing and ADOS as a step 2 follow up. Still not a good situation. The fact that y'all don't have standard parent-report measures readily available is a bad sign if you're actually giving diagnoses. I hear you that your clinic is under-resourced but many of these are pretty inexpensive. (And some screeners are free, like the MCHAT, althouh those are just screeners and not diagnostic tools per se).

Your situation sounds alarming though maybe not all that uncommon sadly. Send me a PM if you're interested and I'll share a doc of a guided interview with some examples we use with students in our clinic, which would be better than nothing if you can't do / get an ADI-R.
 
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SmallBird

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I'm currently a first year child fellow and occasionally get psych evals in my outpatient clinic, where the caregiver expects I try to diagnose autism in order to help facilitate services. I am not 100% certain at times and it is hard to take a good history (I'm also still learning how to ask parents some of these questions), but sometimes I am unclear. It is sometimes evident that the child may be on the mild end of the spectrum, but I can't definitvely say, then I have the parents unhappy that I didn't make a diagnosis. Is there any rating scale I can use in the clinic? An ADOS is too costly and we don't have the psychologists in this clinic to help with that.

Also, I don't like making such a big diagnosis on the first visit.

There is an underlying conceptual issue that is relevant here. ASD is thought to be a brain based disorder, but there is no neuroscientific account of ASD which is universally accepted, or thought to account for almost all the symptoms seen in almost all the the cases seen. As such, there are likely people with high scores on ADOS and ADI-R that do not have the same brain based issues, but are similar in meeting a phenomenologic threshold for social impairments and repetitive behavior. Recently, many papers have highlighted the "non-specificity" of ADOS and ADI in clinical populations; a challenge of this work is that the gold standard in these cases is often the vague "multidisciplinary assessment", which may similarly struggle for issues of specificity and is very unlike something like a biopsy as a gold standard. In this context, I think it is unimportant to obsess over a strict yes or no diagnosis, but rather, the task should be to collect as much data as possible to describe the dimensions of impairment, and what might be helpful to address this. I have had patients who have such prominent social cognitive deficits that a history and very high score on a rating scale has given me enough confidence to write a school letter saying that they have multiple symptoms of ASD and should be provided available supports. And then I have seen patients over two days with multidisciplinary teams where after two days we continue to be unsure as to the best way to describe and label the presentation, where the decision to confer the ASD label ultimately seems like a distraction, and where we nevertheless have a range of behavioral, educational and psychiatric recommendations to make.
 
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clausewitz2

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There is an underlying conceptual issue that is relevant here. ASD is thought to be a brain based disorder, but there is no neuroscientific account of ASD which is universally accepted, or thought to account for almost all the symptoms seen in almost all the the cases seen. As such, there are likely people with high scores on ADOS and ADI-R that do not have the same brain based issues, but are similar in meeting a phenomenologic threshold for social impairments and repetitive behavior. Recently, many papers have highlighted the "non-specificity" of ADOS and ADI in clinical populations; a challenge of this work is that the gold standard in these cases is often the vague "multidisciplinary assessment", which may similarly struggle for issues of specificity and is very unlike something like a biopsy as a gold standard. In this context, I think it is unimportant to obsess over a strict yes or no diagnosis, but rather, the task should be to collect as much data as possible to describe the dimensions of impairment, and what might be helpful to address this. I have had patients who have such prominent social cognitive deficits that a history and very high score on a rating scale has given me enough confidence to write a school letter saying that they have multiple symptoms of ASD and should be provided available supports. And then I have seen patients over two days with multidisciplinary teams where after two days we continue to be unsure as to the best way to describe and label the presentation, where the decision to confer the ASD label ultimately seems like a distraction, and where we nevertheless have a range of behavioral, educational and psychiatric recommendations to make.

This is quite interesting nuance and explains rather well the confusion I have had in the past over exactly what leads to particular individuals I have encountered getting an ASD diagnosis or not. It is unfortunate that payors and services definitely do require commitment one way or the other on that diagnostic label, and it has profound consequences for what supports a child will receive or not.
 
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WisNeuro

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Given the ease of misdiagnosis due to the myriad of other things that could be going on, both medically and psychologically. Any evaluation under several hours is likely to be severely inadequate and potentially life altering. If you must do something, I would hedge all my bets and mention repeatedly in my notes that a full evaluation by someone trained in this area is necessary to adequately diagnose such things.
 
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clausewitz2

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Given the ease of misdiagnosis due to the myriad of other things that could be going on, both medically and psychologically. Any evaluation under several hours is likely to be severely inadequate and potentially life altering. If you must do something, I would hedge all my bets and mention repeatedly in my notes that a full evaluation by someone trained in this area is necessary to adequately diagnose such things.

Wish I could upvote this. I have worked with a patient whose parent badgered someone into giving them an autism diagnosis as a young child which profoundly shaped their conception of themselves and their social trajectory. By the time an actual ADOS was done years later, they barely scored at all. This person is on the rigid end of the personality distribution of flexibility, but still.
 
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SmallBird

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Wish I could upvote this. I have worked with a patient whose parent badgered someone into giving them an autism diagnosis as a young child which profoundly shaped their conception of themselves and their social trajectory. By the time an actual ADOS was done years later, they barely scored at all. This person is on the rigid end of the personality distribution of flexibility, but still.

It gets really irritating when research studies start to make claims about ASD comorbidity by using non-specific screening instruments in populations with enriched social symptoms to begin with. The most prominent example is the Gender Dysphoria/ASD research which is mostly absolutely terrible and yet made it onto my psychiatry boards as if its now an established comorbidity.
 

WisNeuro

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Wish I could upvote this. I have worked with a patient whose parent badgered someone into giving them an autism diagnosis as a young child which profoundly shaped their conception of themselves and their social trajectory. By the time an actual ADOS was done years later, they barely scored at all. This person is on the rigid end of the personality distribution of flexibility, but still.

Unfortunately this is the rule rather than the exception, pretty much all around in mental health. Far too many time/billing constraints to adequately and properly evaluate patients, so they get diagnoses based on a 10 minute discussion and maybe a questionnaire. I see it all of the time even in my neuro world, where someone is diagnosed with a dementia by their PCP, I see them several years later and it's just a combination of psych issues, medications, and untreated sleep apnea. But now they've had an increase in depression due to the fact that they believed that they had Alzheimer's and wouldn't make it to 75. I'm sure you all see other variations of this in your own clinical worlds all of the time as well. It's only going to get worse too, we already have BCBS winnowing down what they will allow in pre-auth and it shrinks every year. Pretty soon they'll pretty much only allow me to bill for a 30 minute interview and a MoCA.
 
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whopper

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I remember my first 3 months in psych residency I had an attending that pretty much didn't teach and just tried to use residents as free labor.
I didn't know or learn much during those 3 months. The guy wrote an evaluation saying so without taking any responsibility for his lack of teaching. The way he saw it I was the equivalent of a golf caddy and I didn't caddy well.
E.g. Nurses asked me to do an admission. I hadn't done one before as a resident (and each hospital has a slightly different way of doing it). So instead of him being there or a senior resident being there (one wasn't), I was just stuck with the job of doing it and the nurses would then berate me for not knowing how to do one. When I finally gotten a handful done I still hadn't had any attending review any of them and give me feedback.

By the end of my first year I knew more psych (and IM) and was a better psychiatrist than he ever was. By the time I was chief resident the head of the department told me several stories of how pathetic this guy was as a resident and still was as an attending but she had to keep him because she couldn't get someone better to replace him.

Lots of times people are in denial that they've got a bad teacher. The culture and the high respect physicians have lead most students to think that all professors are good. It wasn't until about 2nd year that I was even considering it as a possibility.
 
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clausewitz2

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Unfortunately this is the rule rather than the exception, pretty much all around in mental health. Far too many time/billing constraints to adequately and properly evaluate patients, so they get diagnoses based on a 10 minute discussion and maybe a questionnaire. I see it all of the time even in my neuro world, where someone is diagnosed with a dementia by their PCP, I see them several years later and it's just a combination of psych issues, medications, and untreated sleep apnea. But now they've had an increase in depression due to the fact that they believed that they had Alzheimer's and wouldn't make it to 75. I'm sure you all see other variations of this in your own clinical worlds all of the time as well. It's only going to get worse too, we already have BCBS winnowing down what they will allow in pre-auth and it shrinks every year. Pretty soon they'll pretty much only allow me to bill for a 30 minute interview and a MoCA.

See I was thinking 15 minutes and a Buzzfeed quiz.
 

DokterMom

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I'm not 100% sure, as we have a Psychologist (there is only one in the clinic and he cannot take all our referrals, I don't think he does an ADOS), whom send the referrals for testing or we ask the parents to send their kids to the school district to do the testing (via an IEP), our job as the Psychiatrists is just do the medication management.

Sadly, sending the parent to the school system for a diagnosis is putting the child into limbo for months while (typically) the school system stalls and hedges until the child ages out of birth-to-3 services or can be put off until they enter kindergarten -- at which point, since the child has no diagnosis, s/he is still not receiving needed services. School systems have also been known to claim they do not do diagnostic testing or that they only test during certain months or with certain [grossly insufficient] tests.

It is unfortunate that payors and services definitely do require commitment one way or the other on that diagnostic label, and it has profound consequences for what supports a child will receive or not.

Given the ease of misdiagnosis due to the myriad of other things that could be going on, both medically and psychologically. Any evaluation under several hours is likely to be severely inadequate and potentially life altering. If you must do something, I would hedge all my bets and mention repeatedly in my notes that a full evaluation by someone trained in this area is necessary to adequately diagnose such things.

This. THIS! If the child has an ASD, early and appropriate intervention is critically important and without a diagnosis, the child can't qualify for those services and goes months-years without treatment. If you don't feel qualified to evaluate, for goodness sake, say so! Better yet, demand the training to become qualified. Or if nothing else, find out who in your area IS qualified and send the parents there.
 
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