The aim, in this article is to provide comparative information on the BOSA with its scoring approaches, key logistical considerations for assisting CAMHS clinicians as well as highlight the advantages to this new way of working.
The global Coronavirus (COVID-19) pandemic has forced major changes to the delivery of healthcare systems worldwide. COVID-19 and the social distancing measures imposed to limit its spread have created unparalleled challenges in Autism diagnostic services. Many CAMHS teams were required to pause or reduce their in-person services, possibly indefinitely. There was an instant and unmaintainable increase in CAMHS waiting lists for Autism Spectrum Disorder (ASD) assessments. A new way of working within CAMHS has suddenly become very important in the context of the COVID-19 pandemic. It was evident that an open approach to autism assessments was required during this time; old procedures have had to be put on hold or modified and new approaches have been developed as a result. This article will explore the different methods and highlight the positive contributions of the Brief Observations of Symptoms of Autism (BOSA) has made to CAMHS service development during COVID-19.
Autism Spectrum Disorder (ASD) is a group of complex neurological and developmental disorders that effect brain development and cause social communication challenges. Young people with the condition tend to struggle with social interaction on both the verbal and nonverbal level. Further, they may exhibit repetitive behaviors or have special interests. Patterns of ASD can appear during the early years and typically last a life time. No two individuals with ASD are the same and their difficulties can present very differently. These capable individuals may mask their difficulties to blend in with neurotypicals. Thus, detailed assessments are required to diagnose ASD.
ASD diagnostic assessments are multi-disciplinary evaluations tailored to the needs of each family; they include a thorough review of the young persons’ behavior and development. Clinicians seek information about the child’s behaviour along with a comprehensive developmental history, through direct observation and interviews with parents. Before COVID-19, the Autism Diagnostic Observation Schedule (ADOS-2) was the gold standard diagnostic tool used to help assess ASD.
The ADOS-2 is a one-to-one in-person interaction that was used to investigate the key indicators of ASD, including communication, social interaction, and restricted and repetitive behaviors. One of the reasons the ADOS-2 cannot be conducted during the pandemic is because it does not allow for social distancing and puts both the young person and clinician at risk of infection. However, the main reason the ADOS is not currently used, is because face masks and personal protective equipment (PPE) can impact how the young person behaves, so the results will not be dependable.
CAMHS assessments are now predominantly conducted virtually, and the face-to-face interactions have been adapted to allow for a safe observation of the young individual. This new clinical approach is called the Brief Observation of Symptoms of Autism (BOSA); developed by the authors of the ADOS-2. The BOSA was adapted from the ADOS-2 and the Brief Observation of Social Communication Change (BOSCC); this guarantees that children suspected of ASD can receive valid diagnostic assessments throughout the pandemic.
Welcome development for those involved at CAMHS when assessing for autism. This means that multi-disciplinary assessments for ASD can recommence whilst still adhering to national guidance for PPE and social distancing during the Coronavirus pandemic. So far, the BOSA has been positively received by families as per the feedback we received at CAMHS.
Like the ADOS-2, the BOSA is only one component of a multi-disciplinary diagnostic assessment. It acts as a substitute to the ADOS-2 and is a direct observation of the young person’s behaviour. The aim of the BOSA is to create a setting in which indicators of autism can be directly observed while remaining socially distanced. The BOSA can only be administered and interpreted by ADOS-2 trained clinicians, because the tool relies primarily on ADOS-2 experience. Unlike the ADOS-2, the BOSA involves the young person interacting with their parent (or an adult they are comfortable with) rather than directly with the clinician. Additionally, multiple clinicians are involved with the BOSA assessment, the clinician guiding the parent (Administering clinician) and a clinician observing the interaction. This observation could be virtually, from the next room with an observation window or in the room with observers wearing PPE and socially distanced.
During the BOSA assessment the parent will use a set of standardised tasks that presses to cue responses from their child. In order to do this effectively the administering clinician will give parents clear instructions so that they can be well prepared for the assessment. If the parent is unsure during the assessment, the clinician is there to provide support and can coach the parent. However, the young person is expected to show initiative during the early stages of the assessment without assistance or outside prompting from their parent or the clinician. This can be a challenge for parents as they are often used to supporting their child with social communication difficulties (e.g. asking follow up questions). This can be a challenge for parents, especially during conversation tasks where the young person’s difficulties are often more prevalent. The purpose of the BOSA assessment is to see how the young person behaves without assistance. This means that the clinicians can get a better understanding of how the child normally presents.
Inside the assessment process:
- The BOSA delivers openings for a parent to engage in social interactions with their child through structured games, playful questions and conversation. This creates a context and platform in which indications of autism can be observed.
- The parent takes a lead role in carrying out a set format of activities with their child which are observed by the clinicians.
- Parents are provided with instructions before the assessment to minimise assistance needed from the clinician. During the assessment, the clinician offers ongoing support and clarification to the parent. The observation could be from the next room with an observation window or in the room with clinicians wearing PPE and appropriately socially distanced.
Online CAMHS services are playing a lead role in service development across England. There is also growing evidence that is suggesting that young people with suspected social communicational difficulties are responding far better to the BOSA assessment. Due to the anxiety that many have with suspected social communication difficulties the BOSA provides an excellent alternative particularly when meeting new people. An assessment completed with a parent alongside the young person is slowly proving to be a highly effective way to work within CAMHS. For example young people would feel more comfortable to share ideas and thoughts with a parent as opposed to a clinician. This process promotes engagement. This can be particularly beneficial when the young person has anxiety or is selectively mute. Additionally, the clinician can observe how the child interacts with their parent compared to the clinician. Drastic changes in how the child presents interacting with different people can provide evidence for ASD. Generally, in CAMHS we have found having a parent close by aids emotional wellbeing and helps the young person maintain a relaxed frame of mind.
The BOSA involves games that are quick and fun. Often, families already know these games (e.g., Pop the Pirate, Jenga, etc.) making it easier for them to engage with and enjoy the activities without interference from the clinician. There are time limits on each of the activities to ensure that the young person remains engaged. The games were chosen specifically to promote reciprocal social interaction and turn taking. The BOSA was designed to be fun and interactive for all ages.
The use of the BOSA has reintroduced collaborative working for CAMHS clinicians. The BOSA is conducted with two clinicians: one in the room administering and another observing indirectly (e.g. virtually, in an observation room or pre-recorded). The team involved in observing the BOSA are all ADOS trained and have experience in the administration of the ADOS. Having two qualified staff involved with the BOSA is a valuable addition to ASD assessments. Two sets of eyes mean more observations; what one clinician might miss the other will catch. It also allows for different perspectives and bouncing ideas off of each other. It allows for clinicians to learn from each other and to continue to develop.
Dr Mark Chapman (Clinical Neurodevelopmental Psychologist) and Taylor Saravanamutto (Assistant Psychologist)