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Mark Chapman looks at the vital contributions families and school staff make to the autism assessment process

Autism is a neurologically based pervasive developmental disorder. The word “neurological” points to how this condition affects the brain and “pervasive” means that it affects many areas of global development. 

A diagnosis of autistic spectrum disorder (ASD) is generally made only when all other possible explanations have been ruled out. There usually needs to be enough evidence across different environments prior to assessment to go ahead with an assessment. 

Professionals around the world agree that the earlier the condition can be diagnosed and the sooner clinical interventions can be implemented, the more likely the child will be to develop and reach their full potential. What’s more, by providing the earliest possible support tailored to the child and the family’s unique needs, we can generally reduce stress within the family and promote a growth in knowledge, especially in relation to parenting skills. We can also promote both a willingness and an ability within the family to find solutions to the challenges that lie ahead.

Many children with autism and their families benefit from having a diagnosis. Having an explanation for the problems that a child has been facing can bring a sense of a reprieve. Diagnoses can provide the information one requires to get access to the most appropriate education and service provision within the community. 

Autism assessments

Autism is currently diagnosed by the presence or absence of certain behaviors which usually occur across different environments, such as school and home. Some children with autism do not exhibit any clinically significant delays in their language or cognitive development in the first three years of life and have higher overall academic abilities than the average. 

Crucial to any assessment is using well-respected informal and formal assessment tools in conjunction with evidence from the family and school in order to gather a functional evaluation of the child’s social communication abilities and social perspective-taking skills. It is important to identify specific learning difficulties as an assessment of nonverbal learning is very useful when assessing for Autism. Generally, a profile of cognitive styles, strengths and difficulties better informs the assessment.

Despite an unremarkable developmental history, some young people have clear difficulties with social understanding, interaction, and reciprocal communication and have patterns of restricted, repetitive patterns of behaviour or interests. 

Assessment of autism should be conducted by a multi-disciplinary team and all reports from educational psychology, paediatric medicine, speech and language therapy and child psychiatry should be integrated into the final decision.

How can parents help this process?

Key to any professional assessment is the quality of information received from the family and the school.

Some parents are desperately trying to unravel the reasons for their child’s difficulties. They often seek an explanation for their child’s behaviour, which they feel has not yet been completely explained. Parents may also be looking for information that will more efficiently guide their selection of intervention or management approaches, or strategies that will ensure their child reaches their full potential. 

Receiving an autism diagnosis for their child can come as a great shock to parents and it can take a while to accept the reality of it. However, although it can seem like the end of the world for some parents, it is important to remember that their son or daughter is the same person they've always been. The only difference is that the family is now aware of the condition their child has and is in a much better position to help them make the most of their potential and live life to the fullest.

Some parents prefer not to get a formal diagnosis for their child. They may feel that their child will make greater progress if they do not think of themselves as having a condition or a disability. Sometimes, for these parents, knowing the likely source of their child’s difficulties appears to be enough. 

The signs of autism at home

There are a number of key indicators that parents and teachers can look out for that might suggest that it would be worth exploring the possibility that a child could be on the autistic spectrum. 

Parents and carers might notice that their child:

  • seems confused by language and takes figures of speech literally 
  • presents with an unusual tone of voice, or uses speech in an unfamiliar way
  • has a very good vocabulary and talks in a formal or old-fashioned way
  • finds it hard to follow a set of instructions involving more than one action
  • has trouble reading non-verbal cues, such as body language or tone of voice, to guess how someone else might be feeling
  • uses eye-contact in an unusual way
  • expresses fewer emotions on their face than other children, and might have difficulties reading other people’s facial expressions
  • uses very few gestures to express themselves, such as shrugging, pointing or using hands to demonstrate things in discussion
  • ignores other children
  • does not respond very well to people outside the family
  • doesn’t use “you” and “me” correctly
  • doesn’t show a wide range of emotions
  • exhibits behavioural extremes and might be unusually aggressive, fearful, sad or shy
  • is unusually withdrawn and not active in social situations
  • is easily distracted and has trouble focusing on an activity for more than five minutes
  • doesn’t respond emotionally to people or responds only superficially
  • can’t tell the difference between real and make believe
  • doesn’t participate in a wide variety of games and activities
  • doesn’t use plurals, pronouns or the past-tense properly
  • doesn’t talk about daily activities
  • loses skills they once had
  • struggles with simple daily activities.

How parents can support assessments

There are a number of key things parents and carers can do to support the assessment process and prepare the forms for child and adolescent mental health services (CAMHS). How your child plays, learns, speaks and acts offers crucial clues about development.

Prior to assessment, parents could write down everything they remember about their child’s early development, for example in terms of language and communication, using language in context, stereotyped conversation, social relationships, and facial expressions as an infant.

It can also be helpful to provide as much information as possible on your child’s early imaginative play, such as playing pretend games, and on social cooperative play, such as pass the parcel, musical chairs or hide and seek. When your child is with others, how do they play? Do they lack the understanding of how to play with other children or avoid social contact? Can you remember if the staff at nursery raised concerns and, if so, what were they?

What is the child’s conversational style like? Is it often one-sided and more of a monologue than a dialogue? Does your child only like talking when the conversation is based around their unique special interest?

Parents play a crucial role in collecting all the information required prior to assessment, such as school reports and academic transcripts. These can provide invaluable information from teachers and on how the child is performing academically. 

It is important to bear in mind that children with intellectual difficulties have different profiles of clinical features in terms of such things as IQ. Some children are slower to develop communication and adaptive behavioural skills or show significant delays in the acquisition of general skills. The main task is to determine whether the behaviour in question is a result of autism or difficulties with intellectual abilities.

Signs of autism at school

Crucial to an efficacious assessment is the evidence gained from school and it is unlikely that a diagnosis can be reached without this information. Warning signs at school could include the child:

  • having long-standing difficulties in social behaviours, such as struggling to understand another pupil’s perspective or getting upset if rules are broken
  • struggling with any kind of change, such as a change in classroom routines
  • coming across as naive and lacking in common sense
  • not developing appropriate independent behaviour
  • being unduly quiet or talking at others rather than have a to-and-fro conversation
  • talking excessively about topics of interest and not being able to pick up if the person is listening 
  • struggling to understand sarcasm or work out if someone is teasing them
  • lacking awareness of personal space and struggling to understand social boundaries
  • showing intolerance of intrusions into their own personal space
  • exhibiting rigid thinking and behaviour in class
  • displaying a strong preference for familiar routines
  • showing unusual reactions to sensory stimuli
  • having difficulties in making and maintaining friendships
  • seeming uninterested in peer group norms or keeping up with their peers
  • exhibiting a strong sense of justice, such as telling people off for breaking the rules
  • being seemingly unresponsive to other peoples facial expressions and feelings
  • struggling to use imagination
  • being easily overwhelmed by social events
  • struggling to join groups 
  • lacking awareness of classroom etiquette by, for example, openly criticising teachers in front of the class
  • being overly tense and struggling to relate to adults.

How schools can support assessments

Teachers play a very important role in contributing their ideas and experiences in the domains of social interaction at school. Does the child seem unaware of the rules that govern social interaction or lack awareness of the thoughts and feelings of others? Has the child been observed to approach other pupils or teachers in an inappropriate or repetitive way? Does the child respond when addressed in a group? 

School staff can also provide valuable information to those conducting autism assessments about the child’s academic abilities and their cognitive strengths and difficulties. It can be very useful to know what the child’s main difficulties are in the classroom and how long they have been evident. The child’s behaviour at school and their levels of concentration, activity, attention, and organisation are also important.

School staff are usually well placed to gauge a child’s language and communication abilities. Issues could include delayed language development, pedantic speech patterns, unusual intonation, an inability to understand jokes and a tendency to take comments literally

The child may also struggle to understand nonverbal cues and, in smaller group work, may have difficulty following other people’s agendas. The child may also prefer to talk about facts that are not relevant to the situation.

Teaching staff may also be able to identify any difficulties in flexible thought and behaviour processes. 

Is the child heavily reliant on routines in class? Does the child have obsessions or follow certain rituals at school? The child may also exhibit difficulties generalising concepts in class and may focus on minor details rather than on the bigger picture.

Further information

Dr Mark Chapman is Approved Lead Psychologist, CAMHS Neurodevelopmental Disorders Team at South West London and St Georges NHS Trust:
www.swlstg-tr.nhs.uk

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