Exploring the diagnostic process for autistic spectrum conditions

We spoke with Dr Pawan Rajpal (MBBS, PGDip Mental Health Law, PGDip Psychological Medicine), exploring autistic spectrum conditions (ASC) further. This article offers insight into how a GP can diagnose this condition, what the signs and symptoms to look out for are, and the best treatment available.

The 'A word' is featuring more and more in discussions surrounding mental health, and with television programmes such as 'Employable Me' showing the importance of breaking down the stigmas associated with this condition, there's no better time to stress the importance of diagnosing an autistic spectrum condition.

In a recent survey, the incidence of autism was as high as 1% in the UK’s general population. In pragmatic terms this means that in a list of 5,000 patients, it would be estimated that between 18 and 24 people would have ASC.

Autism spectrum conditions, including Asperger syndrome, are recognised disabilities. If someone meets the relevant criteria, set out in ICD-10 or DSM-5, they should be diagnosed with ASC.

How is Autism diagnosed?

A specialist would use an official questionnaire to begin the diagnosis of a patient with suspected ASC and assess the ASC symptoms they might be struggling with. Such questionnaires include:

The Royal College of Psychiatrists’ questionnaire for ASC diagnosis

This is an autism toolkit which aims to be a 'one stop shop', user-friendly guide to autism, for primary care professionals, people affected by autism, provider trusts and local systems, as well as interested members of the general public.

The Diagnostic Interview for Social and Communication Disorders (DISCO)

This is a dimensional approach to support experienced professionals in diagnosing and developing a further understanding of ASC.

The DISCO helps to collect information concerning all aspects of an individual’s skills and behaviour, not just the features of ASC. Detailed information is collected to reflect the individual’s development over time, as well as the current picture.

The Autism Diagnostic Observation Schedule (ADOS)

This is an assessment of communication, social interaction, and play, and consists of four modules, each of which is appropriate for children and adults of differing developmental and language levels.

The ADOS offers GPs the opportunity to observe social behaviour and communication in standardised, well-documented contexts.

The use of this tool in ASC diagnosis should be accompanied by information from other sources, particularly a detailed history from parents for children, whenever possible.

It is also important that a GP considers the conversation that they may have with a patient who is struggling with their symptoms and finding a potential ASC diagnosis to be a daunting prospect.

Questions to consider when talking to your patient include:

• Do you find social/group situations to be confusing (even though you may seem OK talking on a one-to-one basis)?
• Do you find it difficult to understand humour and sarcasm?
• Do you find it difficult to make and maintain friendships?
• Are you struggling to maintain a job or keep a place of education due to interpersonal difficulties?
• Do you have special interests or hobbies that seem to be taking up all of your time?
• Do you struggle to manage change in routines?

If a patient answers ‘yes’ to the majority of these questions, then they would benefit from a referral to an ASC diagnostic service.

Unfortunately, not everyone with ASC will receive a diagnosis until later in life and many people will be unaware why they experience the difficulties that they do.

Benefits to being diagnosed

There are many benefits to providing a diagnosis to a patient who visits your surgery, who is showing signs of an ASC. They include:

• Being able to offer clarity and a sense of understanding for the individual
• Allowing the patient to make sense of their history, which is often marked by difficult experiences and misunderstanding from others
• Allowing them the chance to gain ‘adaptations’ throughout life under the Equality Act
• Being able to offer support for families, friends and carers, to help them to better understand and cope with their loved one’s needs and behaviour
• Providing access to appropriate services and support networks
• Being able to allow the patient support at work, school, etc., as well as with social and housing services, benefits agencies and other organisations

Spotting the signs and symptoms of ASC

An individual with autism will likely have an ‘unusual’ social style, have few or no friends, experience higher levels of anxiety or stress, and may find it more difficult to complete a college course or maintain a job. During a visit to your surgery, they may also report to you with one or more of the following symptoms:

• Inappropriate social interactions
• ‘Robotic’ or repetitive speech
• Challenges with non-verbal communication, e.g. gestures, facial expression, etc.
• Average to above-average verbal skills
• Tendency to discuss themselves rather than others
• Inability to understand social/emotional issues or non-literal phrases
• Lack of eye contact or reciprocal conversation
• Obsession with specific, often unusual, topics
• One-sided conversations
• Awkward movements and/or mannerisms

A child or adult may have mild to severe symptoms and could have just one or all of these symptoms. Because of the wide variety of symptoms, no two individuals with ASC are alike.

With more of a focus on assessment and diagnosis in young children, it is often when a child is diagnosed that their parents start to recognise certain behaviours in themselves. Getting an ASC diagnosis as an adult can be difficult, especially as the condition isn’t always easily recognised, making early diagnosis even more important.

Co-morbidities

Many people with ASC also have co-existing disorders and may also experience symptoms of these conditions. Examples to look out for include:

• Attention deficit hyperactivity disorder (ADHD)
• Executive function deficits
• Anxiety disorders, including social anxiety disorder
• Depression, especially in adolescents
• Obsessive compulsive disorder (OCD)

Treatment

The earlier an ASC diagnosis is made, the sooner adaptations can be put in place to help to reduce the negative effects that are caused by ASC and their potential co-morbid executive functions.

Simply having the awareness and knowledge of an ASC diagnosis is very effective in reducing the stress and anxiety caused by the associated behaviours and deficits within school, work and family life.

There is no cure for ASC and as such, it is a lifelong condition. However it can stabilise over time and improvements can be seen, given the correct care and support. This includes:

• One-to-one sessions such as cognitive behavioural therapy (CBT)
• Group therapy such as social skills workshops
• Intensive inpatient programmes where clinically appropriate
• Appropriate medication
• Speech and language therapy
• Sensory assessments with suggested recommendations for communication

Priory’s nationwide network of inpatient hospitals and outpatient wellbeing centres are well-placed to offer support for individuals with ASC.