Multidisciplinary Evaluation for ASD in a Clinical Setting
Best practice guidelines for autism assessment call for a comprehensive evaluation including the following components: parent interview, review of relevant records, cognitive/developmental assessment, direct play observation, adaptive assessment, and comprehensive medical examination (National Standards Project, 2015). As an autism specialty clinic, we have followed these guidelines in our diagnostic protocol; however historically the medical evaluation occurred only after the autism diagnosis had already been made by a psychologist. There are many problems with this approach. By delaying the medical evaluation to the end of the diagnostic process, important medical information will not be incorporated into the diagnostic formulation. Neurological disorders that better account for the developmental concerns, e.g. cerebral palsy, or medical conditions that preclude a diagnosis of ASD, e.g. profound visual or hearing impairment, will be missed. When medical conditions are not taken into proper consideration, inappropriate behavioral assessments are utilized and underlying diagnoses are conceptualized incorrectly.
The objective of our current initiative is to meet best practice guidelines through an integrated multidisciplinary approach, which includes incorporating medical and behavioral assessment findings in the conceptualization of each child’s diagnosis.
In the new diagnostic model, patients are first seen by a medical provider (child neurologist, developmental-behavioral pediatrician, child psychiatrist, or pediatric nurse practitioner) who conducts a parent interview, reviews medical records and performs a physical examination. When significant red flags for autism are present and medical/neurological conditions do not account for the developmental delay, children are referred on to a psychologist for a comprehensive evaluation of behavioral symptoms. After psychological testing is completed, the physician/nurse practitioner(NP) and psychologist confer to conceptualize the case and determine diagnosis, followed by a joint feedback session with the family.
Multidisciplinary evaluations were rolled out as a pilot in our clinic in May 2016. Patients participating in this pilot identified as White (58%), Black/African American (32%), Asian (5%) and Other (9%), and 59% had Medicaid as their primary insurance. A total of 85 patients received a diagnostic interview with a physician/NP. Of these, 38% were not referred on for additional testing (ASD ruled out for 18%, and clear ASD already established for 20%). 15% of the patients had significant medical conditions (e.g. congenital CMV, agenesis of corpus callosum, sensorineural hearing loss, complex congenital heart disease). Of the children who were referred on for comprehensive psychological assessment, 72% met criteria for ASD.
Autism spectrum disorders can be very challenging to diagnose, particularly in young children, as other neurodevelopmental disabilities can have similar presentations. An autism diagnostic assessment requires a comprehensive evaluation, ideally in a multidisciplinary setting. Both medical and behavioral assessments should be thoughtfully integrated to inform diagnostic formulation. Experts from different fields who are well trained in ASD assessment should work collaboratively to establish a diagnosis of autism in order to develop more comprehensive care plans that take all aspects of the child’s profile into consideration. Future plans for multidisciplinary diagnostic assessment involve expansion of expertise to include professionals in speech language pathology, nutrition, and clinical genetics.