Autism Assessment A Report

Service: Child and Adolescent Mental Health Service (CAMHS) Clinician: Dr. Emily Watson, Consultant Psychiatrist, GMC 1234567 Session Date: 01/11/2024 Client Identifier: CL00789-23 Date of Birth: 15/03/2010 (14 years) Gender: Male Report Purpose: This report details the findings from Assessment A of a comprehensive autism spectrum disorder (ASD) diagnostic evaluation for [Client Identifier]. It is intended for the client's parents, the referring GP, and the multi-disciplinary team involved in the assessment process. The purpose is to provide an initial summary of developmental history and presenting complaints, contributing to an overall understanding. The findings presented here are preliminary and require further evaluation in Assessment B before diagnostic conclusions can be drawn. Reason for Referral The client, a 14-year-old male, was referred by his General Practitioner following concerns raised by his parents and school regarding long-standing social communication difficulties, intense restrictive interests, and challenges coping with changes in routine. These difficulties have been present since early childhood, manifesting as struggles with peer relationships, difficulty understanding social cues, and significant distress in response to unexpected events. The duration of these challenges has led to increasing functional impairment in academic and social settings, prompting the request for an autism assessment. Assessment Process and Methodology This assessment comprised an initial diagnostic interview with the client's parents, utilising the Autism Diagnostic Interview-Revised (ADI-R) to gather comprehensive developmental history. This stage of assessment focused on eliciting information regarding early development, social interaction, communication, and repetitive behaviours. Data sources included parental report during the structured interview and review of previous school reports and GP correspondence. Current Presentation / Presenting Complaints [Client Identifier] presents with significant difficulties in social interaction, often struggling to initiate or maintain conversations with peers and preferring solitary activities. He exhibits a restricted range of interests, primarily focused on historical events and complex railway systems, which he discusses at length without always gauging the listener's interest. Behaviourally, he demonstrates repetitive finger flicking when anxious and experiences considerable distress in response to unexpected changes to his schedule. Attentional challenges are noted in classroom settings, particularly when not engaged in his areas of special interest, impacting his academic performance in subjects outside of history. Developmental History Prenatal and birth history were unremarkable. Early milestones were met within typical ranges, though parents recall [Client Identifier] being an unusually quiet baby with limited reciprocal smiling. He developed single words around 18 months, with phrase speech emerging later than peers. From nursery age, he struggled with imaginative play and demonstrated a strong preference for lining up toys. Socially, he found it challenging to form friendships, often playing alongside rather than with other children. Family history reveals a paternal uncle diagnosed with ASD and a maternal cousin with significant social anxiety. ADI-R Results and Interpretation The ADI-R was administered to the client's mother. Scores indicated elevated concerns across all three domains. In the 'Qualitative Abnormalities in Reciprocal Social Interaction' domain, the score exceeded the threshold, highlighting difficulties in shared enjoyment, emotional reciprocity, and social approaches. For 'Qualitative Abnormalities in Communication', scores were also above the clinical threshold, noting atypical language use, repetitive phrases, and difficulties with conversational turn-taking. The 'Restricted, Repetitive, and Stereotyped Patterns of Behaviour' domain similarly showed scores exceeding the threshold, reflecting strong adherence to routines, specific sensory sensitivities (aversion to certain textures), and intense, narrow interests. These results are highly suggestive of a neurodevelopmental profile consistent with Autism Spectrum Disorder. Communication [Client Identifier]'s expressive language is grammatically correct but often appears formal and lacks typical prosody. He uses a monotonous tone and struggles with vocal inflection to convey emotion. He tends to be verbally fluent on topics of interest but may become dysfluent or withdrawn when discussing other subjects. He frequently misinterprets non-literal language and struggles with abstract concepts. Reciprocal conversation is challenging, as he often talks at length without pausing for input from others or adjusting his communication style to the listener. Social Interaction Social engagement is limited. [Client Identifier] struggles to initiate interactions with peers and adults unless it pertains to his special interests. He has one close friend with whom he shares his railway interest, but otherwise avoids group activities. Non-verbal behaviours are atypical; eye contact is often fleeting or intense, and his facial expressions can be incongruent with the situation. He demonstrates limited social reciprocity, finding it difficult to understand others' perspectives or engage in give-and-take in social situations. He reports feeling 'different' from his peers and struggles to form meaningful connections. Emotional Experiences [Client Identifier] struggles significantly with identifying and labelling his own internal emotional states, often reporting a general feeling of 'unease' or 'frustration' rather than specific emotions. He finds it difficult to articulate his feelings to others. Emotional regulation is a significant challenge; he frequently experiences meltdowns or shutdowns when overwhelmed, particularly in social situations or when routines are disrupted. He appears to have a limited understanding of how others might be feeling, which further impacts his social interactions. Attention and Cognition His attentional profile is characterised by hyperfocus on topics of special interest, where he can sustain attention for extended periods. Conversely, he shows significant distractibility and difficulty maintaining focus on tasks he finds unengaging or repetitive. Shifting attention between tasks or topics is challenging. Memory appears strong for factual information related to his interests. Problem-solving tends to be highly logical and rule-bound, often struggling with flexible thinking or adapting to novel situations. Monotropic tendencies are evident in his deep engagement with specific topics, making it difficult to disengage. Sensory Differences [Client Identifier] reports significant auditory sensitivities, particularly to loud or sudden noises, which can cause him considerable distress. He also has tactile sensitivities, disliking certain clothing textures and avoiding messy play. He demonstrates a preference for bland foods and is highly sensitive to strong smells. Proprioceptive input appears to be sought through rocking behaviours when stressed, and he has a low interoceptive awareness, often missing cues for hunger or thirst until they become intense. Routine and Change He exhibits a very strong preference for routine and predictability. Unexpected changes, even minor ones like a different route to school, can cause significant anxiety and distress, sometimes leading to behavioural outbursts. He uses elaborate planning strategies to maintain predictability, such as creating detailed daily schedules. The emotional impact of unpredictable events is profound, often resulting in prolonged periods of dysregulation and difficulty returning to baseline functioning. Substance Use [Client Identifier] denies any current or historical use of illicit substances, alcohol, or other recreational drugs. His parents corroborate this, reporting no concerns in this area. Clinical Observation and Mental-State Examination During the assessment, [Client Identifier] presented as a well-nourished male, dressed appropriately. He made limited eye contact, often looking away or past the clinician. His affect was generally restricted and flat, with occasional moments of enthusiasm when discussing his special interests. Speech was coherent and goal-directed but lacked prosody and varied in volume. Thought processes appeared logical but rigid, with a tendency to perseverate on specific topics. He demonstrated repetitive finger flicking throughout the interview, particularly when asked questions that required abstract thinking or social interpretation. He engaged minimally with small talk. Psychological Formulation (Preliminary) [Client Identifier]'s presentation is understood within a neurodevelopmental framework, with strong indications of an autism spectrum profile. His core difficulties in social communication and interaction, coupled with restricted, repetitive patterns of behaviour, interests, and activities, appear to be foundational. These underlying neurodevelopmental differences likely predispose him to anxiety and emotional dysregulation, particularly when faced with unexpected changes or social demands that exceed his coping capacities. His intense interests serve as a coping mechanism and a source of predictability. Sensory sensitivities further impact his engagement with the environment and contribute to overload. His cognitive style, characterised by monotropism and a preference for systematic thinking, shapes his problem-solving approaches but also creates challenges in flexible adaptation. Structured Risk Assessment No immediate risks to self or others were identified. Predisposing factors for mental health difficulties include his neurodevelopmental profile (suspected ASD) and family history of anxiety. Precipitating factors include increasing academic and social demands at school. Perpetuating factors include difficulties in social interaction leading to isolation and limited opportunities to develop flexible coping strategies. Protective factors include supportive parents who are actively seeking assessment and intervention, his strong intellectual curiosity in areas of interest, and his one close friendship. Summary and Impression The developmental history describes longstanding patterns in social communication, sensory experiences, and preference for predictability. These features appear to have influenced the individual’s daily functioning, relationships, and responses to change across different life stages. The information gathered contributes to an understanding of the individual’s developmental profile and highlights areas of both strength and difference that may be relevant to their current experiences. Conclusion (Assessment A)"The developmental history provides valuable context but is not sufficient on its own to determine whether diagnostic criteria are met. Further evaluation in Assessment B will consider current presentation alongside this history to inform diagnostic and support considerations." Recommendations 1. Proceed with Assessment B, including ADOS-2 administration and direct observation of [Client Identifier] in various settings. 2. Provide psychoeducation to parents and school staff regarding autism spectrum characteristics and their impact on learning and behaviour. 3. Recommend a referral to an Occupational Therapist for a comprehensive sensory assessment and development of a sensory diet. 4. Advise the school to implement visual schedules and prepare [Client Identifier] for any changes in routine well in advance. 5. Encourage [Client Identifier] to continue engaging with his special interests as a source of comfort and strength. 6. Consider a referral to a clinical psychologist for support with emotional regulation strategies and social skills development. 7. Liaise with the referring GP to discuss preliminary findings and coordinate ongoing care. Statement on Capacity Based on observation during the session and discussion with his parents, [Client Identifier] is deemed to have capacity to assent to participation in the assessment process. His parents have provided informed consent for the assessment and the sharing of this report with relevant professionals involved in his care. Clinician: Dr. Emily Watson, Consultant Psychiatrist, GMC 1234567 Date: 01/11/2024