Autism diagnosis

Autism Diagnosis: Patient Information: - Patient name: Oliver Smith - Date of birth: 12 July 2019 - Gender: Male - Address: 123 Main Street, Anytown - Contact information: (0123) 456 7890 Presenting Concerns: - Oliver was brought in today by his parents due to concerns about his social interaction, communication skills, and repetitive behaviours. Parents report that Oliver has difficulty engaging with peers, struggles to express his needs verbally, and exhibits repetitive hand movements. Developmental History: - Oliver met early developmental milestones, but his parents noticed delays in speech development around 18 months. He began to use single words but has struggled to form complete sentences. He was walking at 12 months. Medical History: - No significant past medical history. No previous surgeries. - Medications: None. - Allergies: None. Family History: - No family history of autism or other relevant conditions. Social History: - Oliver attends a local nursery school. He has limited interaction with other children and often plays alone. He has a close relationship with his parents and enjoys playing with his toys. Behavioral Observations: - During the assessment, Oliver showed limited eye contact and responded inconsistently to his name. He exhibited repetitive hand-flapping and vocal stimming. He struggled to follow instructions and showed a preference for routine. Assessment Tools Used: - Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) - Autism Diagnostic Interview-Revised (ADI-R) Diagnostic Impressions: - Based on the assessment findings, Oliver meets the diagnostic criteria for Autism Spectrum Disorder. Oliver Smith has been diagnosed with Autism Spectrum Disorder. Their current behavioural profile continues to meet diagnostic criteria for Autism Spectrum Disorder under the *Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, Text Revision (DSM-5-TR)*. This diagnosis was made in conjunction with the extended report conducted by the psychologist. Severity level for Autism Spectrum Disorder: - Social Communication: Level 2 - Restricted Repetitive Behaviours: Level 2 Oliver Smith also has the following challenges/disabilities: 1) Speech delay 2) Social interaction difficulties 3) Sensory sensitivities 4) Difficulty with transitions Oliver Smith would require coordinated multidisciplinary team support. I recommend the following allied health services to help address the health difficulties above: - Physiotherapist - Speech Therapy - Occupational Therapy - Psychologist / Counselor - Dietician - Behavioural Therapist I also recommend carer support as the patient has a very high level of needs. I strongly support the family's application for early childhood intervention service. Recommendations: - "Today’s diagnosis of Autism Spectrum Disorder will enable the child to access 20 allied health sessions under Helping Children with Autism (HCWA) funding." Eligible Allied Health treatment practitioners include: - Psychologist (MBS items 82015, 93035, 93043) - Speech Pathologist (MBS items 82020, 93036, 93044) - Occupational Therapist (MBS items 82025, 93036, 93044) Additional recommendations: Further assessment by a speech therapist and occupational therapist is recommended. Follow-Up: - Review in 6 months. Clinician Information: - Clinician name: Dr. Emily Carter - Clinician title: Paediatrician - Date of report: 1 November 2024