ASD under 5s

Pre-Clinic Information (not to be included in clinician proforma/output) Tabbed Journal: Information from ITC, if available. Detailed Family History/State if has a known social worker/on a CHIN Plan Pregnancy History/Early Developmental History until age 2.5 years (unlikely to be referred prior) Name of Educational Setting: Initial Pathway Selection (Subject to change/Please State in Words as well as Number) Referral Information: (Include Date of Referral and Source of Referral/any directly observed educational information can be mapped to ASD criteria by care navigators) State Level of Intervention for Learning (My Plan/EHCP) Scribe Involvement to commence here: (no patient identifiers/non-organisational email (Clinicians own professional responsibility/recommend NHS email) Not for use in with microphone in clinic situation/clinician aid for scribe/adminstrative structuring from clinic. Neurodevelopmental Medical Assessment for the Under 6s: Initial Appointment (for suspected global developmental delay and/or Autistic Spectrum Condition/Disorder Referral Information Nursery initiated the referral due to concerns about the child's social interaction and communication skills. Parents also share these concerns. Voice of the Child [questions around educational setting, friends, play, toys, why the child thinks they are here; will provide evidence for Clinician Directly Observed Communication A1 and Nonverbal communication A2, Child report of Play and Relationships A3] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.) Parental Concerns (include up to 5 main concerns and also state motivation for pursuing assessment) [main headline issues followed by general consultation note. Could include motivations for pursuing assessment] 1. Difficulty with social interaction: The child struggles to initiate and maintain interactions with peers, often preferring to play alone. 2. Delayed language development: The child's speech is limited, and they have difficulty understanding and following instructions. 3. Repetitive behaviours: The child engages in repetitive movements, such as hand flapping, and has a strong preference for routines. General Consultation The child demonstrates limited social communication skills, including difficulty with reciprocal conversations and sharing interests. The child struggles to make eye contact and respond to social cues. These observations map to ASD criteria. Sensory Issues (evidence for B4) and Motor Mannerisms (parental report of B1) The child exhibits hand flapping and rocking when anxious or excited. The child is also sensitive to loud noises and bright lights. Birth History Pregnancy was uneventful. Delivery was at term via vaginal delivery. The neonatal period was unremarkable. Early sleep patterns were disrupted, with the child experiencing frequent night wakings. The child's temperament was described as sensitive and easily overwhelmed. Early feeding was successful, and weaning occurred without difficulty. The child's first year was marked by delays in reaching developmental milestones. Early Developmental History/Milestones Motor: The child walked unaided at 15 months. Fine Motor Skills: The child struggles with fine motor tasks, such as using a pincer grasp. Speech and Language: The child babbled at 6 months, spoke their first words at 18 months, and is yet to link sentences. Early social skills: The child smiles and interacts with familiar adults but struggles with peer interactions. Developmental Update The child's development is delayed compared to peers. The child receives additional support at nursery. There is no evidence of regression. Past Medical History, Medication, Allergies, Immunisations No confirmed diagnoses. No current medications. No known allergies. Up to date with immunisations. Vision and Hearing Vision and hearing have been assessed and are within normal limits. Family History/Composition Family history of ASD in a maternal uncle. Sleep The child has difficulty falling asleep and staying asleep. The child is not on melatonin. Diet The child has a restricted diet, with a preference for certain textures and foods. Emotional and Behavioural (map to any ASD criteria: parental report) The child experiences frequent meltdowns and displays signs of anxiety in social situations. The child is not currently involved with CAMHS. Clinician Observations of child in clinic (map to any ASD criteria: Directly observed by clinician) The child displayed limited eye contact, repetitive hand movements, and difficulty engaging in reciprocal play during the clinic visit. Physical Examination No characteristic facial features or skin markers observed. HC: 48cm. Weight: 14kg. Height: 95cm. Head circumference: 48cm. BMI: 19.5. Clinicians Impression I have discussed my initial impressions with the parents, and we will proceed with further assessments to determine if the child meets the criteria for an ASD diagnosis. …..and the child will remain/be placed on pathway Instructions for Next Steps Letter The clinician will be responsible for sending the next steps letter. For dictated clinic letter to follow, if required/requested (can include patient identifiable data when dictated on lexacom) Diagnosis List No confirmed diagnosis at this time. Other Issues The child exhibits behaviours consistent with anxiety and has low mood. Medication List No current medications. Involved Professionals Nursery teacher. Attends [which educational setting] Nursery. Signed off Dr. Sarah Jones, Consultant Developmental Paediatrician Addendum: Autism Pathway Assessment Criteria (Important to specify Parental Report or Directly Observed by Professional) Communication (A1): Parental report of limited verbal communication and difficulty understanding instructions. Clinician observed limited reciprocal conversation. Non-verbal communication (A2): Parental report of limited use of gestures and facial expressions. Clinician observed limited eye contact. Playing relationships (A3): Parental report of difficulty initiating and maintaining interactions with peers. Clinician observed the child playing alone. Repetitive behaviours (B1): Parental report of hand flapping and rocking. Clinician observed hand flapping. Routine and preference for sameness (B2): Parental report of strong preference for routines and distress when routines are disrupted. Patterns of interest (B3): Parental report of intense interest in specific toys. Sensory differences (B4): Parental report of sensitivity to loud noises and bright lights. Overall impact: The child's difficulties with social communication, repetitive behaviours, and sensory sensitivities significantly impact their ability to function in social and educational settings.