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Diagnostic Evaluation for Autism Spectrum Disorder: a Survey of Health Professionals in Australia Downloaded from http://bmjopen.bmj.com/ on March 13, 2018 - Published by group.bmj.com Open Access Research Diagnostic evaluation for autism spectrum disorder: a survey of health professionals in Australia Lauren J Taylor,1,2 Valsamma Eapen,2,3 Murray T Maybery,1,2 Sue Midford,4 Jessica Paynter,2,5,6 Lyndsay Quarmby,7 Timothy Smith,2,8 Katrina Williams,2,9,10,11 Andrew J O Whitehouse2,12 To cite: Taylor LJ, Eapen V, ABSTRACT et al Strengths and limitations of this study Maybery MT, . Diagnostic Objectives: There is currently no agreed Australian evaluation for autism standard for the diagnosis of autism spectrum disorder ▪ spectrum disorder: a survey This is the first national study to investigate the (ASD) even though there are specific diagnostic of health professionals in diagnostic practices of health professionals from Australia. BMJ Open 2016;6: services available. We suspected inconsistency in the different disciplines across Australia. e012517. doi:10.1136/ diagnostic practices of health professionals in Australia ▪ While the study included clinicians from a range bmjopen-2016-012517 and aimed to assess these practices across the nation of professional backgrounds, there were an by surveying all relevant professional groups. unequal number of respondents from each pro- ▸ Prepublication history and Design: In this study, we completed a survey of 173 fessional group. additional material is health professionals whose clinical practice includes ▪ Respondents were self-selected and may be available. To view please visit participating in the diagnostic process for ASD in committed to high standards of clinical practice. the journal (http://dx.doi.org/ Australia. Participants completed an online 10.1136/bmjopen-2016- questionnaire which included questions about their ‘ ’ 012517). diagnostic setting, diagnostic practice and diagnostic individual. The gold standard in ASD diag- outcomes in 2014–2015. nosis is a best estimate clinical diagnosis Participants: Participants covered a range of which is determined in accordance with Received 10 May 2016 disciplines including paediatrics, psychiatry, current diagnostic classification systems and Revised 11 August 2016 psychology, speech pathology and occupational following rigorous assessment practices. Accepted 16 August 2016 therapy. All states and territories of Australia were There is general consensus that a rigorous represented. diagnostic assessment for ASD would consist Setting: Participants came from a range of service of a physical examination, hearing test, child settings which included hospitals, non-governmental observation and parent interview which organisations, publicly funded diagnostic services and includes a full developmental history (NICE, private practice. 2011). ‘Best-practice’ ASD assessments are Results: There was variability in diagnostic practices more comprehensive, and also comprise for ASD in Australia. While some clinicians work within standardised developmental or cognitive a multidisciplinary assessment team, others practice independently and rarely collaborate with other testing, language assessment and information clinicians to make a diagnostic decision. Only half of from more than one setting, ideally from a the respondents reported that they include a source other than the parent or carer who 1–5 standardised objective assessment tool such as the has been interviewed. Rigorous assess- Autism Diagnostic Observation Schedule in ASD ments enhance the accuracy of diagnoses assessments, and one-third indicated that they do not and provide information about an indivi- include measures of development, cognition and dual’s strengths and difficulties which is language in assessments where ASD is suspected. important for intervention planning. Conclusions: Reported practice of some professionals Despite the internationally recognised best in Australia may not be consistent with international practice guidelines for ASD diagnosis,3 and best practice guidelines for ASD diagnosis. These position statements from professional findings highlight the need for a minimum national – bodies6 8 Australia does not have a national standard for ASD diagnosis throughout Australia that ensures best practice regardless of the type of setting in standard for ASD diagnosis. In addition, For numbered affiliations see which the service is provided. health services are governed on a state or ter- end of article. ritory basis, rather than on a national level. While in some jurisdictions, eligibility for Correspondence to In the absence of biomarkers, diagnosis of publicly funded intervention for children Dr Lauren Taylor; autism spectrum disorder (ASD) is based on with ASD requires a diagnosis made by a [email protected] the behavioural presentation of an multidisciplinary team comprising a medical Taylor LJ, et al. BMJ Open 2016;6:e012517. doi:10.1136/bmjopen-2016-012517 1 Downloaded from http://bmjopen.bmj.com/ on March 13, 2018 - Published by group.bmj.com Open Access professional, psychologist and speech pathologist, other METHOD states have less stringent criteria, requiring only a paedia- Participants trician or a psychiatrist. Furthermore, eligibility for We aimed to include responses from a range of profes- funding from the Helping Children with Autism sional groups, working across different clinical and geo- funding package is determined following a conclusive graphical locations, to reflect the diversity of diagnostic ASD diagnosis which can be provided by a single paedia- assessment practice in Australia. Recruitment took a trician or a psychiatrist.9 multifaceted approach: (1) The Cooperative Research Identifying ASD accurately and early is essential given Centre for Living with Autism (Autism CRC) website that state and federal funding for early intervention is and social media platforms were used to advertise the based on a formal diagnosis made before a child turns research. The Autism CRC is a national cooperative 7 years.9 An inaccurate diagnosis may mean that chil- research effort focused on ASD across the lifespan which dren are not eligible for early intervention which con- includes universities, government agencies, service provi- tains elements that specifically focus on areas of ders, Autism awareness groups and professional bodies; difficulty in ASD.10 Alternatively, children who are mis- (2) relevant member bodies and professional organisa- diagnosed with ASD may access services that are not tions, including Speech Pathology Australia, the relevant or effective for their areas of difficulty thereby National Rural Health Alliance, the Western Australian wasting resources. In addition, it is well established that Autism Diagnostician’s Forum, the Neurodevelopmental early intervention improves outcomes for children with and Behavioural Paediatric Society of Australasia and ASD11 12 and that children who start intervention at a the Autism South Australia diagnostician’s membership young age make more improvements than children who list, distributed information about the survey via mailing – start at an older age.13 15 While ASD can be reliably lists, newsletters and social media platforms; (3) psychol- – diagnosed at two years,16 18 the average age of diagnosis ogists with contact details listed on the Australian in Australia is over 4 years (49 months), with ASD most Psychological Society ASD Provider list were individually frequently diagnosed at 71 months19 Variability in the emailed and invited to participate in the research; (4) age of diagnosis has been observed between Australian government-funded diagnostic services in each state states, with significantly earlier age of diagnosis in were identified and the survey was either emailed or Western Australia and New South Wales relative to all mailed to each service, along with a personalised letter other states and territories. The variation in age at diag- inviting the service to complete the survey and (5) the nosis may be associated with inconsistent diagnostic researchers used individual networks to distribute the practices across the nation. survey to colleagues. All states and territories,i as well as While three previous studies have investigated diagnos- all disciplines included in multidisciplinary assessments tic practices for ASD in Australia, this research has for ASD were represented (see table 1). – included only paediatricians,20 24 psychiatrists20 23 24 and There was a similar number of responses from the psychologists.24 Skellern et al22 examined the assessment public/non-government (n=66, 38%) and private (n=76, practices of paediatricians (N=79) and child psychiatrists 43%) sectors, with 31 (19%) respondents working in the (N=26) in Queensland, finding considerable variability in public and private sectors.ii Public services and non- the diagnostic practices of these clinicians.2 The results government organisations (NGOs) were grouped when of a more recent survey has shown similar findings. In a participants provided background information. study of 124 paediatricians across Australia, Randall et al20 Respondents who indicated that they worked in the found that only a minority of participating clinicians public sector or NGO (n=38) were asked to specify usually included information from cognitive/develop- whether this was a hospital (n=27), government (n=21) mental assessments, or involved other disciplines in the or NGO (n=17). There were only eight completed diagnostic process. These practices are inconsistent with responses obtained for health professionals working in current
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