Private Assessment of my daughter: still left with questions

Will try and keep this brief (but will no doubt fail):

My 8 year old daughter has cause me concern since she was about 15months old. By age 4 her language was severely delayed and disordered. I engaged a private SALT and worked intensively with SALT and saw extremely good results and a lot of language development (including better attention and eye contact). Fast forward to now and school are recognizing anxiety when under pressure, hypersensitive to noise and demanding silence in class (yeah right!) slow progress in literacy and numeracy (poor reading comprehension despite good decoding) poor attention, slow output (despite adequate fine motor skills and extremely neat handwriting but strangely with no spaces between the words) and failure to finish work. She now has an IEP, ear defenders, help with literacy, social skills classes, visual plans. At home we have had severe meltdowns and very difficult/extreme behaviour, phases of constant unhappiness, difficulties with social skills, apears very rude to us and has difficulties with the unwritten social rules around playdates etc. sensory issues (extreme aversion to 'scratchy materials' and never wears socks in the house). She can be very anxious when asked to do homework, and often this is impossible. She can also meltdown at seemingly nothing, losing control, shaking, bloodshot eyes, screaming at the top of her voice, often this seems irrational and happens despite being given clear instructions, choices and consequences. Her language was recently re-assessed by the same SALT and her structural grasp of language was found to be age-appropriate but understanding of non-literal language and conversational skills markedly different on 1st centile. SALT suggested Aspergers. Sick of waiting around for NHS (still waiting for ADOS) I decided to have a private assessment carried out. The assessor did ADOS/ADI-R and observed in school at lunchtime (anxious) and at after school club (repetitve overtures to other children, didn't recognize when others were not interested, just carried on talking and repeated over and over with other children). The outcome of the assessment was that my daughter has 'significant' impairments which affect her in each area of the diagnostic criteria on an 'everyday' level, yet are not severe enough for a diagnosis. He noted her lack of gesture, lack of acknowledgement and interest in him, inconsistent interpretation of non verbal language, mild sensory issues, rituals, inflexible thinking, difficulties with social rules and very literal interpretation of written language. Yet because they are not 'severe' she needs help as per Aspergers kids but does not merit a diagnosis.

I was very impressed with this man but I wish he could have come on holiday with us and seen how many insurmountable difficulties she encountered from hot sand to new environment to suddenly deciding to not take turns at something. She is 8 years old and has just started Y4. We just watched the end of Casualty and there was about to be a car accident so the channel got changed and my daughter complained, saying she liked watching 'the travel news'. Am I right to question this non-diagnosis?

Parents
  • I agree.  He should have diagnosed her.  It's all the more annoying as you paid for the assessment.  So many clinicians are not aware of the sometimes more subtle presentation in females on the spectrum.  This is rubbish "not severe enough for a diagnosis".  She clearly has Asperger's.

    Don't rely too much on the ADOS (or CAMHS as many areas have a crap CAMHS service).  CAMHS failed to diagnose my 12yo using this and I researched and found it's only 77% reliable in high-functioning people as it was researched on prototypical (classic) autism cases.  I have read the DISCO is more in-depth, and no assessment should be treated like a tick-box exercise anyway.  She may need to see someone in a specialist autism assessment centre.  The NAS has the Lorna Wing Centre, and there is the Maudsley's Newcomen Centre.  You could ask your GP for a referral to such a centre.  In the meantime, I think you should write to the assessor with this information, saying you believe he should have diagnosed her and can he look again at her case:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864898/ (study on the unreliability of ADOS-2)

    http://www.autism.org.uk/about-autism/autism-and-asperger-syndrome-an-introduction/gender-and-autism/women-and-girls-on-the-autism-spectrum.aspx (relevant to females on the spectrum and how assessment shouldn't be a tick-box exercise)

    According to NHS NICE Guidelines (which would be best practice for a private one), the following are rules that clinicians must follow:

    http://www.nice.org.uk/nicemedia/live/13572/56428/56428.pdf

    1.2.2 Always take parents’ or carers’ concerns and, if appropriate, the child’s or young person’s concerns, about behaviour or development seriously, even if these are not shared by others.

    1.2.4 To help identify the signs and symptoms of possible autism, use tables 1–3 (see appendix C). Do not rule out autism if the exact features described in the tables are not evident; they should be used for guidance, but do not include all possible manifestations of autism.
     
    1.2.5 When considering the possibility of autism, be aware that: signs and symptoms should be seen in the context of the child’s or young person’s overall development
    • signs and symptoms will not always have been recognised by parents, carers, children or young people themselves or by other professionals

    • when older children or young people present for the first time with possible autism, signs or symptoms may have previously been masked by the child or young person’s coping mechanisms and/or a supportive environment

    • autism may be missed in children or young people who are verbally able

    • autism may be under-diagnosed in girls


    1.2.7 Do not rule out autism because of:

    • good eye contact, smiling and showing affection to family members

    • reported pretend play or normal language milestones

    • difficulties appearing to resolve after a needs-based intervention (such as a supportive structured learning environment)

    • a previous assessment that concluded that there was no autism, if new information becomes available.
    1.4.4 When deciding whether to carry out an autism diagnostic assessment, take account of the following (unless the child is under 3 years and has regression in language or social skills – see recommendation 1.4.2):
    • the severity and duration of the signs and/or symptoms

    • the extent to which the signs and/or symptoms are present across different settings (for example, home and school)

    • the impact of the signs and/or symptoms on the child or young person and on their family or carer

    • the level of parental or carer concern, and if appropriate the concerns of the child or young person

Reply
  • I agree.  He should have diagnosed her.  It's all the more annoying as you paid for the assessment.  So many clinicians are not aware of the sometimes more subtle presentation in females on the spectrum.  This is rubbish "not severe enough for a diagnosis".  She clearly has Asperger's.

    Don't rely too much on the ADOS (or CAMHS as many areas have a crap CAMHS service).  CAMHS failed to diagnose my 12yo using this and I researched and found it's only 77% reliable in high-functioning people as it was researched on prototypical (classic) autism cases.  I have read the DISCO is more in-depth, and no assessment should be treated like a tick-box exercise anyway.  She may need to see someone in a specialist autism assessment centre.  The NAS has the Lorna Wing Centre, and there is the Maudsley's Newcomen Centre.  You could ask your GP for a referral to such a centre.  In the meantime, I think you should write to the assessor with this information, saying you believe he should have diagnosed her and can he look again at her case:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864898/ (study on the unreliability of ADOS-2)

    http://www.autism.org.uk/about-autism/autism-and-asperger-syndrome-an-introduction/gender-and-autism/women-and-girls-on-the-autism-spectrum.aspx (relevant to females on the spectrum and how assessment shouldn't be a tick-box exercise)

    According to NHS NICE Guidelines (which would be best practice for a private one), the following are rules that clinicians must follow:

    http://www.nice.org.uk/nicemedia/live/13572/56428/56428.pdf

    1.2.2 Always take parents’ or carers’ concerns and, if appropriate, the child’s or young person’s concerns, about behaviour or development seriously, even if these are not shared by others.

    1.2.4 To help identify the signs and symptoms of possible autism, use tables 1–3 (see appendix C). Do not rule out autism if the exact features described in the tables are not evident; they should be used for guidance, but do not include all possible manifestations of autism.
     
    1.2.5 When considering the possibility of autism, be aware that: signs and symptoms should be seen in the context of the child’s or young person’s overall development
    • signs and symptoms will not always have been recognised by parents, carers, children or young people themselves or by other professionals

    • when older children or young people present for the first time with possible autism, signs or symptoms may have previously been masked by the child or young person’s coping mechanisms and/or a supportive environment

    • autism may be missed in children or young people who are verbally able

    • autism may be under-diagnosed in girls


    1.2.7 Do not rule out autism because of:

    • good eye contact, smiling and showing affection to family members

    • reported pretend play or normal language milestones

    • difficulties appearing to resolve after a needs-based intervention (such as a supportive structured learning environment)

    • a previous assessment that concluded that there was no autism, if new information becomes available.
    1.4.4 When deciding whether to carry out an autism diagnostic assessment, take account of the following (unless the child is under 3 years and has regression in language or social skills – see recommendation 1.4.2):
    • the severity and duration of the signs and/or symptoms

    • the extent to which the signs and/or symptoms are present across different settings (for example, home and school)

    • the impact of the signs and/or symptoms on the child or young person and on their family or carer

    • the level of parental or carer concern, and if appropriate the concerns of the child or young person

Children
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