Clinical guidance documents play an important role in ensuring access to high-quality autism spectrum disorder diagnostic assessment practices. The objective was to perform a systematic review of professional association and government clinical guidance documents for autism spectrum disorder diagnostic assessment, analyzing their quality and content. The government search was limited to English-speaking, single-payer, publicly funded health systems. A quality appraisal was conducted by two appraisers using the Appraisal of Guidelines Research and Evaluation, second edition tool. A content analysis was conducted for recommended clinical personnel and psychometric tools. The 11 documents demonstrated higher quality in Scope and Purpose (mean: 90.1, standard deviation: 7.4) and Clarity of Presentation (mean: 82.8, standard deviation: 9.4) and lower quality in Applicability (mean: 43.3, standard deviation: 23.8) and Rigor of Development (mean: 52, standard deviation: 21.9). All documents either recommended multidisciplinary team assessment or stated it was ideal. The documents varied substantially in their recommended tools and personnel for diagnostic assessment. There was little supporting evidence for team and personnel recommendations. Multiple guidance documents exist for autism spectrum disorder diagnostic assessments, with varying quality and recommendations. The substantial variation likely stems from insufficient evidence supporting assessment practices. Research is required to close the evidence gaps and inform high-quality clinical guidelines.
Objectives: Many jurisdictions across Canada and internationally are grappling with providing diagnostic and intervention services for children with autism spectrum disorder (ASD). The objective was to compare Canadian and United Kingdom (UK) policies governing ASD diagnosis. Methods: The policy scan extended from January 2000 to December 2017. Canadian federal, provincial/territorial, and UK government publications related to ASD diagnosis were retrieved from official websites by searching for ASD and related terms. Retrieved documents were filtered for relevance, with all relevant documents undergoing full text review. Data extracted included personnel and testing requirements for diagnosis, wait times, and eligibility for ASD services and funding. Results: The included jurisdictions varied substantially in their approach to ASD diagnosis and eligibility for intervention. Nine of the 13 provinces/territories restrict which clinicians can diagnose ASD by requiring certain documentation for service eligibility. Three provinces require multi-disciplinary team assessment (British Columbia [BC], Quebec, and Nova Scotia [NS]). Three provinces (BC, NS, and Prince Edward Island [PEI]) require specific diagnostic tests for diagnosis. Only two provinces, BC and NS, have target wait times for assessment. Jurisdictions differed in whether they allowed children with a provisional diagnosis of ASD to access services. At a national level, the UK provides more clinical guidance for ASD diagnosis, which can be attributed to its centralized system of national healthcare delivery. Conclusions: ASD diagnostic assessment policies vary across Canada, and between Canada and the UK. Further evidence supporting ASD diagnostic practices is needed to streamline the journey from identification to intervention.
ImportanceWait times for autism spectrum disorder (ASD) diagnosis are lengthy because of inadequate supply of specialist teams. General pediatricians may be able to diagnose some cases of ASD, thereby reducing wait times.ObjectiveTo determine the accuracy of ASD diagnostic assessments conducted by general pediatricians compared with a multidisciplinary team (MDT).Design, Setting, and ParticipantsThis prospective diagnostic study was conducted in and a specialist assessment center in Toronto, Ontario, Canada, and Ontario general pediatrician practices from June 2016 to March 2020. Children were younger than 5.5 years, referred with a developmental concern, and without an existing ASD diagnosis. Data analysis was performed from October 2021 to February 2022.ExposuresThe pediatrician and MDT each conducted blinded assessments and recorded a decision as to whether the child had ASD.Main Outcomes and MeasuresMain outcomes included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A logistic regression was performed to identify factors associated with accurate pediatrician assessment for children with or without an ASD diagnosis.ResultsSeventeen pediatricians (12 women [71%]) participated in the study and referred 106 children (79 boys [75%]; mean [SD] age, 41.9 [13.3] months). Sixty participants (57%) were from minoritized racial and ethnic groups (eg, Black, Asian, Hispanic, Middle Eastern, and multiracial). Seventy-two participants (68%) received a diagnosis of ASD by the MDT. Sensitivity and specificity of the pediatrician assessments compared with MDT were 0.75 (95% CI, 0.67-0.83) and 0.79 (95% CI, 0.62-0.91), respectively. The PPV of the pediatrician assessments was 0.89 (95% CI, 0.80-0.94) (ie, 89% agreement with the MDT), and NPV was 0.60 (95% CI, 0.49-0.70) (ie, 60% agreement with the MDT). Higher pediatrician certainty (odds ratio [OR], 3.33; 95% CI, 1.71-7.34; P = .001) was associated with increased diagnostic accuracy for children with ASD. Lower accuracy was seen for children with higher Visual Reception subscale developmental skills (OR, 0.93; 95% CI, 0.89-0.97; P = .001), speaking abilities (OR, 0.17; 95% CI, 0.03-0.67; P = .03), and White race (OR, 0.32; 95% CI, 0.10-0.97; P = .04). Age, gender, and Autism Diagnostic Observation Schedule, 2nd Edition composite scores were not significantly associated with the accuracy of assessments. All 7 children with a sibling with ASD received an accurate diagnosis; otherwise, no significant factors were identified for accuracy in children without ASD.Conclusions and RelevanceThis study of concordance of autism assessment between pediatricians and an expert MDT in young children found high accuracy when general pediatricians felt confident and lower accuracy when ruling out ASD. These findings suggest that children with co-occurring delays may be potential candidates for community assessment.
Despite the rapid increase in suicide rates among children, limited data exists regarding the prevalence and correlates of suicidality specifically in preadolescent children. The current study examines the relationship between Adverse Childhood Experiences (ACEs), depression, and suicidality among a child population receiving inpatient psychiatric treatment. Scores on the Center for Youth Wellness Adverse Childhood Experiences Questionnaire for Children (ACE-Q) and Childhood Depression Inventory, Second Edition (CDI-2), and patients with suicidal ideation (SI) or suicide attempts (SA) contributing to their inpatient admission were analyzed to explore potential associations in a sample of 153 children. Results indicated both admission SI and admission SA were linked to suicidality endorsed on the CDI-2 (item 8). Depressive symptoms measured by the CDI-2 were positively linked to specific ACEs. Children with SI and SA at the time of admission showed statistically higher scores on the CDI-2. Having experienced four or more ACEs was marginally associated with admission SA; however, there was no association between admission SI and having experienced four or more ACEs. Specific ACEs were positively correlated with admission SI and admission SA. There was no link found between total ACEs score and admission SI, yet there was a marginal association between admission SA and total ACEs score. Lastly, item 8 on the CDI-2 predicted SI and SA on admission while ACEs total did not predict either. Specific ACES were identified as predictive of both SI and SA on admission.
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