Early identification

& intervention –

ASD, ADHD and behavioural

difficulties in children and

young peopleDr. Denise McConnellogue

Clinical Psychologist

Primary Behaviour Service / WLMHT CAMHS

Objectives:

To be able to identify early signs of a neurodevelopmental condition by

comparing to how we expect children to develop normally.

To be aware of why it is important to ask more questions if behavioural

difficulties are reported.

To be confident about what to do if you think a child may be presenting with

early signs of ASD or ADHD.

To know how to discuss a referral for specialist assessment with parents and

obtain informed consent.

To have a clear understanding of key information to include with the referral.

To understand what to expect after making a referral and post investigation.

To understand what to expect from services.

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Normative Development – 1 year(Taken from Meggitt, 2007)

Emotional Cognitive Social Physical

• Fluctuating

moods.

• Often want a

comfort object.

• Understand simple

instructions associated

with a gesture (e.g.

wave bye), point & look

to where others point,

speak 2-6 recognisable

words and show they

understand much more.

• Babbling developed

into more speech-like

form with increased

intonation.

• Hand objects to adults

when asked.

• Closely dependent

on adult’s reassuring

presence

• May be shy with

strangers.

• Affectionate

towards familiar

people.

• Enjoy socialising at

mealtimes, joining

in conversations.

• Play pat-a-cake &

wave goodbye on

request.

• Sit up, stand without

help, crawl/bottom

shuffle/bear-walk,

cruise using

furniture, walk

alone using arms &

feet to maintain

balance.

• Point with the index

finger at objects of

interest.

Normative Development – 2 years

Emotional Cognitive Social Physical

• Beginning to express

how they feel.

• Impulsive & curious

about their

environment.

• May be clingy &

dependant at times

& self reliant &

independent at

others.

• Often feel frustrated

when unable to

express themselves

(half 2yr olds have

tantrums almost

every day).

• Now speak over 200

words.

• Still repeat words

spoken to them

(echolalia).

• May omit opening or

closing consonants

‘us for ‘bus’.

• Follow simple

instructions and

requests (e.g. please

bring me the book).

• Recognise familiar

people in photos .

• Listen to general

conversation with

interest.

• Provide comfort

when other babies

cry.

• Want to share songs,

conversation,

rhymes and more.

• Can run safely

avoiding obstacles.

• Draw circles, lines &

dots .

• Enjoy picture books.

• Can copy a vertical

line & a ‘v’ shape.

Normative Development – 3 yearsEmotional Cognitive Social Physical

• Like to do things

unaided.

• Often develop fears

(e.g. of the dark) as

they become more

capable of

pretending and

imagining.

• Begin to understand

concept of time –

remember events in

past & can

anticipate events in

future.

• Often ask ‘why?’.

• Use personal

pronouns & plurals

correctly.

• Can carry on simple

conversations but

often miss link

words like ‘the’ and

‘is’.

• Enjoy family

mealtimes.

• Can think about

things from someone

else’s point of view.

• Show affection for

younger siblings.

• Enjoy helping adults

e.g. tidying up.

• Willing to share toys

with children and

beginning to take

turns when playing.

• Make friends & are

interested in having

friends.

• Join in pretend play

with other children.

• Can walk backwards

& sideways, stand on

one foot, climb

stairs with 1 foot on

each step.

• Good spatial

awareness & can

manoeuvre

themselves around

objects.

• Can copy a circle

and letters V H & T.

• Draw a person with

a head, squiggles for

face and legs.

• Eat using fork or

spoon.

• Use toilet

independently.

Normative Development – 5 yearsEmotional Cognitive Social Physical

• Definite likes &

dislikes.

• Dress & undress

alone.

• Ask about abstract

words (e.g. what does

beyond mean).

• Recognise their name

& attempt to write it.

• Talk about past,

present & future &

have a good sense of

time.

• Fluent in speech &

mostly grammatically

correct.

• Love to be read

stories & then act

them out later alone

or with friends.

• Enjoys jokes &

riddles.

• Show sympathy &

comfort friends who are

hurt.

• Choose their own friends

• Understand social rules

(e.g how to greet

someone).

• Instinctively help other

children when they are

distressed.

• Enjoy team games.

• Play complicated games

with miniature objects

(small world play).

• Enjoy elaborate pretend

play with others.

• Play alone or with

others.

• Increased agility,

can run, climb,

dodge and skip.

• Good balance &

coordination.

• Can use a knife &

fork competently.

• Can draw a person

with a head, body,

arms, legs, nose,

mouth & eyes.

• Can do jigsaw

puzzles with

interlocking pieces.

Normative Development – 7 yearsEmotional Cognitive Social Physical

• Learn how to

control their

emotions.

• Realise that

they can keep

their own

thoughts private

& hide their

true feelings.

• Begin to think in

terms of who

they are but

also who they

would like to

be.

• Express

themselves in

speech &

writing.

• Perform simple

calculations in

their head.

• Begin to

understand how

to tell the time.

• Are able to

arrive at logical

conclusions & to

understand

cause & effect.

• May be able to speak

up for themselves

(e.g. when visiting

dentist).

• Form close

friendships, mostly

with their own sex.

• Engage in complex

cooperative play,

using more people,

props and ideas.

• Have a clear sense of

right & wrong –

realise it is wrong to

hurt other people

physically.

• Can ride a 2

wheeled bike or use

roller skates.

• Increased stamina,

swimming, skating,

gymnastics.

• Skilful in catching &

throwing ball using

one hand.

• Able to control their

speed when running

& can swerve to

avoid collision.

Autism Spectrum Disorder (ASD):

• Autism is a lifelong developmental disability that affects social and

communication skills. People with an ASD may find it difficult to understand

how the world and people around them operate and find it hard to interact.

“Reality to an autistic person is a confusing mass of events, people, places,

sounds and sights. There seems to be no clear boundaries, order or meaning to

anything. A large part of my life is spent trying to work out the pattern behind

everything.” (a person with autism)

ASD - The triad of impairment

(Lorna Wing)

Sensory-

Motor

Processing

Difficulties

Causes of Autism:

Genetic:

Researchers at Autism Research Centre in Cambridge have identified a group of 8-15 genes thought to be responsible for autism

Autism is known to run in families – 1 in 20 chance of a sibling also being diagnosed if one child in the family already has the condition

Environmental Factors:

Possible triggers include being born before 35 weeks of pregnancy but no conclusive evidence has been found

Other health conditions: (associated with ASD)

Infantile Spasms

Other rare genetic conditions such as Fragile X, Retts Syndrome or Tuberous Sclerosis

Misconceptions about the causes of ASD:

The MMR vaccine

The way a person has been brought up

Diets such as eating wheat or dairy products

http://www.nhs.uk/Conditions/Autistic-spectrum-disorder/Pages/Causes.aspx

https://www.theguardian.com/society/2017/jul/08/david-mitchell-son-autism-

diagnosis-advice

Early signs of ASD

Social interaction difficulties:

Poor turn taking skills / not able to share

Lack of reciprocity in their social relationships – difficulty in building a to and fro conversation

Limited use of language

Few if any relationship repairing skills

Exceptional knowledge around their areas of interest – will talk excessively about this if given the

chance

Not interested in their partners point of view or interests

Appear aloof/less interested in others (making it more difficult for them to develop friendships)

May experience difficulty in relating to others

May try to initiate social contact but not understand ‘social rules’.

Social interaction Clip from Kennedy Krieger Institute (04:24-05:58)

https://www.youtube.com/watch?v=YtvP5A5OHpU

Early signs of ASD

Communication difficulties:

Use of gestures are limited

Stiff/awkward body posture

“unstreetwise” presentation

Poor quality of rapport

Poor eye contact or has a staring quality

Comprehension difficulties

Can make abrupt and/or insensitive comments

Narrow range of conversational topics

Difficulty in conveying feelings

Speech abnormalities, includes:

Language development delay (some but not all cases)

Overly formal and stilted language, but with poor comprehension

Difficulties with specific concepts such as time words, emotions

Misinterpretation of implied meaning – eg, sarcasm, not be able to inference

Early signs of ASD

Communication difficulties:

Better in 1:1 but unable to manage group situations

Volume, rate of speech (prosidy) – may talk with a squeaky voice, not be able to

moderate volume, talk too fast etc.

Poor communication style – may either not join in or cut across topic of

conversation

Limited use of language

Communication

Clip from Kennedy Krieger Institute (05.59-07:57)

https://www.youtube.com/watch?v=YtvP5A5OHpU

Early signs of ASD

Imagination and flexibility:

Find abstract thinking difficult – eg. Concepts about God/death

Have a limited range of imaginative activities

Not initiating or joining in with pretend play

Focus on minutiae/detail rather than the bigger picture – eg. Wheels on a car

Pursue activities in a rigid and repetitive way

Hand flapping/spinning/rocking

Develop an obsessive interest in a specific interest –eg. Timetables, dinosaurs, spiders

Early signs of ASD

Imagination & flexibility:

Have difficulty separating fact from fiction

Not realise that other people have their own thoughts/feelings and agendas

which may differ from their own.

Find it difficult to accept another’s point of view (poor theory of mind)

Rigidity in thought and/or behaviour – have to do things in a particular way

Lack the ability to generate new ideas spontaneously or decide which actions to

carry out.

Early signs of ASDSensory:

Many people with autism have sensory processing difficulties that lead them to under or over respond to sensory stimuli in their environment.

Hypo (under-stimulated) hyper (over-stimulated)

7 senses

Vestibular / movement - Situated in inner ear - provides information about where our body is in space and its speed, direction and movement.

Proprioception / body awareness - Situated in muscles and joints - provides information about our body position.

Auditory / hearing - Situated in the inner ear – tells us about sounds and noises in our environment. Important for speech and language.

Vision / sight - Situated in the retina of the eye – sight helps us to define objects, people, colours, contrasts and spatial boundaries.

Olfactory / smell - Situated in the nose - most primitive sense and the first sense we rely upon.

Gustatory / taste - Receptors positioned on the tongue – tells us about different tastes – sweet, sour, bitter, salty and spicy.

Touch - Situated in the skin. Assists us to relate to touch, pressure, pain and temperature (hot and cold)

Sensory difficulties - clips

Clip: Can you make it to the end (NAS video) – http://www.autism.org.uk/get-

involved/tmi/about.aspx

Clip: Make it stop (NAS video) - http://www.autism.org.uk/get-involved/tmi/film.aspx

Clip: How many questions can you answer (NAS video) - http://www.autism.org.uk/get-

involved/tmi/take%20the%20test.aspx

ASD NICE guidance (2011)

Prevalence about 1% of children

Intellectual disability occurs in approximately 50% of young people with

autism.

Approximately 70% of people with ASD also meet diagnostic criteria for at least

one other (often unrecognised) psychiatric disorder, e.g. Anxiety disorder,

depression, OCD.

Core ASD behaviours typically present in early childhood but features are not

always apparent until circumstances of the child change.

Children & young people with certain coexisting conditions (such as

intellectual disability) are less likely to be diagnosed with ASD.

Autism in girls – what to look out for…….Social Interaction:

Girls tend to be more socially motivated to be socially interactive but their friendships may be characterised by an inability to maintain friendships

They may appear excessively shy, avoid interacting with others or making the first move socially.

They can gravitate towards older or younger girls.

May seem uncomfortable during conversation – poor eye contact, lack of social understanding of rules or will want to dominate conversation around their chosen themes.

May only have one close friend. If she has more than one, she may either be on the periphery of their group or will want to lead the group and play.

May play appropriately with toys and engage in pretend/imaginative play with others.

Can show empathy and compassion (be caring) but may be confused by non-verbal signals from others.

May have difficulty fitting in with peers due to clothing and hairstyle choices.

Girls commonly get described as ‘shy’.

They can often create an elaborate fantasy world.

They may be seen as imaginative, but their play, like boys is often repetitive with the same narrative running through.

Social Communication:

She may have an exceptional vocabulary.

Girls are better at masking their symptoms – they will mimic (without understanding) or watch and copy what other girls do. They may not initiate social contact but can ‘go through the motions’ of how they are expected to behave.

Consequently, they may converse in predictable and ‘scripted’ ways.

They can struggle with non-verbal aspects of communication such as body-language and tone of voice.

They may have difficulty dealing with unexpected verbal responses.

Social Imagination:

Parents may perceive their daughter as ‘odd’ but not be able to put their finger on the difference.

Imaginative play does exist, but it is intense in nature, often focused on stereotypical female interests, such as dolls, make-up, animals and celebrities – which is why girls with ASD may not seem that different to females not on the spectrum.

The key is the intensity and quality of these special interests, which are exclusive, all-consuming and experienced in detail

Often have difficulties in moving on from their toys/clothes from when they were younger.

May play with dolls or toys well beyond the typical age for these items.

Behavioural Symptoms:

They are often less disruptive than boys

Girls can develop friendships, but moving into adolescence, the differences between

neurotypical girls and ASD girls becomes greater which may lead to higher rates of

anxiety and/or depression.

http://autism.lovetoknow.com/Aspergers_in_Girls (this has an embedded

video on ‘aspergirls’

https://spectrumnews.org/features/deep-dive/the-lost-girls/

http://www.autisminpink.net/ also has embedded video better than the

other one as made by NAS

https://everydayaspie.wordpress.com/2016/05/02/females-with-aspergers-

syndrome-checklist-by-samantha-craft/amp/

What is Pathological Demand Avoidance?From: Pathological Demand Avoidance Syndrome – www.pdasociety.org.uk

Understanding Pathological Demand Avoidance Syndrome in Children (2012). Christie, P., Duncan, M., Fidler, R. & Healy, Z.

PDA is not a recognised diagnostic label, nor is it likely to become one in the near future.

CAMHS is only able to ascribe diagnoses to children using the ICD 10 manual soon to be ICD 11.

Although we may see PDA type behaviours, these will be understood as part of the autism spectrum.

Avoidance of and resistance to, the demands of everyday life – ie. demand avoidance. These can range from direct and explicit instructions to the more subtle demands of everyday life.

Any suggestion put to a child can be perceived as a demand.

Underpinning the avoidance is extremely levels of anxiety about conforming to social demands and a strong need for them to be in control, which in turn further heightens their anxiety.

Avoidance can be at all costs: tantrums/meltdowns, panic attacks.

Children with PDA have better social communication skills than others on the spectrum.

They often use these skills to try to avoid demands through negotiation, manipulation or distraction. (Manipulation is used because children with PDA are successful in avoiding demands because they have sufficient social empathy to do so.)

There is surface sociability, but apparent lack of a sense of social identity, pride or shame.

They will present with lability in mood and as impulsive and led by the need to control.

They will be comfortable in role-playing.

Large majority of children with PDA will have some speech and language delay.

Obsessive behaviour, similar to that seen in children with autism.

What might teachers see in the classroom

with PDA? Need to be in control

Explosive behaviour

‘slipping under the radar’ – create an act of ‘doing’/’busy doing nothing’

Threatening language

Poor sense of self-esteem

Expressed desire to be equal or better than

Desiring friendships but inadvertently sabotaging them

Ambivalent about success and enjoyment

Lack of permanence and transfer of learning and experience

Very poor emotional regulation

Variability in behaviour

Extensive involvement in fantasy and role play

How to help with PDA…….

First thing to remember is every interaction, or exchange is a transactional

(two way) process. The adult has to consider their contribution, from which

solutions are possible.

The child ‘can’t help won’t’: the child can’t help the fact that s/he won’t do

it, on this occasion.

Expectations and ground rules: compromise, prioritising, flexibility and

negotiation should be at the core.

Avoid being directive – use invitations or suggestions such as ‘I wonder how

we might….’ or ‘I can’t quite see how to do….’.

Keep calm in the face of disruptive or challenging behaviours. Do not take it

personally.

Be flexible and adaptable: strategies are likely to need changing more

frequently than for a child with autism.

How to help with PDA continued…..

Structured teaching and visual support.

Building on a child’s strengths and interests as learning opportunities.

Using drama and role play.

Monitoring and adjusting use of language – for example, allowing sufficient

time to process information.

Depersonalising demands and requests. Eg. If they are on the computer, use

an electronic timer which plays a pre-recorded message to indicate ‘game

over’.

Consider the learning environment: visual support materials, noise levels,

visual distractions, lighting, given the child space and clearly defined areas.

ASD Vs Attachment difficulties

Heather Moran – the Coventry grid:

Clip of Heather Moran talking about ASD & attachment -http://network.autism.org.uk/knowledge/insight-opinion/interview-

heather-moran

To access the Coventry grid -http://drawingtheidealself.co.uk/drawingtheidealself/Downloads_fil

es/Coventry%20Grid%20Version%202%20-%20Jan%202015.pdf

ASD Classroom Recommendations:

Support to develop social skills through social skills group/nurture

group/social stories.

Child with ASD often learn and respond to information that is presented to

him or her in a visual format. All verbal information should be supported by

visual cues/prompts/slides.

To avoid literal interpretation of language, verbal instructions in class

should be short, specific and clear.

Whole-class instructions may need to be repeated to the individual to

ensure they have understood

Small group work may need to be supported to encourage success and feel

that they are a valuable member of the class.

Give advanced warnings of any change to the usual routine of the class.

Social stories can help with this.

Contact the SENSS team/EP for further support and interventions.

In pairs or small groups…(5 mins)

Have a think about whether you recognise any of these early signs of ASD in

children you have previously worked with?

What might help you keep these early signs in mind for the year ahead?

Attention Deficit Hyperactivity Disorder

(ADHD): ADHD is a combination of overactive, poorly modulated behaviour

with marked inattention and lack of persistent task involvement.

These behaviours must be pervasive across situations and persistentover time and at higher levels than what is expected in a child of the same chronological age (ICD 10).

ADHD is a developmental disorder and there should be a history of symptoms in childhood.

Concentration and attention difficulties can also arise for other reasons (e.g. emotional difficulties, high anxiety level) and may be linked to recent life events (such as parental separation, frequent moving). In this case, difficulties may be more transient and parents may not report historical difficulties with attention and concentration.

Causes of ADHD:

Genetics

ADHD tends to run in families.

Strong genetic factors – parents and siblings of a child with ADHD are 4 to 5 times likely to have ADHD, but the way it is inherited is likely to be complex and not due to a single gene

Brain Function and structure

Research has identified a number of possible differences in the brains of people with ADHD including differences in the frontal lobe (responsible for decision making and moral judgements) and an imbalance in some of the neurotransmitters or chemical which help the brain to work properly

Other possible causes:

Being born premature (before 37 weeks) and having a low birthweight

Brain damage either whilst in the womb or in the first few years of life

Drinking alcohol/mis-using drugs and smoking

3 subtypes of ADHD:

1. Inattentive subtype

2. Impulsive / hyperactive subtype

3. Combined subtype

What is ADHD?

Clip: (7:42 mins)

https://www.youtube.com/watch?v=0Wz7LdLFJVM

Core features of ADHD:

Attention Problems

Impulsivity

Hyperactivity

Early signs of ADHD:

Attentional Problems:

Avoids tasks that require sustained mental effort.

Inattention and distractibility (by self or environment).

Difficulties in sustaining attention (unless supervised) and not listening.

Difficulties in organising and following instructions and completing tasks.

Fails to closely attend to work and makes careless mistakes.

Losing things and forgetfulness.

Impulsivity:

Difficulties in waiting their turn.

Blurting out answers before questions are completed.

Interrupting conversations or games.

Doesn’t learn from mistakes.

Poor judgement in self-awareness and therefore fails to anticipate situations.

Poor sense of road safety/danger.

Early signs of ADHD:

Hyperactivity:

Fidgety

Runs about or climbs excessively/inappropriately.

Always on the go.

Trouble staying seated.

Talks incessantly.

Inappropriately noisy/boisterous.

ADHD NICE guidance (2016)

Based on narrower criteria of ICD-10, hyperkinetic disorder is estimated to

occur in 1-2% of children & young people in the UK.

Based on broader criteria of DSM-IV, ADHD is thought to affect 3-9% of school

aged children & young people in the UK (NICE, 2016).

Common co-existing conditions in children with ADHD are disorders of mood,

conduct, learning, motor-control and communication and anxiety disorders

(NICE, 2016).

What’s it like to have ADHD?

Clip: https://www.youtube.com/watch?v=Hl7Ro1PUJmE&feature=youtu.be

(2 min 15 secs)

Children’s descriptions of how ADHD affects them

What might the teachers see in the

classroom? Primary Schools

Children with ADHD may:

Struggle with continuing with tasks such as writing or colouring for very long

Move from one activity to the other without finishing anything

Not enjoy playing with toys or games and prefer active games

Appear not to hear you when you speak to them and may forget when you have asked

them to do something

Fidget constantly, make noises and talk all the time

Be easily distracted by others

Be impulsive and prone to accidents

Hate to wait and will do anything to avoid being bored

Interrupt when people are talking and struggle to wait for their turn in class

What might the teachers see in the

classroom? High Schools

Children with ADHD may:

Be less physically active and fidgety but still struggle to concentrate for

extended periods – internal restlessness

Classroom Recommendations for ADHD: Write out the most important 3-5 class rules for the child on his/her desk.

Ensure instructions are broken down and repeated and that instructions have been understood.

Highlight any key words needed to focus on in the work.

Break work into manageable chunks. Eg. First 3 questions then seek further instructions from the teacher or TA.

Alternatively, ask the child to complete his/her work for timed chunks, eg. 10 minutes and then come and seek help. Try different timers to see if this makes a difference.

Try giving the child a specific number of lines to write into – use a highlighter to mark out the number of lines.

To reduce calling out, encourage the child to count to 5 in his head first.

Children with ADHD often manage best if they are sat at the front, faced forward with little visual distractions around their table.

Use a range of fidget toys to see if this helps – change fidget toys regularly.

Allow the child to stand up to write if that enables him/her to keep to task.

Use visual aids to support learning – colour coded boxes for planning of tasks or spidergrams to get their ideas down on paper.

Try and give immediate feedback on behaviour whether positive or negative.

Try not to remove lunch play as this is likely to impact behaviour in the afternoon.

Reading – if a problem can be encouraged by alternating being read to and reading to the child.

Use a ruler to highlight sentences that need to be read.

In pairs or small groups…(5 mins)

Have a think about whether you recognise any of these signs of ADHD in

children you have previously worked with?

What would you do if you thought a child was showing signs of ASD or ADHD?

Behavioural Difficulties High number of children referred for support with behavioural difficulties

show significant indicators of a neurodevelopmental condition that warrant

specialist assessment.

42 % of children open to Clinical Psychology in the Primary Behaviour Service

referred for further assessment of ASD / ADHD (Sept 15–July 16)

If the main difficulty is ‘behaviour’, consider asking for more information

Parenting intervention

If you are seeing a child that is demonstrating behavioural difficulties or early signs of a neurodevelopmental condition…consider referring them for a parenting intervention.

Regardless of the underlying reason for the difficulties, parenting groups provide a useful space to support parents with:

Improving positive interactions with their child

Understanding their child’s behaviour

Using praise and rewards

Behaviour management and discipline strategies

Understanding the importance of consistency

Understanding the importance of their own self care

This is likely to be a helpful intervention for parents and children regardless of the underlying reason for the difficulties.

If you think a parent may struggle to access a group, there may be more individualised support available

“I don’t need to go to a parenting group!”

Well begun is half done!

Think about how you approach a parent and don’t ask them

to ‘go to a parenting group’

Talk to them about the things they are struggling with and

explain how things in the group might be beneficial to them

Say it’s a group for parents or use some other name but try

to avoid saying ‘parenting group’ or ‘parenting class’ as it

can evoke ideas about being seen a bad or useless parent.

Normalise their experience – all parents struggle, there’s no

guidebook and no one gets it right all the time. Emphasise

the group is about pooling resources & parents sharing ideas

Say its about taking time out to be able to see clearer and

make a plan rather than make it up on the spot when

adrenaline is flowing.

What to do if you think a child may have

a neurodevelopmental condition:

Discuss with your manager/supervisor/SENCO

Hypothesising – it could be a neurodevelopmental condition but lets get more information

How severe are the difficulties?

How long have they been present?

How pervasive are the difficulties? Are they across contexts?

ADHD – 2 or more important settings

But why might parents report no difficulties at home?

What else could it be?

Consider factors that are associated with an increased prevalence of ASD and ADHD - e.g. for ASD -

sibling with ASD, intellectual disability, gestational age less than 35 weeks etc (see NICE, 2011)

Try strategies to see if they make a difference

Consider watchful waiting for up to 10 weeks if concerns about ADHD (NICE, 2016)

If you still think it may be a

neurodevelopmental condition…

Refer for parenting intervention

Parent-training/education programmes are usually the first-line treatment for

parents and carers of pre-school children and children and young people of school

age with ADHD and moderate impairment (NICE, 2016)

Discuss with member of ASD / ADHD assessment team (NDS or CDT)

Referral to agencies for further assessment

EP

OT – sensory needs / SLT

CDT – ASD assessment IF child is 0-6 years old but no ADHD assessments for under 7’s

NDS – ASD assessment IF child is 6+ years old & ADHD assessments

Discussing the referral with the parent and

getting consent

Discuss your concerns in terms of strengths and weaknesses

“So we have talked about how X is really good at maths and

completing tasks by himself and we have talked about some

of the things he seems to find more difficult, like

communicating with others, socialising with peers and talked

about how he can get quite stuck doing activities he likes

and seems to find it difficult to think flexibly. This pattern of

strengths and difficulties could be indicative of social

communication difficulties or an autism spectrum disorder.

Have you heard of social communication difficulties or

autism spectrum disorder before? What do you know about it

already? What do you think? Have you thought about this?”

Discussing the referral with the parent

and getting consent

Don’t be afraid to say ‘autism spectrum disorder’ – the parent may get a

shock when they go to the first CAMHS appointment if they do not know this is

what the assessment appointment is for. Clarify any confusion and talk about

it being a spectrum.

It may be helpful to explain that you are NOT giving a diagnosis of ASD/ADHD

but you think it might be helpful to have this further assessed by the

specialist team.

Explain what will happen on referral to the ASD/ADHD assessment team if

they are referred.

Key information to include with the referral to NDS ASD:

Parental Consent.

Descriptions of behaviours that you have seen within the ‘Triad of Impairment’, social communication/interaction; communication (verbal and non-verbal); flexibility of thought and behaviour.

What has been done so far to support the young person’s learning?

Have any other professionals been involved in the young person’s care/education?

ADHD:

NB. NICE guidelines for ADHD recommend a period of watchful waiting by the GP as well as parents attending a recognised parenting programme before referral to CAMHS Tier 3.

Parental Consent.

Descriptions of behaviours that you have seen regarding hyperactivity; impulsivity; inattention.

What has been done so far to support the young person’s learning?

What other professionals have been involved and in what capacity?

The better the information you provide, the more likely the referral will be accepted!

Waiting for the assessment…

NDS referrals are not subject to the 18 week deadline

Children can wait 12 + months for the assessment to be completed

Continue to involve relevant services and put things in place for the child

or young person while waiting for the assessment to be finished. Try

strategies!

Do not wait for this assessment to be finalised before applying for an

Education Health Care (EHC) plan – describe the needs and difficulties you

are seeing when applying.

If you are concerned about the child or young persons mental health or feel

they are at risk while they are on the waiting list, contact the service you

referred them to and discuss your concerns.

What will happen if the child is referred

to CDT or NDS?

The child and parent may be invited in for several appointments.

The assessment may involve:

Talking to the parent to get a developmental history for the child and a good

understanding of their early history

Doing a play based assessment with the child

A group observation (a clinician observing the child interact with other children all

invited in to the clinic)

An observation of the child in their school

Asking the parent and child’s school to complete some questionnaires

Discussion with other agencies already involved in supporting the child

What CAMHS teams offer……

Tier 2 includes CAMHS staff based in:

SAFE

PBS

CLiPS

CAMHS-LD

MAST

Parenting

LAC

Connect

Tier 3 includes:

FYPS – Family & Young Person’s Service - 0-13 years

NDS – Neurodevelopmental Service - 6-18 years

PLS – Paediatric Liaison Service - 0-16 years

ACS – Adolescent Community Service - 14-18 years

EDT – Eating Disorders Team – any age

Ealing CAMHS consists of two levels of service delivery: Tier 2 and Tier 3

Tiers are distinguished by the level of severity of presenting problem. For example, low

mood would be referred to SAFE teams, whereas a child who is low in mood and expressing

consistent desire to end their life or who have tried to commit suicide would be Tier 3.

What problems do the T3 teams see….?

Depression with severe indicators

Self Harm – suicide attempt, suicidal ideation, repeated self-harm

Eating Disorders – rapid and sustained weight loss, anorexic behaviour, bulimic patterns

Anxiety Disorders – Significant anxiety, especially OCD and severe phobias

ADHD – Assessment and treatment for ADHD

Behaviour Problems – only as part of another condition

Anger Problems – only as part of another condition

Sleep Problems – only as part of a complex picture or as part of other problems

Low self-esteem – not as the only reason for referral, but part of another problem

Substance Misuse – young people are referred to EASY Project

Enuresis / Encopresis – Not as the only reason for referral

Bereavement, loss and trauma – for pathological grief reactions; PTSD

Divorce and Separation – not unless there is clear evidence of a specified mental health problem

School-based problems – not unless there is clear evidence of a specified mental health problem

Severe Learning Difficulties – usually seen by CAMHS-LD but by NDS if they are in mainstream education

School refusal – not unless there is evidence of or need for an assessment for a mental health problem

Psychosis – Assessment and treatment of all psychotic disorders

Autism Spectrum Disorder – Assessment of children with normal language and intellectual development for ASD including concerns of co-morbid mental health problems

What to expect from services

In CAMHS, children or young people with significant mental health needs are

prioritised; this will be the same for children on the waiting list. If a child or

young person has been diagnosed with ASD or ADHD and doesn’t have

significant mental health needs they can be supported by relevant community

services.

There isn’t a designated service for children or young people who have been

given a diagnosis of ASD or ADHD without significant mental health

difficulties.

Dawn Clegg can provide teaching / training to schools about ASD

Don’t forget about voluntary services:

National Autistic Society (NAS)

National Attention Deficit Disorder Information and Support Service (ADDISS)

Family Lives

Post- investigation – what to expect

The child’s needs will still be the same

A diagnosis may help people understand the child or young persons needs.

This is not necessarily the case and people may still need support to

understand these needs: PDD-NOS

Groups (ASD/ADHD parenting group, parenting groups for conduct disorder)

Drug treatment?

Not recommended for children under the age of 7 years with ADHD

Can be tried for school age children with ADHD with moderate impairment after

parent training and psychological therapies (CBT, social skills training) or those

with severe symptoms

Contact details to discuss referrals

Neurodevelopmental Service (NDS) –

Ealing CAMHS,

1 Armstrong Way

Southall

Middx UB2 4SD

T: 020 8354 8160

Child Development Team (CDT) –

Carmelita House

21-22 The Mall

Ealing

London W5 2PJ

T: 020 8825 8712

Parenting pilot – Sept 2017 – Sept 2018

Your school will be participating in the Ealing-wide Primary School Project to pilot a new type of parent/education programme that is more focused on behavioural issues

Empowering Parents Empowering Communities (EPEC) is an innovative, low cost method of working with communities to ensure that they get effective, evidence based early parenting intervention. It is a collaboration between South London and Maudsley NHS Foundation Trust, Kings College London, Ealing Council and Ealing Clinical Commissioning Group

Two members of your staff at the school will be undertaking the training this term to run a parenting group in both the Spring and Summer Terms. They will be supported by a local Health Care Professional assigned to your school

If you are seeing a child that is demonstrating behavioural difficulties or early signs of a neurodevelopmental condition…consider referring them for a parenting intervention within your school

This is likely to be a helpful intervention for parents and children regardless of the underlying reason for the difficulties

Participating primary schools:

Viking, Selbourne, Hanbrough, Stanhope, Gifford, Little Ealing, Berrymede Junior, John Perryn

Resources:

National Autistic Society: www.nas.org.uk

The Attention Deficit Disorder Information and Support Service (ADDISS):

www.addiss.co.uk

References:

Autism spectrum disorder in under 19s: recognition, referral and diagnosis,

NICE, 2011.

Attention deficit hyperactivity disorder: diagnosis and management, NICE

2008, updated 2016.

Child Development - An illustrated guide – Carolyn Meggit (2007)

Step by step help for children with ADHD – A self-help manual for parents –

Cathy Laver_Bradbury, Margaret Thompson, Anne Weeks, David Daley &

Edmund J. S. Sonuga-Barke (2010).

Evaluation form

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Thank you!