Background
Social factors
Socio-economic and cultural factors
Biomarkers in autism diagnosis
Purpose of the review
Method
Scoping search
Inclusion and exclusion criteria
Inclusion Criteria | |
Documents with guidance-based status for HCPs working in secondary care in the UK; or were published papers, aimed at HCPs, with the aim of reviewing CPGs | |
Documents related to autism diagnosis and assessment for either children, adults or both | |
Documents produced either by or through government or professional clinical bodies or published in a journal aimed at HCPs | |
Documents related to diagnosis and assessment in UK (England, Scotland, Wales and N Ireland) | |
Documents dated from 2009 (reflecting publication of the first UK specific Autism Act) or were the most recent CPG published by a key professional body | |
Exclusion Criteria | |
Documents related solely to referral, treatment, prognosis or support services | |
Reviews of diagnostic criteria and other academic papers | |
Guidelines related to primary care as we were interested in diagnosis rather than referral | |
Narrative reviews, editorials and opinions | |
Documents related to parliament or legislature; national or regional strategies as they are not the primary source for clinicians | |
Local guidance | |
Guidance provided by private providers of diagnostic services | |
International professional body guidelines (other than ICD/DSM) |
Type of guideline | General purpose of type of guideline |
---|---|
Diagnostic Criteria | To assist clinicians in the diagnosis of mental conditions by providing descriptions of the main clinical features in each category |
National Clinical Guidelines | To offer best practice advice and guidance for professionals and service users and their families |
Guidelines from Professional Bodies | To offer profession specific advice to clinicians and healthcare professionals in their specialist area |
Journal Articles | To summarise clinical guidelines in clinician-facing publications to keep clinicians up to date and/or alert them to changes in good practice |
Identification of CPGs
Study selection
Data extraction
Analysis of social factors
Terminology
Results
Characteristics of guidelines
Title | Year | Author(s) | Publisher/Journal | Geographical remit | Target audience | Age range | Range of diagnoses covered | Diagnostic criteria referred to | Age at which symptoms are recognised |
---|---|---|---|---|---|---|---|---|---|
DIAGNOSTIC CRITERIA
| |||||||||
The ICD-10 Classification of Mental and Behavioural Disorders: clinical descriptions and diagnostic guidelines [32] | 1993 | N/A | World Health Organisation | International | Clinical, educational and service use | All ages | Pervasive development disorders | N/A | Before age of 3 years (childhood autism); after age 3 (atypical autism). |
Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) [33] | 2013 | N/A | American Psychiatric Association | International | Clinicians, students, practitioners, researchers | All ages | Autism Spectrum Disorder | N/A | During 2nd year of life (12–24 months) or earlier than 12 months if developmental delays are severe |
NATIONAL CLINICAL GUIDELINES
| |||||||||
NICE Autism in under 19 s: recognition, referral and diagnosis (NICE CG128) [39] | 2011 | National Collaborating Centre for Women’s and Children’s Health | National Institute for Health and Care Excellence (NICE) | England and Wales | Healthcare professionals | From birth up to 19 years | Pervasive developmental disorder (PDD) | ICD-10 or DSM-IV | May be uncertainty before 24 months, or with developmental age of less than 18 months |
Six Steps of Autism Care for children and young people in Northern Ireland (RASDN) [44] | 2011 | Regional Autistic Disorder Network for Northern Ireland | Health and Social Care Board | Northern Ireland | Health care and education professionals, parents, carers, service users and providers. | Up to the age of 18 years | Autism spectrum disorder | ICD-10, DSM-IV, NICE, SIGN, NZ Guidelines, NHS Map of Medicine | Pre-school. Language delay by the age of two years. |
Autism Spectrum Disorder in adults: diagnosis and management (NICE CG142) [9] | 2012 | National Collaborating Centre for Mental Health | National Institute for Health and Care Excellence (NICE) | England and Wales | Health and social care providers and commissioners | Adults aged 18 and over | Autism spectrum disorders | N/S *ICD-10 specified in full version of CG142 [62] | N/A |
Autism Adult Care Pathway (RASDN) [54] | 2013 | Regional Autistic Spectrum Disorder Network | Health and Social Care Board | Northern Ireland | Professionals, adults and families | Adults from age 18 | Autism spectrum disorders | DSM-5 and ICD-10, NICE guidance CG142. | N/S |
Assessment, diagnosis and interventions for autism spectrum disorders: A national clinical guideline (SIGN 145) [10] | 2016 | N/A | Scottish Intercollegiate Guidelines Network | Scotland | Healthcare professionals | Whole age range | Autism spectrum disorder | ICD-10 and DSM-5 | Autism can be reliably diagnosed between the ages of 2–3. |
GUIDELINES FROM PROFESSIONAL BODIES
| |||||||||
RCSLT (Royal College of Speech and Language Therapists Clinical Guidelines (Autism) [41]a | 2005 | N/A | Royal College of Speech and Language Therapists | UK | Speech and language therapists | Children and adults | Autism spectrum disorder | ICIDH-2 (for general clinical assessment) | N/S |
Good practice in the management of autism (including Asperger syndrome) in adults (RCPych CR191) [11] | 2014 | Royal College of Psychiatrists | Royal College of Psychiatrists | UK | Psychiatrists working with adults of at least normal intellectual ability | Adults from age 18 | Autism | ICD-10, DSM-5, NICE, 2012. | N/S |
Autism Spectrum Disorders: Guidance for Psychologists (BPS) [40]b | 2016 | Stuart-Hamilton, Dillenburger, Hood & Austin | British Psychological Society | UK | Psychologists | All ages | Autism Spectrum Disorder | ICD-10 and DSM-5, NICE, 2011. | Both diagnostic manuals consider ASD indicators to be present by the age of 36 months although some children can be identified under the age of 24 months. |
BMJ Best Practice online resource [43] | 2017 | Parr &Woodbury-Smith | British Medical Journal | Outside US and Canada | Medical Practitioners | All ages | Autism Spectrum Disorder | DSM-IV, DSM-5 & ICD-10. NICE, SIGN, AACAP, AAP, NZ ASD guideline, AAN | More than 80% of children with ASD show clear behavioural signs by the age of 24 months, some indicators in 12–18 months |
JOURNAL ARTICLES
| |||||||||
Diagnosis and management of autism in childhood [47] | 2011 | Blenner, Reddy & Augustyn | British Medical Journal | N/S | General clinicians | Children | Autism Spectrum Disorder | DSM-IV TR or ICD-10 | N/S |
Diagnosis and assessment in autism spectrum disorders [48] | 2012 | Carpenter | Advances in Mental Health and Intellectual disabilities | N/S | Those designing and providing diagnostic services | All ages | Autism Spectrum Disorder | DSM-IV TR or ICD-10. Gillberg’s for AS. There are others but few use them (Kopra et al., 2008; Chiappedi et al., 2010). | N/S |
Autism spectrum disorder in adults: clinical features and the role of the psychiatrist [49] | 2013 | Garland, O’Rourke & Robertson | Advances in Psychiatric Treatment | UK | Psychiatrists | Adults | Autism Spectrum Disorders | ICD-10 and DSM-5, NICE | To satisfy ICD-10 criteria for childhood autism, impairments must manifest before the age of 3 years |
Recognising, referring and diagnosing autism [45] | 2012 | Howlett & Richman | Every Child Journal | England and Wales | Professionals working with children and young people | Children and young people | Autism | NICE | The core autism behaviours are typically present in early childhood; but features can appear different with age or change with circumstances |
Autism [50] | 2013 | Lai, Lombardo & Baron-Cohen | The Lancet | N/S | N/S | All ages | Autism or the autism spectrum | DSM-5, ICD-10 | N/S |
Autism [51] | 2009 | Levy, Mandell & Schultz | The Lancet | N/S | N/S | N/S but primarily talks about children | Autism Spectrum Disorder | DSM-IV and ICD-10 | Parents often aware from age 18 months, a diagnosis is often not made until 2 years after the initial expression of parental concern. |
Autism spectrum disorder: diagnosis and management [53] | 2009 | O’Hare | Archives of Disease in Childhood: Education and Practice Edition | N/S but relates primarily to SIGN guidelines | Paediatricians | Children and young people | Autism Spectrum Disorder | ICD-10 and DSM-IV, SIGN | N/S |
Recognition, referral, diagnosis, and management of adults with autism: summary of NICE guidance [58] | 2012 | Pilling, Baron-Cohen, Megnin-Viggars, Lee & Taylor | British Medical Journal | England and Wales | N/S | Adults | Autism | N/S | N/S |
Autism Spectrum Disorders in childhood: a clinical update [46] | 2011 | Reynolds | Community Practitioner | UK | Community practitioners | Children | Autism Spectrum Disorder | ICD-10, DSM-IV | N/S |
The NICE guideline on recognition, referral, diagnosis and management of adults on the autism spectrum [52] | 2014 | Wilson, Roberts, Gillan, Ohlsen, Robertson & Zinkstok | Advances in Mental Health and Intellectual Disabilities | England and Wales | Health care professionals, service managers, service users, practitioners | All adults | Autism spectrum disorder | N/S | N/S |
Definitions of autism
Narrative review of social factors
Operational factors
CPG | Recommended tools | MDT recommended | MDT membership | Assessment targets | Key features of assessment |
---|---|---|---|---|---|
DIAGNOSTIC CRITERIA
| |||||
ICD-10 (1993) [32] | N/S | N/S | N/S | N/S | Diagnose on the basis of behavioural features |
DSM-5 (2013) [33] | No specific tool | N/S | N/S | N/S | Careful clinical history & summary of social, psychological & biological factors. Multiple sources of information: • clinician’s observations • caregiver history • self-report (where possible) Clinical judgement |
NATIONAL CLINICAL GUIDELINES
| |||||
NICE CG128 (2011) [39] | No specific tool recommended | Autism team members should carry out assessment (short version). A diagnosis can be made by a single experienced HCP; profile of strengths & weaknesses is essential, and requires MDT [55] (full version). | Autism team made up of Paediatrician &/or Child & Adolescent Psychiatrist, SLT, Clinical &/or Educational Psychologist & access to paediatrician/paediatric neurologist, Child & Adolescent Psychiatrist, Educational Psychologist, Clinical Psychologist, OT, if not in team. Also consider specialist health visitor or nurse, specialist teacher or social worker. | Start the autism diagnostic assessment within 3 months of referral. Follow up appointment within 6 weeks of assessment. | Seek report from the pre-school or school; gather additional health or social care information. Include in every autism diagnostic assessment: • questions about parent/carer/child’s concerns • details of the child’s experiences of home life, education and social care • developmental history, focusing on developmental and behavioural features • assessment (through interaction with and observation of the child or young person) of social and communication skills and behaviours • medical history, including prenatal, perinatal and family history, and past and current health conditions • physical examination • consideration of the differential diagnosis • systematic assessment for conditions that may coexist with autism • development of a profile of the child’s or young person’s strengths, skills, impairments and needs that can be used to create a needs-based management plan, taking into account family and educational context • communication of assessment findings to the parent/carer/child |
RASDN (2011) [44] | No specific tool | The use of MDT approach is necessary | Involving at least two disciplines: paediatrician; child psychiatrist; SLT, OT, clinical psychologist; specialist health visitor; mental health practitioner (CAMHS); social worker; nurse; ed. psych. Teacher; other trained professionals | Referral screened within 5 days. Info provided within 4 weeks. 13 weeks to first appointment. Feedback within 4 weeks, report within 6 weeks of formulation. | Step one: Initial directed conversation. Step two: Integrated multidisciplinary team assessment (leads to diagnosis/non-diagnosis) includes: • medical history inc: birth history, family history, & general medical concerns • developmental history focusing on developmental & behavioural concerns • observational assessment of the child/young person • further assessment/observations in another setting (school/home) • physical exam in some groups • specific assessments may be required, e.g. SLT assessment • educational assessment Step three: Integrated MDT formulation (leads to wider understanding of difficulties) Step four: family feedback and care planning |
NICE CG142 (2012) [9] | Identification: Consider AQ-10 (without LD); Brief assessment (with LD). Diagnosis and assessment: AAA including AQ and EQ; ADI-R; ADOS-G; ASDI; RAADS-R (without LD). ADOS-G; ADI-R (with LD); DISCO, ADOS-G, ADI-R | Comprehensive assessment should be team based (short version). At a minimum by a qualified clinician usually a clinical psychologist, psychiatrist or neurologist [62] (full version). | Specialist autism team made up of: Clinical Psychologists, Nurses, OTs, Psychiatrists, Social Workers, SLTs, Support Staff | N/S | During a comprehensive assessment, enquire about and assess the following: • core autism signs and symptoms that have been present in childhood and continuing into adulthood • early developmental history, where possible • behavioural problems • functioning at home, in education or in employment • past and current physical and mental disorders • other neurodevelopmental conditions • hyper- and/or hypo-sensory sensitivities and attention to detail. Direct observation of core autism signs and symptoms especially in social situations. Assess for possible differential diagnoses and coexisting disorders Assess risks; Develop care plan, provide health passport, consider 24 h crisis management plan; Assess challenging behaviour Consider further investigations on individual basis |
RASDN (2013) [54] | Screening: GADS, GARS-2, AASQ, ASAS, NAS, AQ-10 History: ADI-R, DISCO, ASDI, RAADS-R; Direct assessment: ASIT, HSST, SSQ, Observation: ADOS-G | Diagnosis must be team based & draw on a range of professionals. | At least two of: clinical psychology (core), psychiatry, SLT, LD/MH nursing; OT, other appropriately trained professionals. | Final report to be provided within 6 weeks of assessment. | As an absolute minimum, elements 2, 3 & 4 must be included in the assessment. 1. Neurodevelopmental history, corroborated via relative/family; 2. Direct autism specific assessment with individual; 3. Observational recording of assessment sessions; 4. Clinical judgement. May also include; standardized measure of adaptive functioning; assessment of language & communication skills; functional assessment of problematic behaviour; full needs assessment |
SIGN 145 (2016) [10] | Identification: AQ-10 Diagnosis and Assessment: E.g. ADI-R, DISCO, 3di, CARS, CARS-2, ADOS-G. NAPC and RCPsych guides. | MDT … should be considered as the optimum approach | Experienced professionals | N/S | • History taking (informant interview): prenatal, perinatal & developmental history; description of the current problems experienced; family history; description of who is in family; coexisting conditions and differential diagnoses • Clinical observation/assessment (individual assessment/interview): directly observe & assess the individual’s social & communication skills and behaviour • Contextual and functional information from a variety of settings and people • Profile of the individual’s strengths and difficulties: communication, cognitive, neuropsychological and adaptive functioning; motor and sensory skills • Biomedical investigations on an individual basis when clinically relevant • Assessment of mental health needs, wellbeing and risk should be considered |
GUIDELINES FROM PROFESSIONAL BODIES
| |||||
RCSLT (2005) [41] | N/S | Should always be multidisciplinary & multi-agency to achieve optimum benefit. | This may include SLT, child psychology, child psychiatry, clinical psychology, paediatrician, EdPsych., OT & teacher | N/S | During assessment, consideration must be given to the triad of social impairments, as well as theories relating to the triad, for example sensory sensitivity and integration; intersubjectivity; executive functioning deficits; motivation; memory and central coherence. • Joint attention • Readiness & ability to focus & shift attention • Social interaction • Use of communicative strategies • Evaluation of child’s play • Info about learning potential • Impact of individual’s mental health |
RCPsych (2014) [11] | Identification: AQ, RAADS-R. RPsych Guide. Questionnaires: ASAS, GARS, GARS-2, SCQ, SRS-2, AQ, AQ-10, RAADS-R, SCDS, ABC. Diagnostic interviews: ADI-R, ADOS-2, DISCO, 3Di, AAA, RPsych Guide, PDD-MRS, ASDI, CARS-2, HBS, WADIC Assessment for associated dev disabilities: AQ, EQ, SQ, Faces test, eyes test, Faux Pas Recognition Test, SSQ, Dewey’s Social Stories, Adult/Adolescent sensory profile | NICE advocates multidisciplinary exercise, but psychiatrists might be expected to diagnose straightforward cases & be alert to indications for a more specialist assessment. | MDT usually includes psychology & nursing as core membership | N/S | • Speak with informant • Take neurodevelopmental history • Consider obtaining early health records Might include assessment for; cognitive ability, functional ability, coexistent neurodevelopmental disabilities, coexistent psychiatric disorders, mental capacity, risk of harm/offending, medical problems Wherever possible, it is essential that the clinician gets accurate accounts of relationships in different settings (e.g. at work & at home), particularly where they might be more demanding for that individual. |
BPS (2016) [40] | e.g. ADOS, ADI, DISCO, ADI-R | It is recommended that assessment is multidisciplinary. | At least one psychologist, in addition to other relevant personnel, such as OTs, mental health workers etc. | It is recommended that assessment is timely. | The taking of a developmental history with carers as well as observation across different settings. Information from a range of sources. Psychologists contribution to identification and assessment may include: • Assessment of protective factors, strengths and abilities • Assessment of associated mental health issues • Comprehensive developmental and family history • Assessment of learning styles • Assessment of strengths and of barriers to learning • Assessment of environmental conditions for learning • Functional behavioural assessment • Assessment of social communication style • Assessment of the needs of families. • Comprehensive cognitive assessment, which may include psychometrics if deemed necessary |
BMJ (2017) [43] | Screening: CHAT, M-CHAT Parental questionnaires: SCQ, CAST, CARS; for adults, the SRS, ASQ. Diagnosis and Assessment: eg ADOS-G, ADI-R; 3di; DISCO | Diagnosis should be confirmed or made by an appropriately trained professional, ideally working as part of MDT | Paediatricians, child psychiatrists, adult psychiatrists or psychologists, & other professionals | N/S | A combination of: • neurodevelopmental history • standardised interview, & • observational assessment Gather information about functioning in more than one environment; A full neurological examination including measurement of head circumference is routinely performed in all children. |
JOURNAL ARTICLES
| |||||
Blenner et al (2011) [47] | Screening: CHAT, PDDST, STAT, CHAT-23, M-CHAT, ITC, SCQ. Diagnosis: ADOS. | Paediatric neurologists, developmental & behavioural paediatricians, child psychiatrists or psychologists, or, ideally, MDT. | N/S | N/S | Comprehensive evaluation that includes • lifetime & family history • review of medical & educational records • behavioural observation • physical examination • administration of standardised instruments such as the autism diagnostic observation schedule • cognitive & adaptive assessment • review of established DSM or ICD diagnostic criteria • Assessment of specific domains, such as communication skills, sensory and motor problems, and family stressors and coping abilities • Look for causes & co-occuring conditions (further tests) |
Carpenter (2012) [48] | Screening: ASDASQ, AQ and EQ, AAA. AQ-10, RAADS-R. RCPsych guide. Observation: PDD-MRS (with ID); ADOS-G. Interview: ADI-R, DISCO, 3Di. AAA to provide structure. | Diagnosis can be made by one clinician. Wider assessment requires a team. A variety of professionals can diagnose. | N/S | Labour intensive - up to 8 h to make & document diagnosis. | Three elements (judged against criteria of ICD-10 or DSM-4): • interview with person • observation • interview with an informant Some clinicians bypass the criteria & test, for example, theory of mind, central coherence. Consider possible co-morbidities Holistic assessments needs to be structured around: • Need for social support and for help with employment • Sensory and processing difficulties • Medical issues • Neuro-psychiatric conditions • Practical skills, including motor difficulties • Social interaction skills • Emotional understanding (of self and others) and personal coping strategies • Interests and preoccupations • Sexual interests and future desires • Insight and future desires and motivation • Psychiatric concerns • Other behaviours that may get person into contact with the law • Support for carers |
Garland et al. (2013) [49] | Screening: AQ-50, AQ-10 Diagnosis: ADI-R, ADOS = G, RCPsych Diagnostic Interview Guide | When mental health difficulties also exist, the expertise of the wider MDT is likely to be engaged. | Outlines psychiatrist’s role. | Enough time should be set aside | • History of presenting complaint • Psychiatric history • Family history • Medical history • Developmental history • Personal & social history • Mental state examination • Assess for comorbid disorders inc. neurodevelopment disorders • Physical assessment • Functional level assessment • Assess risk • Assessment of care & support needs • Consideration of need in areas of education & employment |
Howlett & Richman (2011) [45] | No specific tool | If the local autism team does not have the skills to assess these children themselves, they should liaise with professionals who are able to do so | Minimum, paediatrician &/or child & adolescent psychiatrist, SLT & clinical &/or Ed.Psych. Other professionals … specialist health visitor, nurse, specialist teacher, social worker | Timely & appropriate. Follow up appointment within six weeks of assessment | Should provide detailed developmental profile. Based on NICE guidance. |
Lai et al....... (2013) [50] | Screening: CHAT, ESAT, M-CHAT, ITC, Q-CHAT, STAT (for young children); SCQ, SRS, SRS-2, CAST, ASSQ, AQ (for older children and adolescents); AQ, RAADS-R (FOR ADULTS). Diagnosis and assessment: ADI-R, DISCO, 3Di (for structured interview); ADOS, ADOS-2, CARS, CARS-2 (observational measure). | Assessment needs to be multidisciplinary | N/S | N/S | • Interview with the parent or caregiver • Interaction with the individual • Collection of information about behaviour in community settings • Cognitive assessments • Medical examination • Co-occurring conditions |
Levy et al (2009) [51] | SCREENING: Q-CHAT, M-CHAT, FYI, ECI-4, CSI-4, SCQ, ASDS, KADI, AQ-Child, A (AUTISM) ABC (autism), PDDRS, PDD-MRS, DBC, DBC-ES, PDDBI, ABC (aberrant), CCC, SRS, RBS-R, SCDC. Diagnosis and assessment: PIA-CV, DISCO, ADI-R, 3Di. CHAT, STAT, AOSI, ADOS, CARS | These assessments should be multidisciplinary | The MDT should include clinicians skilled in speech & language therapy, occupational therapy, education, psychology, & social work. | • Use ICD or DSM criteria • Core and comorbid symptoms, cognition, language, & adaptive, sensory, & motor skills. • Review of caregiver concerns, descriptions of behaviour, medical history, & questionnaires. • Include stage 1 data. • Observations across settings • Cognitive, communication, & ASD-specific assessment • Medical assessment • Differential diagnosis | |
O’Hare (2009) [53] | Screening: M-CHAT, NAPC Checklist Diagnosis: ADOS-G, SRS | A multidisciplinary diagnostic approach is recommended | Paediatricians are essential members. | N/S | • Direct clinical structured observations • Critical that information is gathered from different settings, outwith the clinic – there are structured questionnaires for parents/teachers • Physical exam and other specialist tests as required |
Pilling et al. (2012) [58] | Identification: AQ-10. | N/S | N/S | N/S | Inquire about & assess the following: • Core autism signs & symptoms • Early developmental history • Behavioural problems • Functioning at home, education, employment • Past & current physical & mental disorders • Other neurodevelopmental conditions • Neurological disorders (for example, epilepsy) • Communication difficulties • Hypersensory &/or hyposensory sensitivities & attention to detail • Carry out direct observation of core autism signs & symptoms especially in social situations • Functional analysis |
Reynolds (2011) [46] | No specific tool | N/S | N/S | N/S | Observed behaviours with patient presenting symptoms from ‘Triad of Impairments’: social interaction, social communication, social imagination |
Wilson et al (2013) [52] | Identification: AQ-10 Diagnosis and assessment: ADI-R; ADOS-G. AAA, ADI-R, ADOS-G, ASDI, RAADS-R (without ID). ADI-R and ADOS-G (with ID). DISCO, ADI-R, or ADOS-G. | Should be carried out by MDT consisting of professionals who have experience in diagnosing autism (from NICE). | N/S | N/S | A comprehensive assessment of autism should involve an assessment of • core autism signs and symptoms • early developmental history, where possible, and in the absence of an informant written information, such as school reports may be used • behavioural problems • functioning at home, in education, or in employment • past and current physical and mental disorders • other neurodevelopmental conditions • neurological disorders (e.g. epilepsy) • sensory processing and sensory sensitivity issues Assess coexisting mental health disorders. Risk assessment. Functional analysis for challenging behaviour |
The assessment process
‘…testing for specific underlying difficulties such as lack of theory of mind or lack of central coherence and then using these to decide the presence of the behavioural criteria’ [48].
Diagnostic tools
Diagnosis and formulation
‘The outcome of the formulation should be to understand an individual in a more global holistic way rather than merely in terms of signs and symptoms, as in the case of diagnosis’ [44].
‘..the label of autism does not constitute a complete diagnostic assessment and a profile of the child or young person’s strengths and weaknesses is also essential. This requires a multidisciplinary team which has the skills to undertake the assessments necessary for profiling’ [55].
Interactional factors
Multidisciplinary assessment versus single practitioner assessment
Interaction with the person and their family
Contextual factors
Interpreting needs
Masking and social context
Diagnostic uncertainty, thresholds and the role of clinical judgement
Pragmatic outcomes and diagnostic value
‘Diagnosis and the assessment of needs …can open doors to support and services…all of these can improve the lives of the child or young person and their family’ [39].