Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
C- All professionals involved in diagnosing Autism Spectrum Disorders (ASD) in children and young people should consider using either International Classification of Diseases (ICD)-10 or Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV.
Recognition, Assessment, and Diagnosis
Recognition in Primary Care
C - Population screening for ASD is not recommended.
D - As part of the core program of child health surveillance, healthcare professionals can contribute to the early identification of children requiring further assessment for ASD, and other developmental disorders:
- Clinical assessment should incorporate a high level of vigilance for features suggestive of ASD, in the domains of social interaction and play, speech and language development and behavior
- The Checklist for Autism in Toddlers (CHAT) or modified CHAT (M-CHAT) can be used in young children to identify clinical features indicative of an increased risk of ASD but should not be used to rule out ASD
Screening of High Risk Groups
C - The use of an appropriate structured instrument may be a useful supplement to the clinical process to identify children and young people at high risk of ASD.
Timing of Diagnosis
D - ASD should be part of the differential diagnosis for very young (preschool) children displaying absence of normal developmental features, as typical ASD behaviors may not be obvious in this age group.
Methods of Assessment
Components of Specialist Assessment
History Taking (Parent/Carer Interview)
D - Healthcare professionals involved in specialist assessment should take an ASD specific diagnostic history
C - ASD specific history taking instruments may be considered as a means of improving the reliability of ASD diagnosis
Clinical Observation/Assessment (Child/Young Person Assessment/Interview)
D - Healthcare professionals should directly observe and assess the child or young person's social and communication skills and behavior.
C - Healthcare professionals should consider using ASD-specific observational instruments, as a means of improving the reliability of ASD diagnosis.
D - All children and young people with ASD should have a comprehensive evaluation of their speech and language and communication skills, which should inform intervention.
D - Children and young people with ASD should be considered for assessment of intellectual, neuropsychological and adaptive functioning.
D - Where clinically relevant, the need for the following should be reviewed for all children and young people with ASD:
- Examination of physical status, with particular attention to neurological and dysmorphic features
- Karyotyping and Fragile X DNA analysis
- Examination of audiological status
- Investigations to rule out recognised aetiologies of ASD (e.g., tuberous sclerosis, see Annex 3 in the original guideline document)
Conditions Associated with ASD
C - Healthcare professionals should be aware of the need to routinely check for comorbid problems in children and young people with ASD. Where necessary, detailed assessment should be carried out to accurately identify and manage comorbid problems.
Support for Early Communication Skills
D - Interventions to support communication in ASD are indicated, such as the use of visual augmentation (e.g., in the form of pictures of objects).
Interventions for Social Communication and Interaction
D - Interventions to support social communication should be considered for children and young people with ASD, with the most appropriate intervention being assessed on an individual basis.
Intensive Behavioral Programmes
A - The Lovaas programme should not be presented as an intervention that will lead to normal functioning.
Interventions for Specific Behaviors
B - Behavioral interventions should be considered to address a wide range of specific behaviors in children and young people with ASD, both to reduce symptom frequency and severity and to increase the development of adaptive skills.
Auditory Integration Training
A - Auditory integration training is not recommended.
A - Facilitated communication should not be used as a means to communicate with children and young people with ASD.
B - Risperidone is useful for short term treatment of significant aggression, tantrums or self injury in children with autism
B - Weight should be monitored regularly in children and young people who are taking risperidone.
B - Methylphenidate may be considered for treatment of attention difficulties/hyperactivity in children or young people with ASD.
A - Secretin is not recommended for use in children and young people with ASD.
D - Melatonin may be considered for treatment of sleep problems which have persisted despite behavioral interventions.
D - All professions and service providers working in the ASD field should review their training arrangements to ensure staff has up-to-date knowledge and adequate skill levels.
Training and Support for Parents
D - Professionals should offer parents good quality written information and an opportunity to ask questions when disclosing information about their child with ASD
D - Parents should be provided with information in an accessible and absorbable form.
Meeting Support Needs
B - Education and skills interventions for parents of pre-school children with ASD should be offered.
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), or RCT rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B: A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C: A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D: Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g. case reports, case series)
4: Expert opinion