Can I see a patient with Autism Spectrum Disorder (ASD) alone without their guardian present?

Seeing a Patient with ASD Alone When Guardian Does Not Attend

You can and should see the patient with ASD alone when the guardian does not attend appointments, provided the patient has decision-making capacity for the clinical matters at hand and there are no immediate safety concerns requiring guardian involvement. 1

Legal and Ethical Framework

The key consideration is whether the patient has legal capacity to consent to care, not simply whether they have a guardian:

• Parents with legal custody should provide information and can receive information about their child, but the caregiver(s) with primary physical custody and children who have regular contact with the identified patient are usually those who attend interviews 1
• When family members fail to attend even when requested, you should proceed with interviewing those who actually attend, while remaining attentive to the absence and its meaning for the family dynamics 1
• The family interview with members missing, although less than optimal, can nonetheless serve to provide important information, particularly when efforts to ensure their attendance at future sessions are resisted 1

Assessment of Decision-Making Capacity

Before proceeding with solo appointments, evaluate the patient's capacity:

• Adults with ASD who may require a legal surrogate are those who are cognitively impaired to the degree that they cannot understand their situation, understand the risks associated with decisions, and communicate a decision based on that understanding 1
• If an adult's mental competency is in question and no appointed adult surrogate is available, a psychological evaluation should be requested 1
• The majority of individuals with ASD have average to above-average intellectual ability, so do not assume incapacity based solely on the ASD diagnosis 2

Practical Approach to Solo Appointments

When the guardian does not attend:

• Interview the patient alone, as individual interviews often help patients share their history more freely 1
• Document the patient's capacity to consent to the specific clinical decisions being made during that visit 1
• Establish clear communication about what information will be shared with the guardian and what will remain confidential, respecting the patient's preferences unless significant safety risks arise 1
• Consider whether the absence of the guardian represents a pattern that requires addressing as part of the treatment plan 1

Important Caveats

Common pitfall: Do not refuse to see a patient simply because their guardian is absent if the patient can meaningfully participate in their care. However, certain situations require guardian involvement:

• When the patient lacks capacity for the specific medical decisions at hand 1
• When there are immediate safety concerns (suicidal ideation, severe medical instability) that require surrogate decision-making 1
• When legal consent is specifically required for procedures or treatments beyond routine care 1

Documentation and Communication

• Document the patient's capacity assessment and the clinical rationale for proceeding without the guardian present 1
• Establish advance directives with the patient to clarify their wishes for future care, ideally during a time when they are not acutely ill 1
• Address guardianship transfer planning if the current guardian is aging or becoming incapacitated, as this becomes an ethical and legal challenge when not addressed proactively 1