Referral Pathway for a 5-Year-Old with Suspected Autism
Refer immediately to a multidisciplinary autism diagnostic clinic that includes a psychologist, developmental pediatrician or child neurologist, and speech/language pathologist for comprehensive ASD evaluation. 1
Why Multidisciplinary Team-Based Evaluation is Essential
Single-provider evaluation is insufficient for ASD diagnosis—multidisciplinary input is required. 1 The comprehensive diagnostic process requires:
- A psychologist to conduct cognitive assessment, measure sustained attention, working memory, and processing speed 1
- A speech/language pathologist to evaluate receptive and expressive language and pragmatic language skills 1
- A physician (developmental pediatrician, neurologist, or pediatric psychiatrist) to conduct medical assessment, rule out other conditions, and manage comorbidities 1
The criterion standard for ASD diagnosis is a comprehensive evaluation using standardized measures such as the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R), which have sensitivity of 91% and 80% and specificity of 76% and 72%, respectively 2. Screening tools like the M-CHAT are not diagnostic and should not be relied upon for older children, who require comprehensive clinical evaluation with ADOS and ADI-R 1.
Critical Timing Considerations
Do not delay referral, as wait times for team-based evaluations can exceed one year. 1 Although a maximal wait time of 3 to 6 months has been recommended by recent ASD guidelines, the time from referral to team-based diagnostic evaluation commonly takes more than a year in many communities 3. Early recognition, diagnosis, and treatment improve prognosis 4.
Concurrent Actions While Awaiting Evaluation
Refer immediately to early intervention services or school-based special education without waiting for formal diagnosis. 1 This is critical because:
- Intensive behavioral interventions, such as the Early Start Denver Model, are beneficial in children 5 years or younger for improvement in language, play, and social communication 2
- Behavioral interventions based on applied behavior analysis have the highest-quality data supporting their effects on cognitive and language outcomes 5
- These interventions can be time-intensive, with some programs requiring up to 40 hours per week 5
What the Comprehensive Evaluation Will Include
The multidisciplinary assessment will evaluate multiple domains 1:
- Standardized diagnostic tools including ADOS and ADI-R 1
- Cognitive testing with global ability assessment including verbal and nonverbal components 1
- Language evaluation including receptive, expressive, and pragmatic language testing 1
- Adaptive functioning assessment of real-world skills across multiple domains 1
- Motor skills evaluation, as motor dysfunction occurs in nearly all ASD cases 1
- Medical workup including physical examination, hearing screen, Wood's lamp examination for tuberous sclerosis, and genetic testing 1
Screening for Co-occurring Conditions
Approximately 75% of children with ASD have comorbid psychiatric conditions that should be screened for. 1 Compared with people without ASD, individuals with ASD have higher rates of:
- Depression (20% vs 7%) 2
- Anxiety (11% vs 5%) 2
- Sleep difficulties (13% vs 5%) 2
- Epilepsy (21% with co-occurring intellectual disability vs 0.8%) 2
- Attention-deficit/hyperactivity disorder 1, 2
Common Pitfalls to Avoid
- Never rely on screening tools alone for diagnosis in a 5-year-old—comprehensive clinical evaluation with standardized diagnostic measures is required 1
- Do not wait for formal diagnosis before initiating services—refer to early intervention or school-based special education immediately 1
- Do not attempt single-provider diagnosis—ASD diagnosis requires multidisciplinary team input 1
- Do not overlook co-occurring conditions including sleep disturbances, gastrointestinal problems, anxiety, and hyperactivity that require treatment 4