Clinical Perspectives on the Assessment and Diagnosis of Social and Neurodevelopmental Conditions in Children

Assessing developmental differences in children can be challenging. Two of the key stages in the assessment process are identification and formal assessment. This dissertation seeks to explore some of the forms of information, including symptom profiles, which contribute these assessment practices. Specifically, this dissertation focuses on three developmental conditions: autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and attachment-related conditions. This work is designed to reflect a hypothetical child or family’s pathway through services starting with a query of ASD, moving to differential conceptualisation of ADHD and attachment-related difficulties. First, a systematic review identified that GPs had variable knowledge of autism and sometimes leaned on lay sources. Qualitative interviews helped to identify some of the implicit forms of information that GPs draw on in their assessments (e.g. familiarity with the family). Analysis of qualitative interviews also identified the different forms of information that specialists use to inform decisions. In general, specialists tended to speak about the application of diagnosis in “natural” and “pragmatic” terms. That is, some children’s behaviour was a ‘natural-fit’ with diagnostic criteria, whereas the decision to diagnose, or indeed remove a diagnosis, from some children was grounded in pragmatic considerations. A conceptual review explored how attachment concepts are used in ASD and ADHD literature, which include a critical analysis of the Coventry Grid Interview, a tool which seeks to delineate symptom profiles of ASD and attachment difficulties. Qualitative interviews showed that suspicions about attachment tend to be raised by contextual factors and there were also some clear divergences between the developmental and clinical attachment theory discourses. Analysis of the Strengths and Difficulties Questionnaire (SDQ) provided further insight into the symptom profiles of children with ASD, ADHD, and attachment-related conditions, showing differences between subscales, but not in terms of total difficulties or networks of symptoms. The role of clinical judgment in assessments is often acknowledged, but rarely expanded upon. Taken together, this work illuminates some of the forms of information that shape these judgments. By foregrounding these forms of information, this work is well placed to contribute to the sociological, psychometric and applied literature on these topics. In addition, tensions were identified between various stakeholders. Recommendations for next steps include the integration of electronic healthcare records and the development of expert statements on neurodevelopment and attachment.I wish to thank NIHR School for Primary Care Research (RG94577) and Wellcome Trust (WT103343MA) for their support for work on this dissertation. Recruitment for study described in Chapter Two was supported by the Central Research Network (CRN) Eastern. The data for Chapter Five was collected through Clinical Record Interactive Search (CRIS). CRIS is supported by the NIHR Biomedical Research Centre for Mental Health BRC Nucleus at the South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, Psychology and Neuroscience, King’s College London jointly funded by the Guy’s and St Thomas’ Trustees and the South London and Maudsley Trustees. Data are owned by a third party, Maudsley Biomedical Research Centre (BRC) Clinical Records Interactive Search (CRIS) tool, which provides access to anonymised data derived from SLaM electronic medical records. These data can only be accessed by permitted individuals from within a secure firewall (i.e. the data cannot be sent elsewhere), in the same manner as the authors. For more information please contact: cris.administrator@slam.nhs.uk. The views expressed are those of the authors and not necessarily those of the CRN, NHS, the NIHR or the Department of Health