An independent provider in the Cornwall area

3. Mr A complains about an online autism assessment the Provider conducted in January 2025. He says:

• the assessment was prejudiced before it began, undermining its fairness and validity. He says the clinicians who conducted the assessment made prejudicial comments prior to speaking to him.

• factual errors were raised including assumptions about him having lots of friends and an incorrect date related to him being detained under the Mental Health Act.

4. Mr A says he has been left without an autism diagnosis because of a flawed assessment process. He says some of the comments the clinicians made before the assessment were invalidating, distressing, and discriminatory and this has undermined his trust in clinical services. He says the events and a lack of diagnosis continue to affect him daily and he has been denied timely access to the appropriate diagnostic pathway.

5. He has been unable to access a Disabled Student’s Allowance through Student Finance England, despite studying with the Open University and needing support. His degree studies and business startup have been negatively impacted by the delay and a lack of support without a diagnosis.

6. Mr A is seeking service improvements and a reconsideration of the Provider’s decision to not offer him a second assessment.

9. NICE guidance on assessing patients for autism says;

‘1.2.3- For adults with possible autism who do not have a moderate or severe learning disability, consider using the Autism-Spectrum Quotient – 10 items (AQ-10). (If a person has reading difficulties, read out the AQ-10.) If a person scores 6 or above on the AQ-10, or autism is suspected based on clinical judgement (taking into account any past history provided by an informant), offer a comprehensive assessment for autism.

1.2.5- A comprehensive assessment should:

• be undertaken by professionals who are trained and competent • be team-based and draw on a range of professions and skills • where possible involve a family member, partner, carer or other informant or use documentary evidence (such as school reports) of current and past behaviour and early development.

1.2.7- During a comprehensive assessment, enquire about and assess the following:

• core autism features (difficulties in social interaction and communication and the presence of stereotypic behaviour, resistance to change or restricted interests) 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 • sensory sensitivities and attention to detail.

1.2.9- To organise and structure the process of a more complex assessment, consider using a formal assessment tool, such as the Diagnostic Interview for Social and Communication Disorders (DISCO), the ADOS-G or the ADI-R.’

10. Guidance from the Royal College of Psychiatrists on recognising and assessing patients with possible autism says;

‘4.2 Assessment- Although diagnosis is a crucial step, it is only one component of the wider multidisciplinary assessment. Tailored to the strengths, skills, needs and impairments of the individual, the range of assessments might include the following:

• Cognitive ability • Functional ability • Co-occurring neurodevelopmental disabilities – notably ADHD, tics and coordination disorder as well as epilepsy.

• Co-occurring psychiatric disorder – such as anxiety, depression, bipolar disorder, obsessive-compulsive disorder, psychosis and dementia.

• Medical problems – these include disorders whose symptoms might have been ignored or overlooked because of the presence of autism (such as sleep problems, obesity, and cancer). Autistic people often have difficulty in drawing attention appropriately to physical symptoms and overall are less likely than others to get healthcare.

4.6 Tests for autism- A variety of instruments are available, ranging from screening questionnaires through interview frameworks to structured interview schedules, the categories reflecting their different purposes. The interviews help clinicians collect the appropriate information in a format that lets them match it against their agreed criteria as well as giving them a framework to organise their thoughts. They do not make a diagnosis nor, more importantly, do they exclude it. They are a means by which different clinicians in different settings can achieve a recognised, consistent threshold as well as adapt to changing criteria and practice.’

11. Our adviser said clinicians use structured diagnostic interviews to help collect information in a structured and convenient way.

12. In Mr A’s case, the Provider interviewed him with reference to DSM5 Criteria and stated if he met each one of these. The DSM-5 outlines five overarching criteria for an autism spectrum disorder (ASD) diagnosis.

13. The Provider used an AQ10 prior to assessment which yielded a score of 7 out of 10 indicating further assessment was suggested. An AQ10 questionnaire helps indicate whether someone should be referred for an autism assessment.

14. Whether or not professionals employ particular tools or interviews is professional preference and varies between professionals and services. National guidance emphasises the importance of collecting information from a patient and their informant (in this case, Mr A’s mother) about all symptoms or traits associated with autism and comparing these to a standardised diagnostic criterion. DSM5 Criteria are:

‘Criterion A: Persistent deficits in social communication and social interaction- all 3 must be present

A1. Social-emotional reciprocity; difficulties with normal back-and-forth social interaction.

A2. Non-verbal communication; difficulties using or understanding such as eye contact.

A3. Developing, maintaining and understanding relationships difficulties including adjusting behaviour to different social contexts, making and keeping friends.

Criterion B: Restricted, repetitive patterns of behaviour, interests or activities- at least 2 of the following 4

B1. Repetitive movements, speech or use of objects B2. Insistence on sameness, routines or ritualised behaviour B3. Highly restricted, fixated interests B4. Hyper- or hypo-reactivity to sensory input.

Criterion C: Symptoms must be present in the early developmental period although they may not become fully apparent until social demands exceed the person's abilities.

Criterion D: Symptoms must cause clinically significant impairment in social, occupational, or other important areas of current functioning.

Criterion E: Symptoms are not better explained by intellectual disability global developmental delay.

Diagnostic Threshold: to diagnose ASD under DSM-5-TR, the clinician must conclude that:

• All Criteria A must be present:  A1 + A2 + A3 • At least 2 of B1–B4 are present • Criterion C must be met • Criterion D must be met • Criterion E must be met.’

15. The assessors said none of criteria A, B, C, D and E were present. Although the Provider acknowledged Mr A expressed some subjective difficulties in social communication this related to his unwillingness to share feelings rather than inability to experience them. Mr A agreed he was able to experience empathy. His eye contact and other non-verbal communication was not felt to be unusual or impaired and he understood normal social cues and norms. The Provider did not feel Mr A expressed difficulties which excluded him from normal relationships and life.

16. The assessors felt Mr A was well able to engage with daily life, independent in all required functional skills and competent in all areas. They noted his ability to balance demands of family life and his studies and interests in technology. In addition, despite subjective difficulties in social communication, he maintained social friendships (particularly online) and acquaintances such as neighbours and school parents.

17. We have seen no indication the Provider’s assessment was not carried out in line with national guidance. Mr A’s difficulties were fully assessed and compared to the DSM5 Diagnostic Criteria for autism. It is consistent and in line with guidance from NICE and Royal College of Psychiatrists on the assessment of autism.

18. In coming to that view, we considered Mr A’s specific point that comments made before the assessment had started indicated the Provider had prejudged the outcome.

19. Guidance from the GMC says:

• ‘You must treat patients fairly. You must not discriminate against them or allow your personal views to affect your relationship with them, or the treatment you provide or arrange.

• You must listen to patients, take account of their views, and respond honestly to their questions.

• You must not make assumptions about a patient's preferences or the quality of their life.’

20. Our adviser says the role of an assessor is to assess patients with possible autism. Our adviser did not identify any evidence of bias or stereotyping in the records.

21. The discussion heard on audio just before the assessment started was respectful and based on the evidence presented to the clinicians.

22. It consists of initial thoughts of the clinicians when faced with the information contained within the reports they already had. Our adviser said looking for patterns or clues in the information presented is a valid part of the process.

23. Both clinicians picked up on some symptoms of ADHD being present, namely impulsivity, difficulty in focus and concentration reported by schoolteachers and frequent changes of work role. The difficulty focusing was mentioned on several occasions and in different situations by Mr A’s mother making it potentially a more reliable symptom. Mr A’s mother also mentioned Mr A was ‘easily distracted’ according to teachers.

24. None of the information discussed was exaggerated and was based on the evidence the clinicians had been provided with. The transcripts indicate politeness, respect and curiosity expressed towards Mr A. There is no suggestion the clinicians failed to consider relevant evidence. The contents of the informant and patient reports feature heavily in the Provider’s ASD report and it considered alternative explanations for Mr A’s presenting symptoms.

25. NICE guidance says;

‘1.2.2- Consider assessment for possible autism when a person has a history of a neurodevelopmental condition (including learning disabilities and attention deficit hyperactivity disorder) or mental disorder.

1.2.7- During a comprehensive assessment, enquire about and assess other neurodevelopmental conditions.’

26. Clinicians are bound to consider other neurodevelopmental disorders, like ADHD, as part of an autism assessment in line with NICE guidance. This does not amount to prejudice, rather examination of commonly co-occurring neurodevelopmental conditions.

27. We recognise how Mr A may have perceived the comments made prior to the assessment, as heard on the recording we reviewed. We do not consider this is evidence of prejudice or discrimination.

28. We acknowledge Mr A’s view that the clinicians made an error in the date he was detained under the Mental Health Act (MHA) and recognise this may have caused him to worry that the assessment was flawed. There is no reference to a specific date in the ASD Report. The report notes Mr A was briefly detained ‘due to concerns regarding his safety and the seriousness of his suicidal ideation.’ The report also states very clearly ‘no active mental health problems. He discloses no formal mental health support at the time of this assessment, suggesting that his historical difficulties have been relatively stable in recent years.’

29. Our adviser says this indicates the clinicians did not feel Mr A’s mental health was of particular relevance to the ASD assessment or any ongoing difficulties. Therefore, the date of Mr A being detained under the MHA prior to the assessment taking place, would not affect the validity of it.

30. We recognise the frustration Mr A experienced in the way in which an assessment was carried out for autism. We have seen no indication the Provider carried out a flawed or biased assessment. We are grateful to Mr A for bringing their concerns to our attention.

1. We have carefully considered Mr A’s complaint about an independent provider of psychiatry services (the Provider). We understand the events that caused Mr A to complain are important to him. We recognise how upsetting it was to feel like he did not receive the correct care.

2. We acknowledge Mr A’s concerns that the Provider did not carry out a fair and sound assessment for autism. We have seen no indication the assessment was carried out incorrectly.