If it takes a village to raise a neurotypical child, we should be working to provide that and so much more for children with autism spectrum disorder. Among those resources needed may be an autism psychiatrist, a professional whose role encompasses way more than just diagnostics.
Psychologist, psychiatrist, behavioral pediatrician, neurologist, the terms and the function each expert serves, when it comes to autism, can be confusing. While family doctors or pediatricians are often a first stop for parents, the role of a psychiatrist for children on the spectrum may be equally important.
Child psychiatrists and autism spectrum disorders
A simple definition of a child psychiatrist is a doctor specializing in mental health of children and adolescents younger than 18 years. Such doctors may be involved in prevention, treatment, and cure of mental and emotional disorders or conditions.
But what about developmental disorders, like autism spectrum disorder (ASD)? Are child psychiatrists also trained to diagnose and treat autism; a developmental disorder occurring on a spectrum with heterogeneous symptoms and characteristics?
Can a child psychiatrist diagnose autism?
Psychologist, psychiatrist, behavioral pediatrician, neurologist, the terms and the function each expert serves, when it comes to autism, can be confusing. While family doctors or pediatricians are often a first stop for parents, the role of a psychiatrist for children on the spectrum may be equally important.
Child psychiatrists and autism spectrum disorders
A simple definition of a child psychiatrist is a doctor specializing in mental health of children and adolescents younger than 18 years. Such doctors may be involved in prevention, treatment, and cure of mental and emotional disorders or conditions.
But what about developmental disorders, like autism spectrum disorder (ASD)? Are child psychiatrists also trained to diagnose and treat autism; a developmental disorder occurring on a spectrum with heterogeneous symptoms and characteristics?
Can a child psychiatrist diagnose autism?
According to Therapeutic Pathways the following professionals can diagnose autism in a child (this may be influenced according to the standards and regulations in different countries):
- Developmental-behavioral pediatrician
- Pediatric neurologist
- Child psychologist
- Child psychiatrist
A generalized statement like: “Most children with autism will be diagnosed by a pediatrician specializing in developmental-behavioral pediatrics or a child psychiatrist with expertise in neurodevelopmental conditions,” is of course questionable in most developing countries where children are often examined and diagnosed at clinics supported by volunteers, or public hospitals in dire need of funding. Research about prevalence and diagnostics of autism in developing countries is scarce and it would therefore be difficult to obtain information about the role of child psychiatrists in diagnosing autism in contexts other than affluent Western societies.
When young children with access to specialized healthcare are diagnosed with autism it is usually because parents, or the child’s doctor, notice developmental delays and refer the child to a specialist. In this context a pediatrician may be the most obvious medical professional to diagnose the child, especially if they have specialized knowledge about neurodevelopmental disorders. But many feel child psychiatrists—when children have access to such specialists—are in a unique position to not only diagnose and treat autism, but also the comorbid mental conditions frequently found alongside ASD.
What is an autism psychiatrist?
A recent study (Crane et al., 2019) examined “psychiatrists’ knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum”. The online survey utilized in the study revealed most of the psychiatrists’ (self) reported responses indicated they were knowledgeable about autism and that they had received useful training on the condition.
Knowledge, and experience with kids on the spectrum, may be essential, especially when child psychiatrists deal with patients who camouflage or mask their symptoms. Indeed, women diagnosed later in life often reveal mental conditions like anxiety or depression lead to their eventual autism diagnosis, rather than social symptoms typically associated with autism.
A psychiatrist, diagnosing autism, may have to distinguish the condition from others that present in a similar fashion. For example, social anxiety disorder and autism have social deficiencies and symptoms that overlap, and the repetitive and restricted behaviors characteristic of autism are also found in some diagnosed with obsessive-compulsive disorder. The fact that autism is often found alongside and associated with other mental conditions, may muddle and complicate diagnosis.
Mental health conditions or autism?
Before receiving an autism diagnosis, some children and adults may see a psychiatrist for a mental condition like anxiety or obsessive-compulsive disorder (OCD). The symptoms of these conditions may actually be due to undiagnosed autism or such conditions may be comorbid with ASD. A recent study (Kirsch et al., 2020) suggests individuals with ASD may have an increased risk for clinically diagnosed depression, anxiety, and bipolar disorder—in comparision to sex and age matched referents.
When autism symptoms are camouflaged or masked, an individual may be referred to a psychiatrist for challenges other than autism. Anecdotal evidence reveals that when a person is then finally diagnosed with autism, some of these psychiatric “symptoms” may improve or disappear as acceptance and intervention for autism is embraced. When someone on the spectrum realizes their social deficits are due to autism and not some “character flaw’, self-esteem may improve; they may finally receive the correct intervention and this could lead to quality of life improving.
Reading accounts of misdiagnosis, it’s disturbing to imagine a doctor prescribing strong anti-psychotic medication because autism was missed. On these forums individuals speak of decades of suffering serious side-effects because of drugs for schizophrenia, bipolar disorder, and psychosis. When a knowledgeable psychiatrist finally diagnoses autism, it may be life changing for such individuals. Acceptance, understanding and appropriate accommodations are often enough to make a difference.
Distinguishing and diagnosing
As autism is a behaviorally-defined condition, there is no single lab test available to quickly diagnose autism (scientists are hopeful about a blood test for autism). Like other doctors, a psychiatrist will use some or all of the following diagnostic tools to diagnose autism in children:
- Interviews with parents (or other caregivers)
- Interview with the child
- Observation of the child’s behavior
- The psychiatrist may order medical test to rule out other conditions before diagnosing ASD
- In some cases tests to determine language skills and other capabilities may be also be undertaken
To diagnose a disorder based on behavior is challenging, which is why some believe a child and adolescent psychiatrist—with intricate knowledge of medicine, the mind, emotions, and behavior—may be in the best position to do so. They would of course need appropriate knowledge and experience with autism and the behavioral symptoms involved in neurodevelopmental conditions. Considering such behavior may be masked or camouflaged, especially in girls, adds to the difficulty of diagnosing autism.
After conducting semi-structured interviews Corscadden and Casserly (2021) suggest the traits of autism often present more subtlety in young girls. The data also suggest girls increasingly mask social issues as they approach adolescence, increasing anxiety.
The authors highlight the importance of awareness concerning how subtly autism may present in girls for those involved in identifying autism (Corscadden & Casserly, 2021). It would be interesting to gather data about the approach of psychiatrists when diagnosing autism in cases with camouflage or masking present.
Important study results for psychiatrists
A study (Fusar-Poli et al., 2020) titled: Missed diagnoses and misdiagnoses of adults with autism spectrum disorder mentions the importance of results for both child and adult psychiatrists. Some of the findings from the study include:
- For most of the participants a first evaluation by a mental health professional was performed when they were around 13 years of age
- Results then show a gap of about 11 years until receiving an ASD diagnosis, therefore the median age of being diagnosed with autism for participants was 23 years
- Almost of a third of participants never received a psychiatric diagnosis, whereas the rest received a diagnosis different to ASD
- The most frequent of such past diagnoses were listed as: intellectual disability, psychoses, personality disorder, and depression (Fusar-Poli et al., 2020).
The authors of the study conclude by cautioning clinicians to consider autism in the differential diagnostic process.
Some in the autism community feel psychiatrists who work predominantly with adults may have difficulty diagnosing autism if they are not trained in the nuances of how the condition may present, especially in those with high intelligence who adapt their behavior for social acceptance.
A doctor will have to be skilled to see beyond masking and symptoms related to autism but belonging to co-occurring conditions. While masking could be uncovered by thoroughly interviewing parents and caregivers, critical thinking and experience may be necessary for clinicians to distinguish between conditions presenting similarly to autism.
Critical thinking required
Researchers and clinicians are urged to think critically about dimensions affecting restricted and repetitive behaviors in a review by Jiujias et al. (2017). This study is concerned with the similar behavioral profiles of autism and OCD, and the potential confusion such similarities may cause when it comes to diagnosis and treatment.
An inexperienced psychiatrist, with little experience diagnosing and treating autism, may find differentiating between autism and OCD challenging when repetitive behaviors are present which could be a symptom of both disorders. The authors (Jiujias et al. 2017) suggest the differing role of anxiety highlights the crucial difference between ASD and OCD. The authors urge clinicians to use the review as a starting point when clarifying differences in restricted and repetitive behaviors in OCD and autism populations.
This is only one example where a psychiatrist will need appropriate expertise to differentiate between confusing conditions. Furthermore, autism and OCD do occur together and research suggests partially shared etiological mechanisms between the two disorders (Meier et al., 2015), meaning professionals diagnosing autism will need awareness of what autism is, what it is not, and the conditions and characteristics associated with this complicated spectrum condition.
Finding the right psychiatrist for autistic children
It’s interesting to note how many adults, with later life diagnosis, actually requested a comprehensive evaluation for autism. Some feel it is only because of their own research and insistence that psychiatrists considered an autism diagnosis. Taking heed of warnings from the autism community, parents should keep the following in mind when choosing a psychiatrist for their child:
Qualifications
Psychiatry is a highly specialized field—psychiatrists are medical doctors who spend an additional four years specializing in psychiatry (this may differ according to country and specific medical specialization requirements). Their medical degree means these specialists can prescribe medication and help their patients with medication management.
Parents with children on the spectrum not only look for board certification and qualifications when searching for a psychiatrist, most are interested in a doctor specializing in neurodevelopmental conditions and experience diagnosing and treating children with autism.
If you have access to specialized medical care, do your research before consulting with any doctor. Other parents with kids on the spectrum may have experience with the doctors in your area; connecting with such parents on support groups could help with recommendations for the best doctor for your child.
Therapists with a wealth of autism knowledge, especially speech and occupational therapists, and psychologists may also be a great source for finding a suitable psychiatrist. These experts may help with recommendations, additionally they may be in a position to refer patients to psychiatric experts directly.
Sometimes a child on the spectrum may need the help of a specialist to deal with mental disorders like anorexia or bulimia in addition to challenges associated with autism. A child psychiatrist is one of the most suitable experts to help in cases like these, especially when the specific condition co occurring with autism is in their field of specialization.
Even then, a psychiatrist may still face issues treating autism and an eating disorder; researchers can’t agree whether anorexia starves the brain and causes autism-like behaviors, or whether being on the spectrum makes it more likely to develop an eating disorder. Such debates illustrate just how difficult it may be to diagnose and intervene appropriately when a child has autism and symptoms of other mental health conditions.
Trust
An accurate diagnosis and intervention plan helping an autistic child thrive does not only depend on a doctor’s experience and qualifications. Because autism is diagnosed through interaction with the medical specialist your child will probably respond better when a doctor is familiar with autism and acts accordingly; for example, paying attention to the patient’s sensory needs.
Some parents tell me about the nightmare of visiting medical specialists where autism does not seem to be accommodated at all. With loud waiting rooms, flickering fluorescent lights, and overbearing staff, could an autistic child be blamed for shutting down by the time they actually face the doctor?
A psychiatrist with special interest (or specializing) in autism and other developmental conditions would probably consider their patients in every part of their practice. All staff members should be trained to accommodate patients and the environment should be autism friendly if medical experts want to create an atmosphere of trust.
For many parents, especially those in developing countries, these are ideals far removed from reality. As the prevalence of autism increases perhaps grants and funding need to be channeled to ensuring every child on the spectrum has access to specialists like psychiatrists. A medical specialist with knowledge about autism and comorbid conditions— able to prescribe appropriate medication—may be in the best position to diagnose and treat the child.
Many parents in the autism community are appealing for a shift in focus: they want education, acceptance, intervention, and accommodations for those on the spectrum to be prioritized over the search for a cause. Funding channeled to ensure every person on the spectrum has access to all necessary resources (including medical experts like psychiatrists) needed to thrive, may actually help improve quality of life for everyone on the spectrum.
References:
Corscadden , P., & Casserly, A. M. (2021). Identification of Autism in Girls: Role of Trait Subtleties, Social Acceptance and Masking. REACH: Journal of Inclusive Education in Ireland, 34(1). Retrieved from https://reachjournal.ie/index.php/reach/article/view/313.
Crane, L., Davidson, I., Prosser, R., & Pellicano, E. (2019). Understanding psychiatrists’ knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum: online survey. BJPsych open, 5(3), e33. https://doi.org/10.1192/bjo.2019.12.
Jiujias, M., Kelley, E., & Hall, L. (2017). Restricted, Repetitive Behaviors in Autism Spectrum Disorder and Obsessive-Compulsive Disorder: A Comparative Review. Child psychiatry and human development, 48(6), 944–959. https://doi.org/10.1007/s10578-017-0717-0.
Kirsch, A. C., Huebner, A., Mehta, S. Q., Howie, F. R., Weaver, A. L., Myers, S. M., Voigt, R. G., & Katusic, S. K. (2020). Association of Comorbid Mood and Anxiety Disorders With Autism Spectrum Disorder. JAMA pediatrics, 174(1), 63–70. https://doi.org/10.1001/jamapediatrics.2019.4368.
Meier, S. M., Petersen, L., Schendel, D. E., Mattheisen, M., Mortensen, P. B., & Mors, O. (2015). Obsessive-Compulsive Disorder and Autism Spectrum Disorders: Longitudinal and Offspring Risk. PloS one, 10(11), e0141703. https://doi.org/10.1371/journal.pone.0141703.
