Autism spectrum disorder — formative SAQs

SAQ 1 (10)

A 3-year-old boy is referred because childcare staff say he does not respond to his name, lines up toys, and has no pretend play. Language is limited to single words. Hearing has not been tested. Parents want “the autism blood test” and ask whether vaccines caused this. [1]

1. State the DSM-5-TR domain structure required for ASD and one key specifier you will document. (3) [1]
2. List your immediate assessment and support actions this week, including what you will not delay for a final diagnostic appointment. (4) [1] [6]
3. How do you answer the vaccine question and the request for a blood test for autism? (3) [1]

Model answer

Criteria. All three social-communication domains plus at least two of four restricted/repetitive domains, with early developmental onset and impairment. Specifiers include intellectual impairment, language impairment, known genetic/medical condition, or catatonia. [1]

This week. Multi-setting history; paediatric observation; audiology; developmental assessment pathway; start early intervention / speech-language supports while diagnosis proceeds; safety and sleep/feeding screen; written safety-net. Do not wait for paperwork before supports when concern is high. [1] [6]

Communication. Vaccines do not cause autism — state that clearly and without false balance. There is no blood test that diagnoses ASD; diagnosis is clinical. Genetic tests after diagnosis look for aetiologic contributors in some children and guide counselling, not the ASD label itself. [1]

SAQ 2 (10)

A 7-year-old with established ASD has daily aggression and self-hitting. Parent education handouts have not helped. Teachers report overload after noisy assemblies. Parents ask for “the autism tablet” and specifically request an SSRI “to stop the repetitive behaviours.” [2] [4] [5]

1. Outline your formulation steps before any antipsychotic. (3) [1] [4]
2. When would risperidone or aripiprazole be appropriate, and what monitoring is mandatory? (4) [2] [3]
3. Why is an SSRI for core RRBs the wrong exam answer here? (3) [5]

Model answer

Formulation first. Functional analysis (triggers, setting events, function of behaviour); medical pain screen (dental, constipation, otitis, sleep, reflux); sensory and school environment review; optimise structured parent training and education plan; assess safety of siblings and carers. [1] [4]

Pharmacotherapy. For severe irritability with safety risk or major impairment after behavioural measures: risperidone (RUPP evidence; low-start weight-based dosing, often 0.25–0.5 mg/day start with slow titration) or aripiprazole (trial evidence; common start 2 mg daily). Monitor weight/BMI, glucose/lipids, EPS, sedation; prolactin-related symptoms for risperidone; akathisia for aripiprazole; ECG if cardiac risk. Plan dose review and minimisation goals. [2] [3]

SSRI trap. King and colleagues showed citalopram ineffective for high levels of repetitive behaviour in ASD and more adverse events than placebo. Do not use SSRIs as core RRB treatment. Treat true co-occurring anxiety/OCD on their own merits. [5]