ASD Under 5s

Neurodevelopmental Medical Assessment for the Under 6s

Initial Appointment

(for suspected global developmental delay and/or Autistic Spectrum Condition/Disorder)

Referral Information

The referral was initiated by the child's nursery SENCO on 14/11/2025 due to delays in speech and social interaction, and the parents also raised significant concerns regarding sensory sensitivities and rigid behaviours at home.

Voice of the Child

The child was largely non-verbal during the consultation and did not respond to direct questions about nursery, friends, or why they were attending clinic today (Clinician Directly Observed Communication A1). They did not use eye contact or conventional gestures to share interest when shown the clinic toys (Nonverbal Communication A2). Instead of engaging in reciprocal play with the clinician or parents, the child immediately selected the toy cars and lined them up silently along the edge of the desk (Play and Relationships A3).

Parental Concerns

(include up to five principal concerns and state the reason for pursuing the assessment)

The parents are seeking a formal diagnostic assessment to better understand their child's neurodevelopmental profile and to secure an Education, Health and Care Plan (EHCP) prior to starting reception class.

1. Delayed expressive and receptive speech, using mainly single words and echoed phrases.
2. Lack of interest in peer interaction at nursery, strongly preferring solitary play.
3. Extreme distress and prolonged meltdowns in response to minor changes in daily routine or loud noises.

General Consultation

Parents report that the child struggles with back-and-forth social communication, rarely initiates interaction except to have immediate needs met by pulling an adult's hand, and does not respond consistently to their name (A1). Non-verbal communication is reduced, with fleeting eye contact and an absence of pointing to share enjoyment (A2). At nursery, the child engages in parallel play and withdraws when other children approach or attempt to join their game (A3). These features were also directly observed in clinic today, where the child remained focused on solitary object manipulation and made no social approaches to the examiner (A1, A2, A3).

Sensory Issues and Motor Mannerisms

(evidence for B4 and parental report of B1)

Parents report frequent bilateral hand-flapping and spinning in circles when the child is excited or dysregulated, alongside repetitive lining up of household objects and immediate echolalia of phrases from television programmes (B1). In terms of sensory processing, the child covers their ears in response to everyday noises such as hand dryers and vacuum cleaners, shows extreme distress during hair washing and nail clipping, and visually inspects spinning wheels at close range (B4).

Birth History

The pregnancy was unremarkable with normal antenatal scans and no maternal illness. Delivery was at 39+4 weeks gestation via spontaneous vaginal delivery with a birth weight of 3.42 kg, requiring no neonatal resuscitation or SCBU admission. In the first year, the child was described as an unsettled baby with a fragmented sleep pattern, though breastfeeding was established without difficulty and weaning onto puree textures occurred at 6 months before sensory food aversions emerged around 14 months.

Early Developmental History/Milestones

The child sat unsupported at 7 months and walked unaided at 14 months, though fine motor skills remain slightly delayed with an immature palmar grasp on crayons and difficulty using cutlery. Early babbling was noted at 9 months and first single words emerged at 20 months, but the child is still not linking spontaneous three-word sentences at age 4 years and only follows simple one-step requests with visual prompts. Early social skills were atypical, with social smiling noted at 8 weeks, but a persistent lack of proto-declarative pointing, waving goodbye, or showing objects to parents during the second year of life.

Developmental Update

Compared with peers at nursery, the child's communication and social-emotional development are significantly delayed, requiring 1:1 adult support during group activities and transitions under a My Plan. Parents report a possible loss of roughly five single words between 18 and 22 months of age (RED FLAG), though slow progress in vocabulary has resumed since starting speech therapy strategies.

Past Medical History, Medication, Allergies, Immunisations

The child has a confirmed diagnosis of mild atopic eczema and chronic functional constipation. There are no known drug allergies, and routine childhood immunisations are fully up to date according to the UK schedule.

Vision and Hearing

Formal audiology testing on 02/10/2025 confirmed normal bilateral hearing thresholds with normal tympanometry. Orthoptic vision screening was normal with no strabismus or refractive error detected.

Family History/Composition

The child lives at home with both parents and an older brother aged 7 years who has a confirmed diagnosis of ASD and ADHD. A maternal uncle has a history of dyslexia (Specific Learning Difficulty), and there is no known family history of Global Developmental Delay or Intellectual/Learning Disability.

Sleep

Sleep onset is significantly delayed, with the child often taking up to two hours to settle and waking twice overnight requiring parental presence. The child does not currently take melatonin.

Diet

The child has a highly restricted, "beige" diet consisting primarily of dry crunchy foods such as specific brands of crackers, plain pasta, and chicken nuggets, refusing all fruits, vegetables, and mixed textures.

Emotional and Behavioural

(map parental report to any relevant ASD criteria)

Parents report frequent emotional dysregulation and severe meltdowns lasting up to 40 minutes when routines are altered unexpectedly, such as taking a different route to nursery (B2), or when interrupted from playing with wooden trains (B3). CAMHS is not currently involved.

Clinician Observations of Child in Clinic

(map any relevant ASD criteria using direct clinician observation)

During the consultation, the child made fleeting eye contact and did not respond to their name being called by the clinician on three occasions (A1, A2). Speech was limited to repetitive humming and echoing the word "train" without communicative intent (A1, B1). The child did not engage in pretend play or attempt to include parents in their activity, instead spending 20 minutes repeatedly lining up toy vehicles and peering closely at the wheels from the side of their eyes (A3, B1, B4). When a parent briefly moved one of the cars to check the child's engagement, the child became immediately distressed and vocalised loudly until the car was returned to its exact position in the line (B2).

Physical Examination

General physical and neurological examination was unremarkable with normal tone, power, and reflexes, symmetrical gait, no dysmorphic facial features, and no neurocutaneous skin markers under Wood's lamp examination. Head circumference was normocephalic on the 50th centile.

Weight: 16.4 kg (50th centile)

Height: 102.5 cm (50th centile)

Head circumference: 50.5 cm (50th centile)

BMI: 15.6 kg/m² (50th centile)

Clinician’s Impression

I explained to the parents that the history provided and my direct observations today strongly indicate neurodevelopmental differences consistent with an Autistic Spectrum Condition alongside speech and language delay, and we discussed strategies for sensory regulation and visual timetables while formal multidisciplinary mapping is completed.

…..and the child will remain on, or be placed on, the pathway

Instructions for Next Steps Letter

The Care Navigator is responsible for sending the Next Steps letter and collating the nursery observation questionnaire for the upcoming multidisciplinary panel review.

Dictated Clinic Letter

For a dictated clinic letter to follow, if required or requested (patient-identifiable information may be included when dictated using an approved dictation system)

Diagnosis List

1. Atopic eczema.
2. Functional constipation.

Other Issues

1. Suspected Autistic Spectrum Disorder (awaiting MDT panel confirmation).
2. Expressive and receptive speech and language delay.
3. Sensory processing differences and restricted diet.
4. Sleep onset insomnia.

Medication List

1. Macrogol 3350 (Movicol Paediatric Plain®) 1 sachet PO OD.
2. Emollient cream (Cetraben®) topical BD PRN.

Involved Professionals

1. Speech and Language Therapist (Community SLT Team).
2. Early Years SENCO and Health Visitor.
3. Paediatric Neurologist / Neurodevelopmental Clinician.

Attends

Attends a local private day nursery 15 hours per week with 1:1 SEN support in place.

Signed Off

Dr A. Vance, Consultant Paediatric Neurologist.

Addendum

Autism Pathway Assessment Criteria

(Important: identify whether each point is based on Parental Report or Directly Observed by Professional.)

Communication (A1)

Parental Report: Delayed speech, rarely initiates social conversation, pulls adult's hand to reach desired items, and does not respond consistently to their name. Directly Observed by Professional: Did not respond to name when called in clinic, used no spontaneous phrases to communicate with the examiner, and demonstrated immediate echolalia without communicative intent.

Non-verbal Communication (A2)

Parental Report: Reduced eye contact and absence of pointing to share interest or waving goodbye. Directly Observed by Professional: Fleeting eye contact throughout the 45-minute appointment, flat facial expression during social approaches, and no use of conventional gestures.

Playing Relationships (A3)

Parental Report: Prefers solitary play at nursery, does not engage in cooperative or imaginative play with peers, and withdraws when other children approach. Directly Observed by Professional: Played entirely alone during the clinic session, made no attempts to initiate joint play with parents or the clinician, and showed no imaginative or symbolic play with the clinic toys.

Repetitive Behaviours (B1)

Parental Report: Frequent bilateral hand-flapping and spinning when excited, immediate echolalia of television scripts, and repetitive lining up of toys at home. Directly Observed by Professional: Spent the majority of the session lining up toy cars along the desk edge and exhibited brief hand-flapping when spinning the wheels.

Routine and Preference for Sameness (B2)

Parental Report: Becomes extremely distressed if the route to nursery is changed or if bedtime routines do not follow an exact sequence. Directly Observed by Professional: Became immediately distressed and agitated when a parent altered the arrangement of the lined-up cars on the clinic desk.

Patterns of Interest (B3)

Parental Report: Intense, circumscribed interest in wooden trains and spinning wheels, carrying a specific train engine everywhere and resisting redirection to other activities. Directly Observed by Professional: Focused exclusively on the wheeled vehicles in the clinic room and ignored all other play materials offered.

Sensory Differences (B4)

Parental Report: Auditory hypersensitivity to everyday household noises, tactile defensiveness during hair washing and nail cutting, and severe food selectivity based on texture. Directly Observed by Professional: Visually inspected spinning toy wheels closely using peripheral gaze and covered ears when a door closed loudly in the corridor.

Overall Impact

Parental Report and Directly Observed by Professional: These neurodevelopmental differences cause significant functional impairment across home and nursery settings, necessitating 1:1 support in education, limiting peer relationships, and causing marked family distress around daily routines, feeding, and sleep.