NICE Guidelines for Autism Spectrum Disorder in Children

Introduction

The NICE guidelines play a very useful role in setting practice standards in health, wellbeing, and social care. Foremost, the ASD guideline in people up to 19 years has best practice advice for evaluation, intervention, and care. It describes management plans and recognises population characteristics influencing the provision of services. Such guidelines mean that professionals can correctly deliver the right services to those requiring a particular kind of support, while at the same time, can guarantee that they do not favour any group of people over another. Its overall goal is to enhance the quality and effectiveness of care for young people with ASD through the implementation of the best practices and by considering all four domains of the social determinants.

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Treatment Pathways

Overview of Suggested Treatments

The NICE guidelines for autism spectrum disorder (ASD) in children aged less than 19 aims at a comprehensive management plan, approved by combination of therapies and where needed medication. The treatments are basically behavioural/developmental, educational and the medical management.

• Behavioural and Developmental Interventions: In the treatment of ASD, behavioural therapies are critical, including Applied Behaviour Analysis (ABA) and Cognitive Behavioural Therapy (CBT). ABA involves training a child in a programme of reward and punishment to teach the child what is acceptable and what is not acceptable. CBT is specific for use in school going children and adolescents to assist in managing their anxiety and learn how to deal with the stress. These interventions were supported by literature regarding the effectiveness of improving the communication, social skills and adaptive behaviours (Lovaas, 1987; Reichow, 2012).
• Educational Support: Intervention approaches in ASD therefore form the central tool for dealing with the disorder. IEPs and special teaching strategies are implemented to cater to each child’s learning abilities and help him/her to learn academically and socially. Teaching spaces, authentic or structured teaching context as well as use of graphic display are suggested to augment the learning and behaviour (Schreibman et al., 2015).
• Pharmacological Management: Some child patients may be diagnosed with other ailments which require medical treatment by a doctor for it to be addressed separately such as anxiety, hyperactivity, or severe behavioural disorders. Typical prescription drugs include selective serotonin reuptake inhibitors (SSRIs) for anxiety disorders, and stimulants for learners’ attention deficit. Though, the pharmacological therapies should be sought only if less invasive methods have produced poor results, and the pharmacological treatments should be taken alongside the behavioural modifications (Williams et al., 2013).

Key Features of Suggested Interventions

• Behavioural and Developmental Interventions: The efficacy of ABA and CBT has been evidenced in literature and studies have also emphasised on the fact that these interventions have been highly effective in improving the functional skills of children with ASD. Unlike ABA, there is more structure and integration of experimental analysis in this therapy approach that focuses more on the utilization of data; on the other hand, CBT has unique features for the individuality of the person’s cognition and emotions especially the higher cognitive ones (Smith et al., 2000).
• Educational Support: An IEP and structured teaching involve development of manner in which students are taught, for instance, using of visual timetable, social stories and one to one teaching amongst others with adoptions of beneficial teaching styles depending on each child. These methods have research support based on concomitant changes in increase in academic productivity and in social competence (Koegel et al., 2014).
• Pharmacological Management: It is important to realize that the use of medications is rather limited in treating core dysfunctions of ASD because such medications can relieve specific symptoms only but entail serious side effects and a lack of long-term effectiveness data for children with ASD. Lexapro and Adderall are most often administered to mitigate symptoms of the co-existing disorders but they are not curative for ASD and must be employed as a part of a global management plan (Hollander et al., 2003).

Medication vs. Therapy Debate

As for medication versus therapy, there is still a lot of controversy in the intervention for children with ASD. These include behavioural and developmental therapies are commonly recommended as initial treatment due to the fact that they are oriented towards improving lack of skills and other functional ability rather than on the mere presence of symptoms. The great body of empirical evidence speaks to the efficacy of these therapies in enhancing the clients’ quality of life and their developmental course (National Research Council, 2001). On the other hand, taking medicine is usually practiced when the behaviour therapies alone prove inadequate especially when working with patients who have other disorders for instance anxiety or ADHA. Medication can provide only a symptomatic improvement and therefore does not cure the main symptoms of ASD and can have several side effects or lead to addiction (Masi et al., 2007). Most importantly, medications offer considerable advantages for some symptoms but should not substitute for behavioural and development therapies. The use of both therapy and medication as a treatment modality is regarded as being the most effective approach. First, therapy serves the general needs of children with ASD regarding core symptoms, while medication can help manage specific symptoms in children with such disorders, which makes it possible to offer a more integrated approach to promoting children’s development at present, meeting the criteria of evidence-based practices specified by Odom and his colleagues (2010).

Health Inequalities

Identifying Vulnerable Groups in the Guidance

The NICE guidelines for autism spectrum disorder (ASD) point out that there are populations that are at risk and may face difficulties in terms of getting diagnosed and receiving therapy. Some of the others are; people of colour, people from lower-income families, females with ASD, children, and adolescents with comorbidities like intellectual disability or mental health disorders.

• Ethnic Minority Groups: Another paper by Mandell et al., (2009) has revealed trends of ethnic minorities experiencing diagnostic workup delays due to issues such as discrimination, language differences, and restricted access to proper healthcare services among others. These delays are said to cause later intervention and therefore poor prognosis Underdiagnosis and misdiagnosis of the disorder may result from different culture’s interpretation of the manifestation of ASD symptoms making treatment a challenge.
• Low Socioeconomic Status (SES): Some disadvantages include; Low-income families’ children cannot afford healthcare to cover early identification of developmental disorders and the available resources to support treatment and management of the disorders. Lower-income families experience difficulties in transportation, referral to specialists, and the expenses involved in behavioural therapies and medications, which affect the early identification and treatment of children with ASD (Durkin et al., 2010).
• Females with ASD: We receive more diagnoses of females with ASD than before. Still, earlier, the condition was unnoticed in women mainly because it manifests itself differently from that in men. Studies showed that Girls with AS may have lower levels of aggression and may use better masking efforts; thereby frontline diagnoses may occur later or may not occur at all (Lai et al., 2015).
• Children with Co-occurring Conditions: Children with ASD but with other impairments consisting of learning difficulties or other mental complications including anxiety or ADHD are also more hindered in their diagnosis and cure. The disorders that they present are usually chronic and can best be addressed by multi-disciplinary teams and the coexistence or existence of several conditions may result in misdiagnosis or overshadowing of one condition by another and this may result in delayed access to proper care (Simonoff et al., 2008).

Barriers Faced by Vulnerable Groups

• Diagnostic Delays: There is a significant time lag in diagnosing ASD among vulnerable populations and consequent delay in the delivery of early interventions. Lack of awareness regarding the disorder, cultural prejudice associated with the disorder, and the unwillingness of medical personnel to understand various non-specific signs of ASD are the major reasons for such delays (Mandell et al., 2007).
• Access to Specialized Services: Opportunities to receive specialized ASD services such as behavioural, educative interventions together with mental healthcare services are defined by geographical location and financial constraints, and the quality of existing health facilities. The poor may not afford the services of trained personnel, or even diagnostic facilities, which will further widen the gap in health care delivery.
• Stigma and Cultural Barriers: Further, cultural attitude differences are quite distinct because certain cultures accept stigma in ASD or mental health issues. This can result in families not seeking early diagnosis or treatment, especially among the ethnic minority groups (Zuckerman et al., 2014).

Solutions in the Guidelines to Ensure Access to Support

According to the NICE guidelines, the following solutions have been put forward to ensure that vulnerable groups have access to support for autism spectrum disorder (ASD). Screening as early as possible and covering all aspects is highlighted here though it is more relevant to ethnic minorities, females, and low socioeconomic backgrounds. Efforts to increase the use of culturally sensitive and standardized screening instruments and education of healthcare providers regarding the disparity attempt to decrease it. It also provides guidelines such as care teams, with interdisciplinary consultants because children with multiple disorders will need a coordinated approach to their treatment. Special education influences are recommended to be provided such as the individualized education plan (IEP) to the needy learners with the most vulnerable coming from disadvantaged backgrounds with a view of providing an equal chance to access the learning resources. Moreover, strategies consisting of awareness programs to fight stigma and promote the families’ knowledge about ASD as well as the need for early intervention are recommended. These solutions are meant to cater to the challenges that individuals with particular needs experience hence increasing the odds of early and accurate diagnosis and treatment processes.

Critique of the Review’s Coverage of Health Inequalities

Some of the areas where the NICE guidelines show great improvements in health inequalities include diagnosing delays and access to services. The awareness of low-SES families, ethnic minorities, and females with ASD speaks to consideration of the structural factors that create disparities in health results. Still, the guidelines could expand their strategy to eliminate health differences by offering more targeted recommendations. Even though the recommendations made on multi-disciplinary care and the educational support that should be targeted at individual patients have been commendable, they may not be possible in facilities that have few resources. Another weakness is the lack of a proper attempt to elaborate on how socio-economic determinants hinder the receipt of care. There is also very little said about how one can overcome the financial hurdles that low SES families experience in receiving both behavioural therapies and medications. Furthermore, it might be desirable to make these guidelines specify organizational reforms in healthcare systems in more detail, for instance, raising the investment in specialised services for the underprivileged population or offering incentives to healthcare personnel to practice in such areas. The review also has no detailed procedures on how cultural barriers such as stigma can be minimized other than the general outreach programs. There is a need to make the futurology interventions more specific and culturally appropriate to the situation of ethnic minorities.

Considerations for policy makers and service delivery

Feasibility

It can be seen that the implementation of the NICE guidelines is contingent on the availability of resources, professionals, and structures. Early screening and diagnosing programs need to be trained personnel and culture-specific instruments, this may be a challenge in areas that have limited access to healthcare facilities. Also, the recommendation for multi-disciplinary care teams is on its operational challenges because it is not easy to find specialized professionals in rural or neglected areas. Furthermore, integrating care across sectors like education, health, and welfare invariably requires quite a lot of coordination which may not exist in equal measure across the various districts. For this reason, it is possible while on paper implementing the guidelines can be very effective, in practice, the ability to put the guidelines into practice can be hampered by the resources and geographical locations.

Appropriateness

From the current NICE guidelines most of the suggestions are good because they are proposed for people with ASD and are tailored to meet their needs, with a focus on early intervention, the use of multiple professionals, and individualized care. A baseline screening of at-risk populations, including women and people of colour, is warranted because of the disease’s historical under-reporting in these populations. Of all the tools, culturally adapted ones play a big role in making the diagnosis process equitable. Likewise, with IEPs, IEPs precisely correspond with the children’s learning and social development peculiarities in the case of ASD. However, these recommendations should be used depending on the given circumstances in which the recommendations are made. In some contexts, their cultural beliefs regarding ASD may differ with early identification and/or early intervention approaches lessening the applicability of particular screening tools or treatment programs.

Meaningfulness

To some degree, the interventions proposed in the guidelines are valuable because the guidelines identify central disparities in access to ASD treatment, especially for marginalized groups. Early identification, a multi-disciplinary approach to treatment, and education are directly related to the intended goal of enhancing the quality of life in such disorders, particularly in the disadvantaged population. Due to directing intervention efforts at some of the difficulties that affect these groups, like stigmatization or lack of financial support, the guidelines ensure that the services they offer have a meaningful impact on the life of the patient as well as his/her family. However, it can be assumed that these interventions may have different significance from one culture to another and even from one family to another, while the community’s and the family’s perception of mental health and disability may define the ways the services are accepted and used.

Effectiveness

It is important to note that measures laid down by NICE depend on the extent to which improvements to the recommendations offer solutions to limitations of access. Some of the common practices that have proved to be good methods of handling the child include early intervention, where it is considered good practice to attend to the child in the early stages to give him the best results in his development. As for care delivery, the current care models have shifted from a single-specialty approach to a multi-disciplinary care approach and this has proven to give a more comprehensive care delivery lessening the heavy load now offered to families. Special learning plans hold the potential to improve the academic performance of children with ASD and enable them to succeed at school. However, such solutions are only effective if professionals are also capable of providing the services uniformly and fairly. These are likely to disorient the intended positive impacts to the extent of yielding disparities in the quality of offered services.

Conclusion

Altogether, the present NICE guidelines for ASD present realistic, relevant, significant, and useful solutions for early identification and intervention with particular reference to the needs of the priority vulnerable groups. However, successful implementation hence requires tackling barriers in the domains of resources, culture, and geography to provide adequate access and quality to all individuals with ASD.

References

Buescher, A. V., Cidav, Z., Knapp, M., & Mandell, D. S. (2014). Costs of autism spectrum disorders in the United Kingdom and the United States. JAMA Pediatrics, 168(8), 721-728.

Howlin, P., Magiati, I., & Charman, T. (2009). Systematic review of early intensive behavioral interventions for children with autism. American Journal on Intellectual and Developmental Disabilities, 114(1), 23–41.

Mandell, D. S., & Novak, M. (2005). The role of culture in families' treatment decisions for children with autism spectrum disorders. Mental Retardation and Developmental Disabilities Research Reviews, 11(2), 110–115.

National Institute for Health and Care Excellence (NICE). (2021). Autism spectrum disorder in under 19s: support and management. NICE Guidelines [CG170]. Available at: https://www.nice.org.uk/guidance/cg170

Pellicano, E., Dinsmore, A., & Charman, T. (2014). What should autism research focus upon? Community views and priorities from the United Kingdom. Autism, 18(7), 756-770.