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Autism

A comparison of a specialist autism spectrum disorder assessment team with local assessment teams
Iain Mcclure, Tommy Mackay, Haider Mamdani and Roslyn Mccaughey Autism 2010 14: 589 originally published online 5 October 2010 DOI: 10.1177/1362361310373369 The online version of this article can be found at: http://aut.sagepub.com/content/14/6/589

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A comparison of a specialist autism spectrum disorder assessment team with local assessment teams
IAIN MCCLURE TO M M Y M AC K AY
of Strathclyde, UK Royal Hospital for Sick Children, Edinburgh, UK National Centre for Autism Studies, University Acorn Centre,Vale of Leven Hospital, Acorn Centre,Vale of Leven

autism 2010 SAGE Publications and The National Autistic Society Vol 14(6) 589603; 373369 1362-3613(2010)

HAIDER MAMDANI
Alexandria, UK

RO S LY N M C C AU G H E Y
Hospital,Alexandria, UK

A B S T R AC T

Background: Early diagnosis of autism spectrum disorders (ASD) is of crucial importance, but lengthy delays are common. We examined whether this issue could be reliably addressed by local teams trained by a specialist ASD assessment team. Method: Four local teams were trained in diagnostic assessment. Their assessments of 38 children and young people using the Autism Diagnostic Observation ScheduleGeneric (ADOS-G) were video recorded and independently assessed by the specialist team. Results: There was a high level of correspondence between the diagnoses of the local teams and of the specialist team. The number of assessments carried out increased and there was a considerable reduction in waiting times. Conclusion: This study has demonstrated the potential feasibility of creating local, multiagency ASD assessment teams, which will serve to reduce waiting times, improve clinical skills at a lower level of specialism and thereby improve the overall quality of ASD services.

K E Y WO R D S

assessment; autism spectrum disorder; diagnosis; multi-agency

ADDRESS Correspondence should be addressed to: I A I N M C C L U R E , consultant child and adolescent psychiatrist, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK. e-mail: imcclure@nhs.net

ASD assessment (that is, evaluation as to whether a child or young person is or is not presenting with an autism spectrum disorder) is often a complex and time-consuming task, which has historically been thought to require a high level of professional expertise in order to ensure reliability and validity of diagnosis (Moore et al., 1999; Moore, Titcomb, Johnson, et al.,
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14(6) 1998). For example, Howlin and Moore (1997) found evidence that rising recognition across different geographic areas was linked to more clinicians with experience and expertise in diagnosing ASD. A drawback of this assumed requirement is that extensive waiting lists can develop for specialist services and waiting times for ASD assessment are thought to be increasing (Mansell and Morris, 2004). In addition, factors relating to geographical location, socioeconomic status, race and gender are associated with even further delay, with later ASD diagnosis for families in rural areas and nearpoor families (Mandell et al., 2005), for Afro-Americans (Mandell et al., 2007) and for girls (Siklos and Kerns, 2007). However, against this reality of increasing waiting times, clinical guidelines have indicated what patients and carers should expect to receive from hard-pressed services. For example, the National Autism Plan for Children (NAP-C) recommends that the time from referral for specialist assessment to feedback of the assessment outcome/diagnosis should not exceed 17 weeks (Le Couteur, 2003). Given the disparity between the ideal service and the non-ideal reality in many services, it is not surprising to encounter challenges to the aspirations of guideline committees (Preece and Mott, 2006) or, for those clinicians who are able to match such standards by service redesign, arguments for increased resources to maintain these initiatives (Sharma et al., 2007). There is compelling evidence to support the need for early diagnosis of ASD. Extensive waiting times for ASD assessment and diagnosis are very stressful for patients and carers (Goin-Kochel et al., 2006; Moore et al., 1999). Howlin and Asgharian (1999) reported a gap from 18 months to 5 years 5 months for autism, and from 30 months to 11 years for Aspergers syndrome, between the expression of parental concern and diagnosis. Also, delays in obtaining ASD diagnoses may postpone childrens eligibility for early intervention services, which in turn may affect their long-term outcomes (Goin and Myers, 2004). In addition, earlier diagnosis may assist prognosis, as there is emerging evidence that early intervention could be benecial (Autism Research Co-ordination Group, 2006). The 1998 National Institutes of Health Autism Coordinating Committee highlighted the need for improvements to the process of identication and assessment of ASD (Bristol-Power and Spinella, 1999), and there clearly remains a continuing need for research into different possible approaches to inform best practice and address delays in diagnosis. However, there has been comparatively little such investigation (Autism Research Co-ordination Group, 2006). The SIGN Guideline on assessment, diagnosis and clinical interventions for children and young people with ASD (Scottish Intercollegiate Guidelines Network, 2007) found little evidence regarding what models for ASD assessment (for example, single-discipline, multi-disciplinary,
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or multi-agency) are optimal, what methods should be used to assess the core presentation of ASD and what ancillary investigations should be conducted. When a child or young person attends for assessment a considerable variety of approaches will be adopted, with a limited evidence base for their validity, reliability, sensitivity and specicity. Traditionally, ASD assessment and diagnosis is a stage by stage process, which is limited to establishing the presence or absence of categorically (World Health Organization, 1992) or dimensionally described behavioural features (Wing et al., 2002). Initial presentation can be to a wide range of professionals in primary care, education or social services and there may be considerable delay in cases being presented even at this stage, together with low condence in the abilities of these professionals to recognise ASD (Harrington et al., 2006). Inevitably, most cases of ASD are then referred on to specialist services and it is at this stage in the process that waiting lists develop. There is an extensive body of professional opinion supporting the use of multi-disciplinary or multi-agency teams (Baird et al., 2003; Goin-Kochel et al., 2006; Moore, Titcomb, Cronk, et al., 1998) and several expert reviewers and consensus groups have recommended such an approach (Le Couteur, 2003; Scottish Intercollegiate Guidelines Network, 2007). It is nevertheless the case that a signicant amount of specialist ASD assessment is performed on a single-practitioner basis, again with little evidence to support or contradict such an approach. For example, Siklos and Kerns (2007) in a Canadian study found that diagnosis was made by a single practitioner in 75% of cases. Specialist assessment usually involves three elements (Baird et al., 2003; Moore, Titcomb, Cronk, et al., 1998). First, a parent/carer clinical interview is standard practice. This may involve one of the standardised ASD diagnostic instruments. There is an emerging evidence base for such instruments (Leekam et al., 2002; Lord et al., 1994; Skuse et al., 2004) and consequently cautious recommendations from guideline groups that their use should be encouraged (Filipek et al., 1999; Le Couteur, 2003; Scottish Intercollegiate Guidelines Network, 2007). Second, the assessment typically includes a clinical observation and/or interview of the child or young person. This may be based on a non-standardised approach developed in-house by the clinician(s) or it may use one of the limited number of ASD assessment instruments, which also have an emerging evidence base (Lord et al., 2000; Mazefsky and Oswald, 2006; Rellini et al., 2004). Again, these have received cautious recommendation for their use from guideline groups (Le Couteur, 2003; Scottish Intercollegiate Guidelines Network, 2007). Third, it is generally regarded as being important to obtain contextual and functional information from a variety of 591

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14(6) sources such as school, including assessment of intellectual functioning (Le Couteur, 2003). Inevitably, such an approach is very time consuming. The question is can the circle be squared? Is there a way both to achieve a reduction in waiting times to within the NAP-C recommended level and to maintain the high clinical standards found in specialist services? One possible way to do this is to increase the capacity at specialist level to process an increased numbers of referrals. However, with most services working in an environment of no or minimal new investment, any increase in such capacity would be unlikely, even if the necessary specialist staff could be recruited and trained. Indeed, there is evidence that training at specialist level is inadequate and therefore the fact that a child or young person is being assessed by a specialist cannot be assumed to mean that the assessment is reliable or valid (MacKay and Dunlop, 2004; Skellern et al, 2005). This then raises the question as to what kind of training for ASD assessment is required to ensure best practice. An alternative approach is to increase the involvement of local services in assessment. A survey of parents by Moore et al. (1999) indicated that they wanted local services involved in the diagnosis, provided by professionals who had received enhanced training in ASD. However Moore, Titcomb, Cronk, et al. (1998) considered the possibility of increasing the number of assessments at local level, but cautioned against the involvement of inadequately trained personnel in deciding complex diagnostic issues (p. 119). The present study aimed to assess the possibility that relatively inexperienced local practitioners could reach similar levels of reliability and validity in their ASD assessments as more experienced colleagues in a specialist team. Referrals for diagnosis were assessed by both the local multi-agency teams and the specialist team for comparison. The following questions were investigated: 1) whether with appropriate training, a local multi-agency ASD assessment team could perform as reliable and valid an ASD diagnostic assessment as a specialist team within the scope of this question it was also hypothesised that the reliability of the local practitioners ASD assessments compared with those of the specialist team would increase with experience; 2) what effects the new assessment process had on existing waiting times for ASD assessment by the specialist team a baseline search of Embase, Psychlit., the Cochrane library, PubMed and other sources over the last 10 years suggested that no previous study has attempted to answer these questions.
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Method
Setting up of local teams Prior to the inception of the project, nearly all ASD assessments for the health region of Lomond and Argyll in Scotland had been conducted by a specialist ASD assessment team (AAT). A waiting list had been increasing over the previous two years, with no prospect of increasing AAT capacity. By a process of service redesign, funded within the project, three local multi-agency teams were created specically to assess the AATs patients. In addition, a fourth local multi-agency team was set up in the East Renfrewshire area, there having been a single-practitioner ASD assessment service up to the start of the project. Each team comprised at least three professionals drawn from local health, education or other services. The range of disciplines represented were educational psychology, specialist teaching, occupational therapy, paediatrics, speech and language therapy and, from child and adolescent mental health services (CAMHS), psychiatric nursing and social work. The AAT, comprising a consultant child and adolescent psychiatrist, a consultant community paediatrician and a speech and language therapist, was retained as a specialist team rst, to assess all of the local teams patients in parallel (and blinded) throughout the project. Second, on completion of the data collection, the AAT was to remain as a specialist second opinion resource for the local teams, provided they were able to obtain new funding to continue activity. Training provided The four local teams were trained by members of the AAT in an intensive 5-day course prior to the process of data acquisition. A total of 16 professionals participated. The training course involved the following ve components: 1) how to obtain a developmental and clinical history, specic to ASD; 2) how to assess a child or young person in the clinic setting, making use of the Autism Diagnostic Observation ScheduleGeneric (ADOS-G; Lord et al., 2000); 3) how to reach a diagnosis on the autism spectrum using ICD-10 research criteria; 4) how to feed back the results of multi-agency assessment to families and patients; and 5) how to write up clinical reports. The information provided as regards how to obtain a developmental and clinical history, specic to ASD was that used by the specialist team in its clinical practice. For the purpose of the study, the local teams were instructed to exactly mirror the approach of the specialist team in this aspect of their assessments. The information given as regards how to reach a diagnosis on the autism spectrum using ICD-10 research criteria was taken from the protocol stated in published ICD-10 research criteria.
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14(6) Once the local teams began to assess patients, after the training course had been completed, AAT members mentored the local teams in their administration of these ve parameters of ASD assessment and collected clinical data (including video recording of each ADOS-G assessment by the local teams) for use by the AAT in its parallel assessment of the patients. Most of this mentoring process took place in the rst 10 weeks after training, during which time the local teams were building their experience in using the ADOS-G and in the overall diagnostic process. Extreme care was taken to ensure that the mentoring would achieve a balance between practical utility for the local teams alongside avoidance of bias with respect to the AAT parallel assessment. The ADOS-G was selected because, in comparison with other assessment instruments, it has a high level of utility and discriminative ability in the diagnosis of ASD (Mazefsky and Oswald, 2006). Its use is frequently supported by a formal training course in its administration and interpretation, provided by approved trainers, but it is also available for use by practitioners without any prior training. Within the context of the overall training and support in diagnosis provided for the purposes of this study, it was not feasible to ask the professionals involved to undertake a full training in ADOS-G. However, it was also felt essential to ensure that all could gain expertise in how to use it, supported and monitored by experienced practitioners. For this reason the overall training included a period of ADOSG orientation. The two specialist AAT members who provided ADOS-G orientation (IMcC and RMcC) had previously been trained to a researchreliable level of ADOS-G administration. The orientation covered all four ADOS-G modules and, by the end of the course, using trainee evaluation, the two trainers determined that the local teams were able to obtain necessary ADOS-G administrative data, prior to the onset of the studys data collection.

Participants During the 7-month period of data collection a total of 39 children and young people in the 018 age range within the geographical areas of Argyll and Bute (rural) and East Renfrewshire (urban) were recruited. They ranged in age from 3 years 8 months to 14 years 8 months, with a median age of 8 years 9 months. Seven of the participants were female. All but one of these patients was assessed by the local teams. Permission to assess the remaining child was withdrawn by the guardian prior to the assessment. Procedure The local teams ASD assessments were video recorded on a digital camera and the resulting hard drive les were stored in a secure hospital IT system.
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The videos and case-recorded ASD histories (standardised in format on the initial training course) were evaluated in parallel by the AAT, which was blinded as to any diagnosis made by the local teams. The video recording was undertaken in each case by one member of the AAT to ensure consistency of recorded assessment for the subsequent AAT assessment. The member of the AAT rated the video in isolation from the local teams to remain blinded but at the same time to ensure that there was a live rating to compare with the fellow AAT members when they rated from the video recording. For each patient assessed, the AAT compared its own rating, which was a consensus rating with the AAT live coding and the AAT video coding, with that of the local team. As well as having the AAT consensus ADOS-G ratings, to assist in reaching a diagnosis for every patient the AAT members also had access, in all cases, to the standardised clinical history and the multi-agency reports routinely obtained by each local team. The AATs diagnosis was then fed back by the local team to the patient and their parents/carers. In addition, a comparison was made between the local teams and the specialist team in terms of the total time spent on the waiting list from point of referral to completion of the assessment process. This was done by comparing the waiting times of the 38 patients seen by the local teams with the waiting times of the previous 38 patients assessed by the specialist team. Note was also taken of the total time taken by the specialist team to assess these 38 patients in comparison with the 7-month period in which 38 assessments were conducted by the local teams. Ethical approval for this study was obtained from NHS Argyll and Clyde Ethics Committee, which determined the extent to which informed consent from the patients and families involved was required.

Results
Reliability/validity of local versus specialist team diagnosis Table 1 presents the diagnosis given by the local team and by the AAT for all 38 participants. For 33 participants (87%) there was full agreement on diagnosis, not only in terms of whether the child was on the autism spectrum but, if so, the specic diagnosis within the spectrum. For an additional 2 participants, making a total of 35 (92%), there was agreement as to whether the child was on the spectrum, but disagreement on diagnosis within the spectrum. In summary, for 23 out of the 38 participants the conclusion of the local teams was not ASD, and the AAT agreed with 22 of these, diagnosing autism in the remaining case. For 10 participants the local teams diagnosed
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Diagnosis given by local versus specialist team Gender Age (months) Local team diagnosis AS AUTISM AS AS AS Not ASD AS Not ASD AUTISM Not ASD AS Not ASD Not ASD AUTISM Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD AS AS Not ASD Not ASD Not ASD AUTISM Not ASD Not ASD Not ASD AUTISM AS AS Specialist team diagnosis AS Not ASD AS AS AS Not ASD AS Not ASD AS Not ASD Not ASD Not ASD Not ASD AUTISM Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD Not ASD AUTISM Not ASD Not ASD AS AS Not ASD Not ASD Not ASD AS Not ASD Not ASD Not ASD AUTISM AS AS

Table 1 Case no.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

M M M F M M M F M M M M M M M M M M F M M M M F M M M M M F M F M M M M F M

99 48 72 150 75 104 118 60 117 89 63 108 176 44 101 95 128 99 129 136 170 119 115 98 52 107 89 120 117 96 141 85 142 48 140 133 105 132

Note. AS = Aspergers syndrome; ASD = autism spectrum disorder.

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Aspergers syndrome, and the AAT agreed with 9 of these, viewing the remaining case as not ASD. For 5 participants the local teams diagnosed autism, and the AAT agreed with 2 of these, diagnosing Aspergers syndrome in 2 cases and not ASD in the remaining case. Intra-class correlations for inter-rater reliability were calculated for the ADOS-G scores obtained by the local teams on live assessment in comparison with those obtained by the specialist team on video assessment of the same children and young people. These are shown in Table 2 for the four areas for which these gures are provided in the ADOS-G test manual (Lord et al., 2002) communication, social interaction, communication-social interaction total and stereotyped behaviours/restricted interests. There were no signicant differences between the correlations obtained in this study (range 0.79 to 0.82) and those reported in the ADOS-G manual for livevideo ratings (range 0.72 to 0.92).

Effect of increasing experience in the diagnostic process Of the 38 assessments, 15 were completed in the rst 10 weeks of the project, during which period most of the post-training mentoring process took place. It was at this stage that local team practitioners were gaining experience of the new process and of carrying out the ADOS-G. The remaining 23 assessments were conducted after the main period of mentoring had been completed. The number of cases in which there was not full agreement between the local and specialist teams (three in the rst 10 weeks, two for the remainder of the study) was too small to allow comparison. However, to test the hypothesis that the reliability of the assessments by the local teams increased with experience, the combined difference scores between the local and specialist teams on the ADOS-G areas shown in Table 2 were analysed using two-sample t tests. These showed a modest trend towards increased reliability once more experience had been gained by the local teams. The mean difference for communication, social interaction and stereotyped behaviours/restricted interests in
Table 2 team Intraclass correlations for inter-rater reliability: local versus specialist

Local v. specialist team N Communication Social interaction Communication-social interaction total Stereotyped behaviours and restricted interests 38 0.79 0.82 0.82 0.79

ADOS manual 35 0.82 0.92 0.91 0.72

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14(6) the rst 10 weeks was 5.0, while following the period when most of the mentoring had been required, it had reduced to 3.1 (t critical, one-tail, 1.69; df 36; p < .05).
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Waiting list data The average time spent on the waiting list for the 38 patients referred to the local teams was 13 weeks (range 126 weeks), compared with an average of 36 weeks (range 1681 weeks) for the previous 38 referred to the specialist team (t critical, two-tail, 1.99; df 74; p < .001). For the patients referred to the local teams, the average time for completion of the assessment process was 4 weeks less than the NAP-C recommended time limit of 17 weeks (Le Couteur, 2003). This time limit was met in 25 cases, while it was exceeded in 13 cases. The longest time period by which the time limit was exceeded was 5 weeks. By contrast, for the patients referred previously to the specialist team, the time limit was met in only 1 case, and was exceeded in the remaining 37, by periods extending up to 64 weeks. Finally, it is noted that 38 patients were assessed by the local teams within 29 weeks, while the previous 38 patients had taken the specialist team 75 weeks to assess.

Discussion
It has been argued in this paper that there is an impasse in ASD assessment created by the quality standards, including waiting times, recommended by guideline committees on the one hand, and the realities of service provision, funding and availability of trained personnel on the other. In seeking to address this issue, this study sought to determine whether, with appropriate training, a local multi-agency ASD assessment team could perform as reliable and valid an ASD diagnostic assessment as a specialist team. It is recognised that this issue is based on the assumption that the diagnoses conducted by an experienced specialist ASD team are both reliable and valid. There are no generally accepted norms for diagnostic reliability across experienced, specialist ASD assessment teams, and it is the common experience of all clinicians that experts do not agree on all cases. There are times especially in threshold cases when diagnosticians reach a different conclusion either as to whether a child or young person is on the spectrum, or as to the precise diagnosis within the spectrum. Nevertheless, it is proposed that the high level of agreement in the present study between local teams and the specialist ASD team is within the usual parameters familiar to experienced diagnosticians. A key component of training, and of the subsequent assessment process, was the administration of the ADOS-G. It is recognised both in the test 598

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manual (Lord et al., 2002) and in wider clinical practice that diagnosis is a clinical judgement, and that it is not determined on the basis of cut-off scores on an assessment instrument. Other factors have to be taken into account, such as reports of age of onset from the developmental history. However, our choice of this instrument is supported by reports that it shows 75% agreement with team clinical diagnoses (Mazefsky and Oswald, 2006). Indeed, in our study, the three cases where there was disagreement as to whether or not the child or young person was on the autism spectrum were represented by the three highest discrepancies between the local and specialist teams in the ADOS-G scores. Overall, the ADOS-G scores obtained by the local teams on live assessment showed a high level of correspondence with those obtained by the specialist team on video assessment of the same children and young people. The results were comparable to the inter-rater reliability gures obtained for the experienced practitioners who carried out the ADOS-G standardisation, suggesting that the orientation in using the test provided to practitioners in this study equipped them adequately for the task. The ADOS-G scoring ability of the two members of the specialist team (IMcC and RMcC) had already been assessed as being highly reliable, as part of their ADOS training. We acknowledge however, that a potential limitation of this study is that we have only obtained gures for inter-rater reliability across teams and not within teams (including the specialist AAT). The mentoring process carried out mainly in the rst 10 weeks following training was viewed as an important source of support for the local teams while they were gaining experience in carrying out their assessments. The modest trend towards a closer correspondence between the ADOS-G scores of the local teams and the specialist team suggest that such support and the gaining of experience were necessary. This is compatible with the responses of the local teams practitioners to questionnaires that they completed immediately following training, as part of a routine evaluation process. Of the 17 respondents, 13 evaluated themselves as being completely condent in taking the standardised developmental history, but none used this rating for their condence in rating the ADOS-G. Instead for this item, all 17 evaluated themselves as partially condent. We determined that this condence level was sufcient for subsequent data gathering and we believe that our ndings have demonstrated that this assumption was appropriate. A limitation of this study is the small number of very young (preschool) children with autism who were assessed. Of the sample of 38 children and young people, 14 received a diagnosis on the autism spectrum. Of these, the diagnosis for the majority was Aspergers syndrome. Of the 5 who received a diagnosis of autism from the local team, the diagnosis 599

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14(6) did not correspond with that of the specialist team in two cases. In addition, while there was a wide spread of ages of children and young people referred, there was only one child aged less than 4 years, and that child was 3 years 8 months at the time of assessment. While our study has therefore shown good correspondence between local and specialist team diagnoses, the question remains as to how the outcomes would appear with a larger sample of very young children receiving an autism diagnosis. The same issues might also apply to children and young people with moderate or severe intellectual disability (i.e. IQ at or below 70). Although formal cognitive testing of the subjects assessed in our study could not be obtained, we estimate that the majority would be of IQ greater than 70, as most of the subjects attended (or were deemed eligible to attend) mainstream educational placements (including some of those diagnosed with autism). Therefore, further research with larger numbers in both of these categories (i.e. pre-school children and subjects with at least moderate intellectual disability) is indicated, before any recommendation for investment into this model can be authoritatively made. Whilst only one child under 4 years was assessed in this study, over the course of time, earlier identication of ASD cases may be a reasonable aspiration with the service model outlined, as increasing numbers of cases are screened at local level. Another potential limitation is that the local teams ADOS-G assessments were conducted and rated live, whereas two AAT members assessed and rated the cases by means of a video recording of the local teams assessment. However, the diagnostic outcomes of either approach in this study do not suggest any trend that suggests that use of video material for specialist team assessment impairs diagnostic validity or reliability. Other possible limitations of the service model proposed are that establishing local multidisciplinary ASD assessment teams may not necessarily address extended waiting periods (e.g. due to the possibility of increased referrals, less pre-screening and the need for oversight from a specialist ASD assessment team). In our view, if the service model proposed is applied effectively, such limitations should not apply. Local teams should not lead to less pre-screening, because local screening (e.g. by psychological services and speech and language services) will continue as before. It is also theoretically possible that our service model might lead to new service development costs unwelcome, particularly in current nancial circumstances. However, we believe that the service described does not necessarily imply such cost increase. For example, specialist teams tend to involve higher-cost professionals. It therefore makes nancial sense, if clinical quality and efciency can be maintained, to limit the role of specialist teams to second opinion or complex cases, covering as large a geographical area as possible, as our model implies. Our study demonAU T I S M

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strates how specialist overview of local teams can be signicantly reduced after an initial relatively short mentoring period, with no reduction in service quality. Subsequent specialist overview of local teams functioning can be achieved by low-cost measures such as email, telephone conversations, or review of video recordings of ADOS assessments. Also, effective planning of priorities can mean that existing local staff already in post can demarcate a proportion of their time to work in local ASD assessment teams (as occurred in our study and continued in those local teams after the data collection period ended) without the need for any stafng increases. The children assessed by the local teams will already be on such individual practitioners caseloads (as occurred in our study) and therefore colleagues involvement in local team assessments will not represent extra work. Instead, it will be the same work done differently (and more cost effectively). Also, a possibility for further follow-up in future replications or developments of this study would be to include feedback from parents as regards their experience of the process of assessment by the local teams, versus assessment by the specialised team.

Conclusions
Early diagnosis of ASD is of crucial importance. This study has demonstrated the potential feasibility of creating local, multi-agency ASD assessment teams equipped to carry out reliable and valid diagnoses, using professionals from a range of disciplines in health, education and other services. This serves to reduce waiting times, to improve clinical skills at a lower level of specialism and thereby to improve the overall quality of ASD service.

Acknowledgement This study was funded by a grant from the Autism Reference Group of the Scottish Executive Health Department to the Argyll and Clyde Health Board. References
Autism Research Co-ordination Group (2006) First Annual Report of the Autism Research Co-ordination Group. London: Department for Education and Skills. Baird, G., Cass, H. & Slonims,V. (2003) Diagnosis of Autism, British Medical Journal 327: 488493. Bristol-Power, M. & Spinella, G. (1999) Research on Screening and Diagnosis in Autism: A Work in Progress, Journal of Autism and Developmental Disorders 29: 435438. Filipek, P.A., Accardo, P.J., Baranek, G.T., Cook, E.H., Dawson, G. Gordon, B., Gravel, J.S. et al. (1999) The screening and diagnosis of autism spectrum disorders. Journal of Autism and Developmental Disorders, 29, 439484. Goin, R. & Myers, B. (2004) Characteristics of Infantile Autism: Moving toward Earlier Detection, Focus on Autism and other Developmental Disabilities 19: 512.

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