Iain McClure

Gender ratio in a clinical population sample, age of diagnosis and duration of assessment in children and adults with autism spectrum disorder

This article reports on gender ratio, age of diagnosis and the duration of assessment procedures in autism spectrum disorder diagnosis in a national study which included all types of clinical services for children and adults. Findings are reported from a retrospective case note analysis undertaken with a representative sample of 150 Scottish children and adults recently diagnosed with autism spectrum disorder. The study reports key findings that the gender ratio in this consecutively referred cohort is lower than anticipated in some age groups and reduces with increasing age. The gender ratio in children, together with the significant difference in the mean age of referral and diagnosis for girls compared to boys, adds evidence of delayed recognition of autism spectrum disorder in younger girls. There was no significant difference in duration of assessment for males and females suggesting that delays in diagnosis of females occur prior to referral for assessment. Implications for practice and research are considered.2

The relationship between waiting times and ‘adherence’ to the Scottish Intercollegiate Guidelines Network 98 guideline in autism spectrum disorder diagnostic services in Scotland:

The aim of this study was to explore the extent to which the Scottish Intercollegiate Guidelines Network 98 guidelines on the assessment and diagnosis of autism spectrum disorder were adhered to in child autism spectrum disorder diagnostic services in Scotland and whether there was a significant relationship between routine practice which more closely reflected these recommendations (increased adherence) and increased waiting times. Retrospective, cross-sectional case note analysis was applied to data from 80 case notes. Adherence ranged from a possible 0 (no adherence) to 19 (full adherence). Overall, 17/22 of the recommendations were adhered to in over 50 of the 80 cases and in 70 or more cases for 11/22 of the recommendations, with a mean adherence score of 16 (standard deviation = 1.9). No significant correlation was found between adherence and total wait time for untransformed (r = 0.15, p = 0.32) or transformed data (r = 0.12, p = 0.20). The results indicated that the assessment and diagnostic practices were consistent with the relevant Scottish Intercollegiate Guidelines Network 98 guideline recommendations. Increased adherence to the 19 included recommendations was not significantly related to increased total waiting times, indicating that the Scottish Intercollegiate Guidelines Network 98 recommendations have generally been integrated into practice, without a resultant increase in patient waits.

Factors influencing waiting times for diagnosis of Autism Spectrum Disorder in children and adults

AIMS To identify the main factors predicting delays in diagnosis for Autism Spectrum Disorder (ASD) at three stages in the diagnostic process: wait for first appointment; assessment duration, and total wait for diagnosis. METHOD Data were gathered from 150 case notes (80 child and 70 adult cases) from 16 diagnosing services across Scotland. RESULTS Having more information pre-assessment was associated with a reduced duration of the diagnostic process for children. This relationship was partially mediated by a reduction in the number of contacts required for diagnosis. In adults, having more factors associated with ASD (increased risk) reduced the wait time from referral to first appointment, but increased the overall duration of the diagnostic process. The latter relationship was partially mediated by an increase in the number of contacts required for diagnosis. CONCLUSION Within childrens services, increasing the amount of relevant information available pre-assessment is likely to reduce total duration of the assessment process by reducing number of contacts required. Having a high risk of ASD as an adult appears to result in being seen more quickly following referral, but also to increase the number of contacts needed and assessment duration. As a result, it increases and total duration overall.

How the autism epidemic came to be

The marked rise in autism may be the result of changes in diagnostic criteria. But what led to developmental disorders in children being reconceptualised? Iain McClure enjoyed this book that tells the story from a sociological perspective

ADHD is a behavioural construct, not a psychiatric condition

In their helpful overview, Thomas and colleagues explain that attention-deficit/hyperactivity disorder (ADHD) is probably being overdiagnosed because ascertainment of degree of impairment (mild, moderate, or severe) is subjective and therefore unreliable.1 However, the ADHD concept itself is inherently subjective. ADHD is diagnosed according to the recorded presence (or absence) of attention deficit, hyperactivity, and impulsivity. …

A cure for the disease of hate

A Gazan doctor working in Israel describes his life and extraordinary tragedy, with a determination that good must come from bad. Iain McClure recommends his book to all doctors

New ways of thinking about autism

Two innovative studies of autism get to the heart of the matter, finds Iain McClure

Medical Classics : Woyzeck

Georg Buchner (1813-37) packed what most would regard as several lifetimes’ worth of experience into his tragically short 23 years. At the time of his death from typhus in 1837, he had written an incendiary revolutionary pamphlet; a dissertation On Cranial Nerves, which led to his appointment as lecturer in comparative anatomy at Zurich; and two of the greatest plays ever written. The first of these, Danton’s Death (1835) was written in five weeks, during Buchner’s flight into Switzerland from probable imprisonment. It is a gripping political drama, its insight into political intrigue being comparable to Shakespeare. The second play, Woyzeck, though probably unfinished at Buchner’s death, has been responsible for most of the key developments in Western theatre since 1913, when it was first performed in Munich. Quite simply, without Woyzeck, there would be no Brecht and no Beckett. The play was directly based on the miserable life of Johan Christian Woyzeck, who was beheaded in Leipzig in 1824 for the murder of his mistress in a fit of jealous rage. At the time, Woyzeck’s case made legal history because the accused had been subjected to lengthy medical examination in order to establish if his sentence could be reduced due to diminished responsibility. Buchner stuck to most of the factual detail of his protagonist’s life, telling the story of a poor man’s descent into failure and of his brutal romantic loss that ironically echoes Goethe’s Faust. Although short as a play, Woyzeck is endlessly innovative and exciting on many levels. From the medical perspective, it delivers a scabrous attack on the ethical pitfalls of clinical research, namely the danger of the doctor playing God. One of the play’s main characters is that of the unnamed doctor who is paying Woyzeck to be a guinea pig for his scientific inquiries. At the time of the play’s action, the doctor has been feeding our hapless hero with nothing but a diet of peas and is monitoring the physiological and psychiatric results daily. It is the doctor’s total lack of interest in the wellbeing of his subject that is dramatic here and the consequence of his (effectively) chemical intervention on our protagonist’s mental state is Woyzeck’s impassioned murder of his beloved, Marie. What is extraordinary about Woyzeck is how a medical student (who was actively engaged in neurological research at the time of writing his play) had the depth of vision and perception to connect his emerging scientific knowledge with a level of compassion and understanding of human nature that seems beyond his 23 years.

The Doctor Stories.

William Carlos Williams (1883-1963) made his living as a doctor and his reputation as a writer. After initial training in New York he worked as a family practitioner in his home town of Rutherford, New Jersey, for 40 years, seeing—in his own estimation—a million and a half patients. His formative working life was spent during the Depression, his patients being mainly blue-collar workers and the unemployed underclass. Many were immigrants who spoke little or no English, and a chronic feature of his consultations was their struggle to pay …

Medical Classics: The Bell Jar

Chiefly celebrated for her “confessional poetry,” Sylvia Plath (1932-1963) was also ambitious to break new ground with prose. Poignantly, The Bell Jar, published under a pseudonym a month before her death, was her only attempt at the novel form. One of the compelling aspects of this increasingly respected novel is the degree of connection between the troubled life of its heroine, Esther Greenwood, and Plath herself. Inevitably, as we encounter Esthers subtle mental breakdown and successive suicide attempts, we are drawn further into the now almost mythic events of Plaths short life. Despite the inevitable curiosity about the autobiographical content, The Bell Jar is of lasting importance for further reasons. First and foremost is its subject matter, which has increasing relevance 40 years on. The book examines a contemporary concern—how is it that privileged and educated young people (especially young women) increasingly turn to varied kinds of self harm, as a way of coping and escape? Plath was one of the first writers to explore this area, and her description of Esthers escalating suicidality is all the more realistic for being described so matter of factly. Various themes spin out from this central idea, such as the restricted role of women in 1950s America, an emerging feminist viewpoint, and personal renewal through struggle. Esthers development of psychotic depression is Plaths interpretation of the classic “rite of passage” journey. The bell jar of confusion that descends on Esther hampers her personal progress, yet it protects her from being overwhelmed by a highly competitive social world. Plath ushers us into the clinic of the subtly monstrous psychiatrist, Dr Gordon, and exposes us to the stunning brutality of Esthers unanaesthetised electroconvulsive therapy. Psychiatry is redeemed when Esther is renewed under the care of a female consultant, Dr Nolan, who represents what Esther aspires for herself—independence and social respect as a professional woman. In describing Esthers recovery, Plath covers an aspect of mental illness that is not sufficiently publicised. Esther has undergone a life changing experience. Plaths novel serves as an important reminder that our stigmatised psychiatric wards, sometimes places of misery and tragedy, can also nurture momentous personal change and a new beginning. As we finish the novel, we are drawn again into the authors own life. Esthers overriding concern, as she faces the grand round that will decide for or against her hospital discharge, is whether the bell jar “with its stifling distortions” might descend again. Tragically (for once, this word is not misplaced), Sylvia Plath did not escape the fate that Esther fears.