Autism spectrum disorder — assessment to irritability management (MEQ)

(i) Criteria and severity. ASD requires persistent deficits in all three social-communication domains (reciprocity; nonverbal communicative behaviour; relationships) and at least two of four RRB domains (stereotypies/repetitive speech or object use; insistence on sameness; restricted interests; sensory hyper/hyporeactivity), early developmental onset, impairment, and not better explained by intellectual disability alone. Rate severity separately for social communication and RRBs as Level 1–3 support need.^[1]

(ii) Differentials. ADHD: inattention/impulsivity core; social interest often present; high co-occurrence. ID alone: social skills roughly match developmental level; ASD requires deficit beyond developmental expectation. Social anxiety: fear of scrutiny with skills often intact when comfortable. SCD: social language deficits without RRBs. This child has RRBs (timetables, sameness distress) → ASD not SCD.^[1]

(iii) Non-drug package. Educational adjustments, speech/OT, structured behavioural supports, parent training, and early developmental intervention. Name ESDM (Dawson RCT) and PACT (Green parent-mediated RCT); Bearss parent training for disruptive behaviour outperforms education alone.^[4][5][6]

(iv) Irritability medicines. After functional analysis, medical pain screen and behavioural optimisation, severe ongoing aggression/self-injury may justify risperidone (RUPP/McCracken: low weight-based start e.g. about 0.25–0.5 mg/day with slow titration; monitor weight, metabolic panel, EPS, prolactin) or aripiprazole (Owen: start commonly 2 mg daily, titrate toward trial effective range; monitor metabolic effects and akathisia). Neither treats core social deficits. Review for dose minimisation once stable.^[2][3]

(v) Capacity and transition. Decision-specific capacity with supported decision-making; least restrictive care under local law. From mid-teens plan CAMHS-to-adult transition: written care plan, education/employment, medication review, housing, safeguarding against exploitation, and adult mental health follow-up for comorbidity risk.^[1]