Community Paediatrics

Social communication refers to the use of verbal (spoken language) and non-verbal (eye gaze, facial expression, gestures) communication in social situations, to tell people what you want, express feelings, relate to other people and develop meaningful relationships (NHS definition). We use social communication needs as a broad term that covers autism, ADHD and any other diagnosed or undiagnosed need. 

Social communication needs such as autism and ADHD are classed as neurodivergence. We understand that neurodivergence is just a difference and doesn’t need treatment but empathy and understanding. 

The term neurodiversity describes differences in the way people's brains work. The idea is that there's no “correct” way for the brain to work. Instead, there is a wide range of ways that people perceive and respond to the world, with varying strengths and weaknesses. The terms neurodivergent and neurodivergence are now used to describe all people whose neurological conditions mean they do not consider themselves to be neurotypical. 

There are a number of ways of being neurodivergent. They often overlap, meaning many people experience more than one type of neurodivergence. Here are some examples: 

It is important for your child to know that there is nothing wrong with them, and that the purpose of assessments is to understand how their brain works, so that they can learn about themselves and get the support they need to thrive.

You may find it helpful to explain your child’s or your own behaviour using these terms.

Early years – below 5 years of age:

The following may be signs of autism in an early years child though there can be other reasons for this behaviour and these signs can vary significantly depending on the age of your child. Your health visitor will be able to help you when you are worried about these behaviours. Potential signs include:

• Language delay or differences, for example, not yet talking like other children of the same age, difficulty in understanding your simple spoken instructions, reciting chunks of language.
• Challenges in social relationships, for example, may not respond to their name, lack of responsive smiling or rejecting cuddles.
• Differences in developing relationships. For early years this may be no or little copying of others, no or little social interest in others, no or no apparent awareness of personal space, not showing enjoyment.
• Differences in non-verbal communication. For early years this may be little or no eye contact, difficulties in getting and holding their attention, a lack of typical face or body gestures like smiling, nodding.
• Difference in play, for example, focussing on a small part of a toy, or routine play. They may have the same repetitive play that they prefer over and over.
• Unusual or repetitive behaviours. For early years this may be hand flapping, body rocking, unusual gazing at objects.
• Over or under reaction to sounds, smells, taste, and textures. The child may get very upset or sensitive with certain foods, smells, or clothing; or seek out different sensory feedback such as licking item.
• A preference for sameness so moving on from something they really like doing or changing to go out.
• Being very happy doing what they want to do and following what they enjoy but finding it more difficult to show attention to other things.

These potential signs are usually persistent (they don’t change or go away) and are likely to be seen across multiple settings, for example, with grandparents or in an early-years setting. Not all these signs must be present to indicate autism. For example, some autistic children can maintain socially appropriate eye contact.

School aged children – Aged 5 years and over
The following may be signs of autism in school-aged children though there can be other reasons for this behaviour and these signs can vary significantly depending on the age of your child and their circumstances. Potential signs include:

• not seeming to understand what others are thinking or feeling,
• unusual speech, such as repeating phrases and talking ‘at’ others,
• liking a strict daily routine and getting very upset if it changes,
• having a very keen interest in certain subjects or activities,
• getting very upset if you ask them to do something,
• finding it hard to make friends or preferring to be on their own,
• taking things very literally – for example, they may not understand phrases like "break a leg",
• finding it hard to say how they feel.
These potential signs are usually persistent (they don’t change or go away) and are likely to be seen across multiple settings, for example, with grandparents or in school. Not all these signs must be present to indicate autism. For example, some autistic children can maintain socially appropriate eye contact.

It is important to be aware of potential masking, or of the differences in how girls can present. See the individual sections for the details of how to recognise these signs.

School-aged children - aged 5 years and over

The following may be signs of autism in school-aged children though there can be other reasons for this behaviour and these signs can vary significantly depending on the age of your child and their circumstances. Potential signs include:

• not seeming to understand what others are thinking or feeling
• unusual speech, such as repeating phrases and talking ‘at’ others
• liking a strict daily routine and getting very upset if it changes
• having a very keen interest in certain subjects or activities
• getting very upset if you ask them to do something
• finding it hard to make friends or preferring to be on their own
• taking things very literally – for example, they may not understand phrases like "break a leg"
• finding it hard to say how they feel

These potential signs are usually persistent (they don’t change or go away) and are likely to be seen across multiple settings, for example, with grandparents or in school. Not all these signs must be present to indicate autism. For example, some autistic children can maintain socially appropriate eye contact.

It is important to be aware of potential masking, or of the differences in how girls can present. See the individual sections for the details of how to recognise these signs.

For some children, it is important to be aware of masking. This refers to an autistic person’s ability to try and minimise or mask autistic traits from others. This can be done unconsciously and from the desire to fit in and not stand out so they will try to learn from others and copy behaviours. Not all autistic people mask, but those who do may not always be aware they are engaging in masking behaviour. Some may struggle not to engage in masking even when consciously trying. It is worth noting that masking may interfere with an autistic person’s ability to communicate their needs with families or professionals. Therefore, a diagnosis can be more difficult to make.

Autism signs can sometimes be different in girls and boys. Autistic girls are often very good at masking and may:

• hide some signs of autism by copying how other children behave and play
• withdraw in situations they find difficult
• appear to cope better with social situations
• show fewer signs of repetitive behaviours

This means autism can be harder to spot in girls.

A fuller list of signs which may be helpful is available here: Autism in Girls Checklist

This flowchart is a summary of the autism assessment pathway for children and young people in Bromley. You can read about each stage in more detail:

CYP Autism Pathway [PDF]

Families can get support and help at any point during this process. The professionals involved in your journey, or the information provided here can show you what support is available and how to access it.

Community Paediatrics (or sometimes written as CommPaeds) is the single-entry point for all children and young people’s referrals where there are concerns about differences such as autism. The team accept referrals for children from any professional or person who knows your child well, for example, a teacher, a tutor, SENCO, a therapist such as a speech and language therapist, occupational or play therapist, childminder, day nursery or school nursery. If you have raised concerns with your GP then they will advise you to discuss a referral with your child’s school, early years setting, or health visitor. The referral must be made by someone who knows your child as they will be asked to complete a questionnaire. This makes up the requirement for two sources of information. The other source of information will be the details you provide at the first stage in the pathway.

Once the referral has been received and all information has been shared, an appointment will be made with a Community Paediatrician for an assessment of your child’s overall health and wellbeing. This step is important for children who may have other causes for their behaviours.

The person who made the referral will be able to help you understand how to access early support while you wait.

At the Community Paediatric assessment, the paediatrician will take a detailed history of your concerns. This will include current problems, past medical history, birth history, family and social history, history of any allergies, vaccination status, any medications etc. Following talking to you, they will usually do a clinical examination of your child.

The paediatrician will consider the information provided by professionals (schools, pre-school setting therapist etc) in the questionnaire they have been sent. These questionnaires will help gather the full picture of your child’s behaviours – this will include their preferences, and strengths, when they happen, and how often they occur.

Where the information suggests this could be autism then the community paediatrician will share the details of your child’s history with the Complex Communication Diagnostic Service (CCDS) panel. This is where the formal autism assessment pathway begins.

If the information does not suggest autism, then the paediatrician will discuss this with you. They may suggest a period of ‘watch and wait’. This means that more information over time will be helpful to see if this is autism. You may still benefit from strategies that support your child’s social communication needs and you can still seek support for the difficulties that led to diagnosis process.

Other diagnoses may be made at this stage as the assessment is more generic than the specific autism assessments made later in the pathway. This is especially true for children who may have more than one condition.

Once the Community Paediatrician assessment is complete, and autism is suspected, a skilled team of people will meet for a clinical case discussion. This is known as a multidisciplinary team or an MDT. They meet as a specialist panel of professionals known as the CCDS. This usually includes the community paediatrician, a speech and language therapist or occupational therapist, and a clinical psychologist. They will use all the information provided in the questionnaires, and the findings from the general assessment completed by the paediatrician. This is the start of the autism assessment pathway. You will be informed of the outcome via letter.

The potential outcomes following this process are:

The CCDS will advise that an assessment for autism is not clinically indicated at this time, and they will share this information with your referring professionals – they will suggest alternative services, including support services, and will offer written advice. Further referrals can be made, and the team can reconsider cases if more information is provided.

OR

The CCDS will ask for further information which may include a discussion with you, and then the panel will meet to consider the case again.

OR

The CCDS will confirm that the information suggests an assessment for autism would be clinically indicated and will suggest a neurodevelopmental assessment with either a therapist or a clinical psychologist. If the circumstances are particularly complex, for example, if your child has other conditions like epilepsy or ADHD, then the community paediatrician may assess your child again.

For any of these three outcomes, you can still access support for your child’s needs – see Early Help and Support below.

Neurodevelopment assessment is performed by either a speech and language therapist or a clinical psychologist. In some cases, the community paediatrician may also perform a second detailed assessment if your child has multiple conditions or if there is a level of complexity that requires further assessment.

The Autism Diagnostic Observation Schedule, or ADOS for short, is one of the assessment tools we use as part of the overall Autism assessment process. Other tools may be used as appropriate, but ADOS is most commonly used. ADOS is an assessment that can be used with people of all ages, abilities, and language skills. It is a semi-structured, standardised assessment of communication, social skills, play and other behaviours. It enables us to look at how your child or young person communicates, how they interact with us, how they play and their ability to be creative, and also if they have any restricting or repetitive behaviours or interests. The assessment will also consider masking or common signs in girls which can be different from other children with autism.

Masking refers to an autistic person’s ability to try and minimise or mask autistic traits from others. Likewise signs of autism in girls can be different to that seen with boys. Therefore, for both groups a diagnosis can be more difficult to make. The professionals will be aware of this when conducting the assessment.

During the assessment the clinician will play some games with younger children or carry out activities including questions about school, friendships and feelings with older children or young people. By watching the way your child communicates, interacts, plays, and behaves during the games and activities it helps us to understand if there are signs of autism.

After the neurodevelopment assessment(s), the multidisciplinary panel will liaise to look at the information gathered throughout the process. A consensus decision will be made on a diagnosis.

A feedback meeting will be arranged which will include a member of the assessment team, yourself as the family, and a member of the school where possible. If your child is old enough to understand the conversation and who may have questions of their own, then they will be welcome to attend.

This is usually a virtual meeting. This is because it if often easier for schools to join if they don’t have to attend in person. If you would prefer a face-to-face feedback meeting, contact the assessment team who may be able to meet your individual needs.

During this meeting the team will discuss the findings and answer any questions you may have. This will include what the next steps might look like for you and your child.

You will receive a written letter with details of the findings from the assessment and any plans for next steps that have been agreed. The support available to you can be sought at any time but now is a good time to review what might be helpful for you. The assessment team can help you do that.

A full report will be shared with your GP, the school and any other professionals that may need it.

There are some things you can do to help you and your child prepare for the assessment. These actions may make you feel more prepared to provide information about your child, and to advocate for your child. Where a child is prepared they can feel more safe and included.

These actions can include:

1. Think about your child’s development and what information may be helpful. These are examples:

Attitude towards structure, routine, repetition and sameness:

• Do they thrive with routine and structure?
• Any needs for sameness?
• Anxiety or reaction to uncertainty or change?
• Do they move any part of their body in a repetitive manner? This can be small movements.

Sensory experiences and preferences:

• What is their experience of the sensory world?
• Do they notice smells, textures or noises that others don’t?
• Sensory experiences that are upsetting
• Sensory seeking behaviours, for example, listening to the same song over and over, tapping, stroking, fiddling with favourite materials, or rocking.

Co-ordination and motor skills:

• What are their gross motor skills like? For example, balancing, riding a bike, are they heavy handed or have trouble negoitating spaces?
• Walk carefully or on tip toes? Do not take notice of objects in pathway?
• What are their fine motor skills like? For example, writing buttoning up clothes, tying shoes, are they very precise?

Areas of passion or expertise:

• Special interests in things such as books, animals, vehicles, singular topics
• Ability to hyper-focus for a long time on one thing
• Excellent memory and knowledge of a particular subject
• Not interested in other subjects or topics
• Do they like order and tidyness, a perfectionist?

Behaviour:

• Do you have any major concerns/ worries in this area?
• How do they express their distress or anxiety?
• How do they express when they are happy?
• Do they have meltdowns with dramatic behaviour, or do they withdraw and shutdown?
• How are you currently managing this behaviour?

Strengths and appreciation:

• What do you appreciate about them?
• What are their strengths?

Developmental history:

• Pregnancy and birth
• Major developmental milestones, for example, walking
• Developmental delays? For example, speech and language
• Family history of autism, learning disability, mental health problems, speech and language.

Home:

• Self-care skills (washing, dressing, eating)
• Safety skills (road, kitchen)
• Support needs for day to day activities because of difficulties with simple tasks
• What do they doing at home, favoured activities?

School:

• What is school like for them generally?
• Attainment and progression with subjects (learning abilities)
• Additional support in place
• Ability to ask for help
• Favourite and least favourite subjects
• Attention levels
• What do they do after school? What do they talk about regarding school?

Relationships:

• How are things socially? Do they enjoy going on play dates or parties? Do they have friends and relationships?
• Do they ask to have friends over or join clubs to be with friends?
• What is their play style, for example, prefer independently playing, creativity, repetitive play like returning to same toys?

Mental and physical health:

• How is their physical health?
• How is their mental health?
• Any anxiety, low mood, meltdowns?
• What behaviours do they use to communicate distress?

Social communication preferences:

• How is their eye contact?
• What is their communication style, for example, answering direct questions, giving lots of information with little pause, do they enjoy back and forth conversation?

2. It is helpful for young people to know why they are being assessed.

If children do not know what is happening or why they can feel scared or think that something is wrong with them. It is important that they know this is not the case. It is helpful for your child’s self-esteem, anxiety and sense of autonomy to know about the assessment process before they take part.

Starting the conversation may sound something like:

“I’ve noticed you are working really hard at school this year, but it seems like things might be tricky sometimes…I’m thinking that if we know more about how your brain works, your teachers and I could do a better job at helping you. We are going to meet someone who is going to help us learn all about how your brain works so that:

• Teachers know how to teach you
• Our family knows how to support you
• You can understand yourself better
• You can know how to explain what help you need better
• You can learn about the things you are great at.”

Describing the process:

Although some children’s journeys will be different, most children will have one or more conversations with a professional. These meetings might involve:

• Talking about feelings, preferences and challenges at home, with friends, or at school.
• Playing some games and puzzles (some might be easy and some might be hard).

The waiting times can differ because of the need for some children to have different types of assessment by different professionals. Although we aim to keep waiting times as standard for everyone as possible this is not always the case. The approximate time you will wait will be shared on your letter. Please be aware you may wait for a shorter or longer time than indicated.

Your letter will include options for support available to you. Please ensure you take advantage of all the support available to you while you wait. You do not need a diagnosis to access this, and it can be beneficial for your child and for you as a family.

We recognise that as families wait for the assessment process they need more immediate support – that is support that meets their needs and is not restricted to a diagnosis. This section provides links to accessing support that is right for you. Don’t delay in exploring these options as early support is shown to make a positive difference to children, young people, and their families.

Social Communication Needs (SCN) family support service

The Social Communication (including Autism) Needs Targeted Support Co-ordinator was introduced to provide information and advice to parents and carers of children with social communication needs. This service is referred to as ‘SCAN’ and helps parents and carers to navigate the support options and coordinate services available in Bromley and nationally.

Bromley recognises that not all families will require the same support and services. There is a lot of information, and this is where the SCAN service can help. The SCAN service will inform families of the accessible and supportive universal, targeted, and specialist provision available so that families can feel supported at home, in education, and in their community.

Bromley Children Project's Social Communication Needs - next-steps guide (flipbook) is a guide to the services available to you in Bromley and provides answers to some common questions. It includes up to date information in a simple format that is easy to use.

The SCAN [Social Communication (including Autism) Needs] service is the single point of access to Bromley’s specialist provision for those families for who may require additional intensive support for short periods at various points in their child’s developmental journey.

A SCAN referral form is available to access this support.

More information about social needs can be found at: Social and communication needs including autism – London Borough of Bromley

Key local services who may be able to provide support

Bromley MENCAP – Specialist Autism Family Support Service
Provides short-term intensive support to families with children who have social and communication difficulties and who have more complex needs.

CASPA – Community Autistic Support, Pride and Advocacy
Provides support and aims to offer enriching experiences to autistic or neurodivergent children, young people and their families.

Special Educational Needs and Disability (SEND) Local Offer – London Borough of Bromley
The Bromley SEND Local Offer helps children and young people with special educational needs and/or disabilities and their families to find the information and support they are looking for from across Bromley in one place. These pages are designed to be clear, easy to access and have all the information you need to understand what is available to children and young people (from 0 - 25 years) to help to support their educational, health and social care needs in Bromley. The site also signposts families to other local organisations, initiatives and activities that might be of interest or help.

AutismGuide2023 (bromley.gov.uk)
The Do you know…? guide has been pulled together by parents, carers, and professionals across the local area as part of Bromley’s all-age Autism Partnership (BAAP). It provides information and signposts families, carers, and those with social communication needs (SCN) including Autism to support. The guide is for families with children and teenagers who have social and communication difficulties including autism.

Support from your school or education setting

Your school (including pre-school and college settings) will be able to help you refer your child for an autism assessment where there are social communication needs. They will be required to complete a questionnaire on your child. This will give the assessment team the information they need to make a full and effective assessment of your child.

The school can also provide support for your child to meet their needs. This can vary but can include adaptations to teaching methods such as being clearer with instructions or using visual aids for teaching. Or they can use interventions such as reward systems or links to personal interests. The level of support can be that which is open to all children at school, or it may be more targeted through the Specialist Educational Needs or Disabilities (SEND) approach.

Most children and young people with special educational needs or disabilities (SEND) will have their needs met from within an education setting’s own resources with either universal or targeted support as part of the graduated approach. A small number of pupils will need additional support beyond what the setting would normally be expected to provide, in which case they may be eligible for an EHC plan. An EHC plan is a legal document that describes a pupil's special educational, health and social care needs and the support they need to help them to get the best outcomes when they become adults.

To decide whether an EHC plan is necessary, the pupil will need to undergo an EHC needs assessment. The EHC needs assessment is not normally the first step in the process for helping to meet the needs of the child or young person but should be built on coordinated work that is already happening between families, educational settings and any other health or social care services who are involved.

Not all children and young people with a diagnosis of autism will need an EHCP to have their needs met.

If you are over the age of 14, you can access Bromley Well or Bromley MENCAP for support with:

• Social and leisure activities
• Health matters
• Managing your money
• Housing
• Transition into adulthood
• Managing letters, forms, and applications
• Support with employment
• Life skills training
• Signposting to further services.

The children and young people assessment pathway for autism includes young people up to the age of 18. After their 18^th birthday, a person will be more appropriately assessed in adult services (in most cases, people with a learning disability may be an exception). The adult autism assessment service is provided by Oxleas, more information on their assessment pathway can be accessed here.

If your assessment is not yet completed but you are nearing the age of 18, or you have your 18^th birthday whilst waiting, you will still be seen for your assessment by the Community Paediatric service.

Referrals are accepted for children and young people aged up to 18 years with social communication/interaction difficulties, suspected ASD, or Autism Spectrum Conditions.

These referrals must be accompanied with information about the child’s difficulties in school or pre-school.

To aid the process of identifying and referring children, please refer to: Social Communication Differences Toolkit

Pre school children

For pre school children please complete: Pre Schools SQC Questionnaire

School age children and young people

School age children should be referred by their school using the Referral Form for School Age Children with Social Communication Concerns, enclosing the requested information which includes the Social Communication Questionnaire (SCQ). The Social Communication Differences Toolkit can be used to aid the process of identifying and referring children.  All these documents and more can be accessed on the Bromley Education Matters Autism Padlet.

Where a child is not in school, information should be enclosed from another appropriate professional (for example, a speech and language therapist, educational psychologist, behavioural therapist, early years setting etc.) or someone who has close contact with the child in another role such as a sport coach, a childminder, a tutor or scout leader. They will be able to help highlight the difficulties the child is demonstrating, including their observations of the child. The pre-school questionnaire [insert link here] should be sent with the referral form.

Where a GP is approached for a referral, they should signpost the family to either the school or an appropriate professional who can support them effectively with advice and a referral.

Send referrals and completed questionnaires to: bromh.cccpod7@nhs.net or call 0300 330 5777

The completion of the social communication questionnaire is vital for referral. The assessment process requires this, and timeliness of return will help avoid delays. This is a key responsibility for schools and education settings in Bromley.

Communicate with the family and young person if they are old enough to understand the process. Ensure that the parent/carer/young person understands the following:

- How the process works – i.e. they will receive an appointment from the Community Paediatrics team – this is the first step of many to making a diagnosis

- How to access support while they wait – share leaflet or signpost to the Social Communication Needs Flipbook found on the Bromley Local Offer site bromley.gov.uk/LocalOffer

- That parents/ carers will need to provide information on their child/ young person via their first assessment appointment.

Be mindful of masking in children and young people, especially for girls. Gain an understanding of how this can present and how a child who masks can be supported.

Consider interventions and reasonable adjustments to meet the needs of the child or young person. The Social Communication Differences Toolkit provides more details of how this can be implemented.