Supporting Neurodevelopmental Assessment Pathways – The Purple House Clinic Glasgow and NHS Ayrshire & Arran
The Purple House Clinic Glasgow (PHC Glasgow) has an exciting collaborative partnership underway with NHS Ayrshire and Arran. Being aware of the Clinic’s reputation in the local area for delivering high quality neurodevelopmental assessments (NDAs), the NHS Trust approached the Clinical Director, Dr Michelle Muniz (pictured above, left), to discuss commissioning the service.
This comes at a time when there is a drive, at a National level to reduce waiting times. Across Scotland, like much of the UK, there are currently significant waiting lists for neurodevelopmental assessments, many exacerbated by the pandemic. In 2021, there were 10,000 NDAs on the waiting list, according to results of a series of Freedom of Information requests1.
In 2021, The Scottish Government published its new guidance regarding appointment timelines. Children and young people must be seen within four weeks of an identification of need2.
The specifications follow the “Getting it right for every child” (GIRFEC) government framework, which aims to ensure that children and young people receive appropriate support at the earliest opportunity. Scottish NHS Trusts have received funding packages to build professional capacity, and part of that is to reduce the waiting times for neurodevelopmental services by collaborating with external providers.
A Positive Partnership
The contract between PHC Glasgow and NHS Ayrshire and Arran is estimated to span up to eleven months, and the hope for the clinic is that the working relationship may last beyond the term of this contract. The Purple House Clinic Glasgow was already establishing a large neurodevelopmental service prior to this collaboration, and with its proven track record of comprehensive and respected assessments, its reputation was already strong.
The Purple House Clinic team receive NHS commissioned referrals via two pathways: the Child and Adolescent Mental Health Service (CAMHS), and the Community Paediatric Psychology Service, based at Rainbow House, Ayrshire Central Hospital.
Neurodevelopmental assessments include Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD) and Learning Disabilities (LD). Alongside the neurodevelopmental assessments, more specialised neuropsychological assessments focus on known or suspected neurological insults or injuries like acquired brain injuries, led by Purple House Educational Neuropsychologist, Sabella Mansur-Usher.
NHS Ayrshire and Arran complete the initial assessment and all relevant background information is passed onto the clinical team at Purple House Glasgow. Clients are then contacted within two weeks for an appointment, and an appointment is offered within eight weeks, though often sooner.
The clinical team includes three Clinical Psychologists, one Educational Psychologist, a Specialist Nurse and two Speech and Language Therapists. The benefit of having a multi-disciplinary team are two-fold:
- The most appropriate lead clinician for each assessment can be identified based on skill set (e.g. a speech and language therapist for a client where there are particular language concerns; or a clinical psychologist for young people where there may be additional concerns regarding mental health and/or attachment); and at the same time there is a diversity of skill set introduced with the second clinician involved in the assessment process.
- The team has a rigorous consultation process in order to review the evidence gathered in respect to the diagnostic criteria – clinician consensus being a vital part of this process.
The assessment processes are comprehensive and in line with best practice guidelines, such as including cognitive assessments to rule out alternative diagnoses (differential diagnoses). If there is sufficient evidence for a diagnosis, thorough reports outline further support recommendations.
Dr Michelle Muniz has described working with the NHS as “warm and responsive” and the customer satisfaction scores have been exceptionally high. Dr Muniz explains that, “this is a collaboration that the service values greatly and it is a pleasure to work with the families form Ayrshire and Arran.”
Gender – Specialist Insight
According to the National Autistic Society, autism rates across the UK are 1-2% and 5% for ADHD, with the current estimated ratio of 3:1 for male to female autism3.
Historically, girls have been under-reported in autistic statistics. One possibility for this could be explained by how the overt characteristics of autism have traditionally been viewed. For example, the much critiqued (and now modified) ‘extreme male brain’ theory defines autism in terms of the ‘hardwired’ systemizing ‘male’ brain4. Simon Baron-Cohen’s Cohen’s theory postulates that there is a division between the ‘empathizing’ female brain and the ‘systemizing’ male brain. Cohen theorised that autistic children, “fail to become social, instead remaining on the periphery of any social group and becoming absorbed in repetitive interests and activities, such as collecting unusual objects or facts” 5.
By understanding autism in this particular way, it’s not difficult to see how girls might have been underrepresented in autism statistics. Indeed, others suggest that there is a ‘female autism phenotype’ (FAP), which argues that autistic girls have characteristics that don’t fit the traditional autistic profile (they give eye contact, they have empathy and they don’t collect things). Moreover, it is increasingly recognised that girls in particular often use ‘masking’ or ‘camouflaging’ behaviour in social situations – by observing firstly how others play and interact, then, “once they have a script, they may be brave and launch themselves into social play in the hope they will be accepted and liked.” (Dr Tony Attwood, 2022)6.
With this in mind, careful, sensitive observation and diligence is needed to investigate female or indeed, male ‘masking’ coping strategies. For example, frequent ‘meltdowns’ at home following a school day could be due to an undiagnosed cognitive difficulty, perhaps where the pressure of ‘masking’ all day is released on arriving home (the ‘shaken bottle effect’). It may otherwise indicate mental health conditions such as anxiety or a combination of psychological difficulties – however, the value of being able to identify masking behaviours cannot be overstated in terms of autism diagnosis.
As such, the historical inherent male bias of autistic screening is now routinely challenged by many, including Purple House Clinicians.
The impact of thorough and successful neurodevelopmental assessments can be revolutionary for children and young people. Many can feel like ‘failures’, who don’t fit into school or friendship groups and a diagnosis can, once processed, allow some enlightenment in this area. An ASD diagnosis takes time to become integrated into a sense of self-identity but with the right support, children and young people can flourish.
For example, schools can offer soft start and ends to the school day with meet ‘n’ greets, breakfast clubs and reflective sessions. The concept of ‘social batteries’ is also a useful analogy to consider, i.e. the amount of energy required by an individual to cope with different social situations. For example, one young person might be drained just by getting ready or travelling to a social event, whereas another might be able to manage thirty minutes at an event. The lower the battery, the greater the risk of feeling overwhelmed.
The Purple House Glasgow team has thoroughly enjoyed working with NHS Ayrshire and Arran, and are hoping to continue their unique working collaboration going forwards.
With their highly-skilled multi-disciplinary team of clinical experts, they are working swiftly, with intuitive, yet meticulous attention to masking and underlying cognitive difficulties, in order to give a holistic evaluation of a child or young person’s neurodevelopmental profile.
PHC Glasgow is currently the only private Scottish provider working with the NHS, helping not only to reduce the waiting list for neurodevelopmental assessments, but contributing positively to the lives of many children and young people across Ayrshire and Arran.
To learn more about The Purple House Clinic, Glasgow, please click here:
2 National Neurodevelopmental specifications: principles and standards of care for children and young people, September 2021: https://www.gov.scot/publications/national-neurodevelopmental-specification-children-young-people-principles-standards-care/
4 Professor Simon-Baron Cohen, 1999.