Keeping it NICE: Navigating Neurodivergent Diagnoses (Autism, ADHD, Dyspraxia) in Line with NICE Guidance

Neurodivergence, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and dyspraxia / developmental coordination disorder (DCD), is increasingly talked about in clinical and educational settings and on social media, although these conditions are often misunderstood.

Over the last 5 years, carrying out over a thousand neurodevelopmental assessments, I have been asked about NICE compliance and the assessment tools I might use. These questions act as a welcome mirror to hold up to my practice; they prompt reflection and accountability. We should not do things simply because they are standard practice; our work should be evidence-based, clinically reasoned, and defensible. So here are my mid-week musings. **

For me, the most important thing is an accurate diagnosis; this is essential; we need to understand the why. This opens doors to meaningful support, appropriate accommodations, more self-compassion and understanding. But how should diagnosis be approached, and what role do these tools and NICE (the National Institute for Health and Care Excellence) actually play?

NICE Assessments

NICE provides a range of evidence-based guidance designed to improve care quality and reduce unwarranted variation in practice. Its recommendations are incredibly valuable and highly influential, but they are not legally mandatory.

Some of the limitations surrounding NICE guidelines are that they're typically developed by academic and secondary-care specialists and may not fully reflect frontline realities. Their recommendations are based on the “best available evidence,” which can be limited, slow to update, and drawn from clinical trial populations that do not mirror real-world complexity. NICE is also required to weigh cost-effectiveness alongside clinical benefit, which can lead clinicians to experience guidance as restrictive or resource-driven rather than patient-centred, especially when local services lack the funds or infrastructure needed for their implementation.

While NICE emphasises that its guidance does not replace professional judgement, pressures to follow it rigidly can feel at odds with clinical autonomy. Clinicians should be aware that they remain responsible for exercising professional judgement and tailoring decisions to the individual in front of them, considering a raft of factors and possible different diagnoses. Sir Michael Rawlins, while Chair of NICE, stated:

“There appears to be confusion about the circumstances in which it is obligatory for... [doctors] to follow NICE guidance... the quick answer is ‘never’”

Metcalfe (2020)

A diagnosis can still be clinically valid even if every NICE recommendation is not followed rigidly, provided the assessment is conducted by a suitably trained and competent clinician using recognised diagnostic standards.

You might be familiar with assessment tools such as the MABC-3 (Movement ABC-3), ADOS-2 (Autism Diagnostic Observation Schedule) or the DIVA-5 (Diagnostic Interview for ADHD in adults), but these are not essential for assessment and diagnosis. In practice, many standardised tools may have their own limitations, having often been developed in a male and Western-centric system. This means that people of different genders, cultures and socioeconomic statuses have been historically missed. These tools often rely on an observation or response, but don't account for the 'why'.

I often use a mixture of standardised and non-standardised tools along with semi- structured interveiws and clinical observations. Tools are useful in providing norm-referenced data; they allow clinicians to feel more confident in the decision they have made and produce comparable results that professionals can easily interpret.

Tool use is an option in NICE guidance; this is not mandated:

"As an option, use QbTest to help diagnose ADHD in people aged 6 to 17 years" NICE guideline Reference number: NG87

"A diagnosis of ADHD should not be made solely on the basis of rating scale or observational data. NICE guideline Reference number: NG87

"To organise and structure the process of a more complex assessment, consider using a formal assessment tool, such as the Diagnostic Interview for Social and Communication Disorders (DISCO), the ADOS-G or the ADI-R" NICE guideline Reference number: CG142

It is important to distinguish practice guidance from legal or regulatory requirements. A diagnosis remains clinically credible when it is grounded in recognised diagnostic criteria (ICD-11 and/or DSM-5), informed clinical judgement, developmental history, and appropriate assessment tools.

Assessing and Diagnosing ADHD?

NICE is explicit: ADHD should only be diagnosed by clinicians with specific training and expertise in the condition.

An assessment should incorporate developmental history, input from multiple informants where possible, and a direct clinical evaluation. NICE does not require a full multidisciplinary team for ADHD diagnosis. An appropriately qualified clinician can diagnose independently when practising within their competence. While care pathways may involve teams, the diagnostic authority rests on specialist expertise, not headcount or a specific job title.

Assessing and Diagnosing Autism?

For autism, NICE traditionally recommends a multidisciplinary assessment involving professionals trained in autism evaluation. However, it is important to separate best-practice guidance from legal requirements. NICE outlines the 'gold standard'; it does not legislate process.

A diagnosis remains clinically credible when it is grounded in recognised criteria (ICD-11 and/or DSM-5), informed clinical judgement, developmental history, and appropriate assessment tools. In real-world practice, across both NHS and independent services, experienced solo practitioners do conduct autism assessments that are accepted as valid. The determining factor is not whether multiple professionals were present, but whether the evaluation demonstrates sufficient depth, reasoning, and expertise.

Assessing and Diagnosing Dyspraxia/DCD?

Dyspraxia/DCD differs slightly in that there is no single NICE diagnostic guideline dictating who or how this should be diagnosed. Instead, expectations come from broader neurodevelopmental standards.

To meet all DSM-5/ICD-11 diagnositic criterion, a suitable medical professional, e.g., a paediatrician, neurologist or GP, should rule out other causes of motor difficulty. Many NHS pathways are paediatrician-led, with occupational therapists providing detailed motor assessments, but this reflects service design rather than a regulatory rule.

Once again, the central theme holds: competence and adherence to the diagnostic criteria dictate the role in diagnosis, not a specific job title.

Why Some Clinicians Feel Underprepared or Overwhelmed

Research consistently suggests that clinicians who do not have lived experience or those outside specialist neurodevelopmental services often report limited confidence in identifying or diagnosing these conditions, so it makes sense that it would feel safer to use a set tool than rely on one's own clinical expertise. Stakeholders have commented on the gaps in clinician understanding, while research also notes misconceptions and a lack of understanding regarding Autism, ADHD, Dyspraxia/DCD, and how these conditions are diagnosed.

ADHD: "There is a lack of treatment for adult ADHD “because nobody has been formally trained,” he continued........ A participant in the audience noted that ADHD accounted for zero of the 220 questions on the recent psychiatry boards." Shore et al. (2024)

ADHD: “Some GPs are very reluctant to make a label or a diagnosis because of stigma attached to it […] I’m consciously aware that it’s a diagnosis that’s probably not very nice for people to have” French et al. (2020)

Dyspraxia: "Recent evidence shows a broad-spanning lack of awareness among educators, parents and caregivers, clinicians and healthcare professionals." Meachon and De Roubaix, (2025)

Autism: "A significant minority of respondents (30.8%, n = 53) reported that they received no training on autism during their primary medical or foundation degree or specialist psychiatric training." Crane et al. (2019)

Autism: "A large group of participants (53%) reported very little knowledge and/or autism-specific psychotherapeutic training." Lipinski, S., et al. (2021

This reinforces why NICE repeatedly emphasises specialist training and experience over a specific job title.

Neurodevelopmental diagnosis is a field where depth matters. Diagnosis is not a checklist exercise. It involves higher level clincal reasoning, integrating developmental patterns, trait presentation, co-occurring conditions, and real-world functioning.

In practice, skilled clinicians listen carefully and contextualise behaviour. They integrate interviews, observations, and collateral information and apply standardised criteria while exercising professional judgement. Often this occurs within rich multidisciplinary teams, much like the ones I have been privileged to work in; sometimes through highly trained individual practitioners. Both models can produce sound, legally defensible and robust outcomes when executed well.

Final Thoughts

• NICE is authoritative guidance, not a legal mandate

  
  

• Clinicians must adhere to legal regulations and specific practising body codes, e.g., NMC (Nursing and Midwifery Council) and HCPC (Health and Care Professions Council)

  
  

• Professional judgement remains central; tools do not diagnose, clinicians do.

  
  

• Autism often follows a team model in NICE guidance. ADHD can be diagnosed by a suitably trained clinician without requiring a multidisciplinary team. Dyspraxia is not referenced in NICE guidance.

• Many clinicians report feeling undertrained in neurodevelopmental diagnosis, highlighting the ongoing need for specialist education and supervision.

  
  

• Above all, diagnosis is not about labelling. It is about clarity, access to support, and enabling individuals to understand themselves and feel seen, which makes an accurate diagnosis essential.

Assessments are best when they are kept NICE, in every sense: guided by evidence, grounded in expertise, and person-centred.

Reading:

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). https://doi.org/10.1176/appi.books.9780890425787

2. Crane, L., Davidson, I., Prosser, R., & Pellicano, E. (2019). Understanding psychiatrists’ knowledge, attitudes and experiences in identifying and supporting their patients on the autism spectrum: online survey. BJPsych Open, 5(3), e33. https://doi.org/10.1192/bjo.2019.12

3. French, B., Perez Vallejos, E., Sayal, K., & Daley, D. (2020). Awareness of ADHD in primary care: Stakeholder perspectives. BMC Family Practice, 21(1), Article 45. https://doi.org/10.1186/s12875-020-01112-1

4. LaPoint, S. C., Simmons, G. L., Heinly, J., Delgado, D., Shepherd, W. S., Brookman-Frazee, L., Storch, E. A., & Maddox, B. B. (2024). “Education would be step number one”: Community mental health clinicians’ training and support needs to treat anxiety in autistic youth. Research in Autism Spectrum Disorders, 117, 102450. https://doi.org/10.1016/j.rasd.2024.102450

5. Lipinski, S., et al. (2021). A blind spot in mental healthcare? Psychotherapists lack knowledge and expertise surrounding autism. Frontiers in Psychiatry, 12, Article 9344568. https://pmc.ncbi.nlm.nih.gov/articles/PMC9344568/

6. Maddox, B. B., Crabbe, S., Beidas, R. S., Brookman-Frazee, L., Cannuscio, C. C., Miller, J. S., Nicolaidis, C., & Mandell, D. S. (2019). “I wouldn’t know where to start”: Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults. Autism, 24(4), 919–930. https://doi.org/10.1177/1362361319882227

7. Meachon, E. J., Melching, H., & Alpers, G. W. (2023). The overlooked disorder: (Un)awareness of developmental coordination disorder across clinical professions. Advances in Neurodevelopmental Disorders, 8(2), 253–261. https://doi.org/10.1007/s41252-023-00334-5

8. Meachon, E. J., & De Roubaix, A. (2025). The unseen struggle: Mapping and addressing the awareness gap surrounding developmental coordination disorder. Current Developmental Disorders Reports, 12(1). https://doi.org/10.1007/s40474-025-00333-2

9. Metcalfe, D. (2020, December 31). “Advice, not orders”? The evolving legal status of clinical guidelines. British Orthopaedic Association. https://www.boa.ac.uk/resource/advice-not-orders-the-evolving-legal-status-of-clinical-guidelines.html

10. Miller, P. K. (2025). On the experiences of psychological therapists working with autistic people in primary care mental health services. Autism. https://doi.org/10.1177/13623613251341610

11. Miyasaka, M., Kajimura, S., & Nomura, M. (2018). Biases in understanding attention deficit hyperactivity disorder and autism spectrum disorder in Japan. Frontiers in Psychology, 9, 244. https://doi.org/10.3389/fpsyg.2018.00244

12. National Institute for Health and Care Excellence. (2012, updated 2021). Autism spectrum disorder in adults: Diagnosis and management (CG142). https://www.nice.org.uk

13. National Institute for Health and Care Excellence. (2018). Attention deficit hyperactivity disorder: Quality statement. https://www.nice.org.uk

14. National Institute for Health and Care Excellence. (2018, updated 2025). Attention deficit hyperactivity disorder: Diagnosis and management (NG87). https://www.nice.org.uk/guidance/ng87

15. O’Brien, C. (2025). Psychotherapists’ experiences in working with autistic clients: Training gaps and clinical challenges. https://esource.dbs.ie

16. Ostaszewska, A., Harper, G., Davis, R., & Joseph, H. (2025). Beyond Diagnosis: Setting Research Priorities with the Neurodivergent Community. Neurodiversity, 3. https://doi.org/10.1177/27546330251374236

17. Pham, A.V., Charles, L.C. Racial Disparities in Autism Diagnosis, Assessment, and Intervention among Minoritized Youth: Sociocultural Issues, Factors, and Context. Curr Psychiatry Rep 25, 201–211 (2023). https://doi.org/10.1007/s11920-023-01417-9

18. Shore, C., Norris, S. M. P., Berkower, C., Ontjes, N., & Babik, K. R. (2024). Impact of misdiagnosis, bias, and stigma. In Adult attention-deficit/hyperactivity disorder: Diagnosis, treatment, and implications for drug development. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/sites/books/NBK606330/

19. Stampoltzis, A. (2025). Career counsellors’ attitudes about employment-related support for individuals with ASD. Frontiers in Education.

20. Tafla, T. L., Teixeira, M. C. T. V., Woodcock, K. A., & Sowden-Carvalho, S. (2024). Autism spectrum disorder diagnosis across cultures: Are diagnoses equivalent? Neurodiversity, 2. https://doi.org/10.1177/27546330241226811

21. World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th rev.; ICD-11). https://icd.who.int/

**Disclaimer: the views expressed in this article are based on the author’s personal clinical experience, peer discussion, service user reports, interpretation of current evidence and guidance, including NICE recommendations.

These do not necessarily reflect the authors clincial practice.

This content is intended for general informational purposes only and should not be taken as medical, psychological, or legal advice.

Diagnostic decisions must be made by appropriately trained and competent clinicians, in accordance with recognised diagnostic criteria, professional standards, and local governance and specific employer arrangements.

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