In person versus remote assessments and therapy

Monday, 9 June 2025

When I started in the world of neurodiversity and adult assessments for autism and ADHD, over 13 years ago, I don’t think that anyone was engaged in assessing online, and the thought was quite alien to most.  Little did I know at the time how prolific and common online working was to become…

My old boss and good friend, Kobus van Rensburg, Consultant Clinical Psychologist and current President of the UK Adult ADHD Network (UKAAN) was one of the first in the country to promote using Skype as a tool for contacting clients, mainly for follow-up and general sessions.  I recall the local BBC media came to the service and took photos of us using this.  It was a revolutionary idea at the time, and one that we never would have believed could work and be a practical portal to see clients, let alone conduct diagnostic assessments through.

One of the major online companies for autism assessment apparently started in 2013, so not long after I first started.  This has since grown, and when the pandemic hit, and I was then working in the specialist adult ND NHS team and had been there for eight years at the time.

The impact of the Covid Pandemic

I recall waiting for the news to hit as we had been pre-warned a lockdown was imminent, but had no idea how we would manage this.  Then on the Monday, 19 March 2020, I was informed first thing that I had to contact all of my clients and tell them not to come into St Mary’s Hospital, Kettering, but that I would call them for their initial screening assessment.

It took a while to settle into using remote systems.  Some NHS trusts, like the British Government started using Zoom, but I worked for Northamptonshire Healthcare NHS Foundation Trust (NHFT), and our IT department said this was not secure, so we were not allowed.  At the time I believe Microsoft Teams was new and not being used much, even though it was officially announced in November 2016 and generally available three years before the pandemic struck.  NHFT then started using this later in the year, as well as using WhatsApp through work mobiles.

Initially as a diagnostician, my view was that you could not do a quality assessment remotely, and you would have to see someone in person.  But we soldiered on, and started screening, and assessing for both ADHD and autism in this new format, and it seemed to work okay.

I have to say, in a lot of cases a good quality assessment was possible, though increasingly I personally felt that with autism this was less the case, and with clients who had limited hyperactivity ADHD features, there was less to observe, and assessing through a screen was not as good in these cases.

As time has moved on, I have increasingly been of the opinion, that autism does not work as well in a remote context, and I also prefer to see all of my clients at least once, face-to-face, in person, in clinic.  Sometimes a mix of online and in person actually adds value, as some autistic clients behave quite differently in the room compared to over a screen.

Some of the benefits of in-person assessment:

1. Richer observational data:

Clinicians can more easily observe body language, motor skills, eye contact, and social behaviour more directly and naturally.

2. Standardised testing conditions:

Tools like the ADOS-2 (Autism Diagnostic Observation Schedule) are validated only for in-person use, making the results likely to be more reliable.

3. Immediate clinical support:

If the assessment causes distress, clinicians can offer support on the spot.  I have had incidences where the client becomes emotionally affected, and may discreetly start to cry, which is not as immediately evident on the screen.

4. More accurate diagnosis in more complex cases:

Subtle signs of autism or inattention symptoms can be easier to detect in person, especially in clients with co-occurring conditions (e.g., when assessing for ADHD and autism also appears relevant, and mental health factors including anxiety)

Some of the potential drawbacks:

1. Accessibility issues:

Travel, cost, location, and scheduling can be barriers – especially for those living in rural settings or where they do not have local services.  Also, for those with mobility or mental health restrictions.  I assessed a man last year who had not left the house since 2020, so could not come into clinic.

2. Sensory / environmental overload:

Sometimes unfamiliar clinical settings can feel distressing or overwhelming for autistic individuals, which could potentially affect their behaviour during the assessment.  They may feel more comfortable in their own chosen environmental space.

3. Potential for longer waiting times:

In some cases, in-person assessment slots can be overbooked, or scheduling and mutual availability between the client and clinician can lead to longer delays in assessment and a potential diagnosis.

Online ADHD and autism assessments (Telehealth)

Some possible benefits:

 

1. Improved accessibility:

Clients in more remote areas of the country are able to access services without needing to travel.  This also covers people with physical disabilities and access issues as a result.

2. Familiar home environment:

When clients are able to remain at home, this can reduce anxiety and allow individuals to be more comfortable and potentially behave more naturally and at ease.

3. Potential quicker access:

Remote video calls can at times have shorter waiting lists.

4. Convenience for appointment times:

With no need to travel, this can reduce time taken off work, and at times employers may allow the client to have time during their working day for appointments.

Some of the potential drawbacks:

 

1. Limits to the scope of observations:

Clinicians are often not able to observe much of the client, so with ADHD assessments this limits how much restlessness is evident, and with autism, non-verbal behaviours can be harder to pick up on.  It is also more difficult to notice subtle emotional changes in facial expressions, so not only are these harder to read, but also it can be more difficult to tell if the client is becoming upset until this is more pronounced.

2. Technology barriers:

Internet quality,  camera quality and angle, client’s unfamiliarity with video platforms and applications, sound issues.  All these can impact on the quality of the assessment.

3. Not all tools are validated for remote use:

Some observation-based assessments such as the ADOS-2 are not validated and lose clinical relevance and efficacy when conducted online.

4. More difficult to manage and respond to behaviours:

If a client or someone joining them for the assessment becomes distressed or uncooperative, it is harder for clinicians to respond, de-escalate or redirect through a remote platform.

As you can see, it’s a mixed landscape, and there are potential costs and benefits to each.  When working in the NHS, and in liaising with numerous colleagues, I do favour in-person assessment and work with clients.  I’m not averse to remote work, but for those who also feel this is the best way of working, then Clear Sky Therapies Ltd may be a better option.