Changes

November 2025 — minor update. Added additional information regarding possible undiagnosed autism in older adults.

Update

Goals

To support primary health care professionals to:

• Maintain an index of suspicion regarding the detection of autism spectrum disorder in adults.
• Ensure appropriate referral to multidisciplinary autism teams for diagnosis and initiation of management, where appropriate.
• Monitor, liaise with and support the person and their families, partners, and/or carers in primary care.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

• People with possible autism who are referred to an autism team for a diagnostic assessment have the diagnostic assessment started within 3 months of their referral.
• People having a diagnostic assessment for autism are also assessed for coexisting physical health conditions and mental health problems.
• Autistic people have a personalised plan that is developed and implemented in a partnership between them and their family and carers (if appropriate) and the autism team.
• Autistic people are offered a named key worker to coordinate the care and support detailed in their personalised plan.
• Autistic people have a documented discussion with a member of the autism team about opportunities to take part in age-appropriate psychosocial interventions to help address the core features of autism.
• Autistic people are not prescribed medication to address the core features of autism.
• Autistic people who develop behaviour that challenges are assessed for possible triggers, including physical health conditions, mental health problems and environmental factors.
• Autistic people and behaviour that challenges are not offered antipsychotic medication for the behaviour unless it is being considered because psychosocial or other interventions are insufficient or cannot be delivered because of the severity of the behaviour.

[NICE, 2014]

What is it?

• Autism spectrum disorder (ASD) is a lifelong neurodevelopmental condition characterized by persistent difficulties in social interaction and communication, and stereotypic (rigid and repetitive) behaviours, resistance to change or restricted interests [SIGN, 2016; Huang, 2020; NICE, 2021; NCCMH, 2023]. Difficulty with cognitive and behavioural flexibility and emotional regulation difficulties may also be presenting features [Hirota, 2023].
  
  • Difficulties in social interaction and communication [NCCMH, 2023]:
    • Atypical eye contact (staring at people for too long or not maintaining eye contact).
    • Intrusion into others’ personal space (standing too close to someone else, talking too loudly, or touching people inappropriately) or becoming obsessed with a person to an intrusive extent.
    • Reduced interest in socialising.
    • Social anxiety.
    • Loneliness (and risk of depression).
    • Social naïveté and vulnerability to exploitation.
    • Bluntness or lack of diplomacy; unable to tell white lies; reduced empathy.
    • Lack of social awareness.  
    • Difficulties in the following areas: understanding others’ behaviour, motives, and intentions; reading other people’s facial expressions or vocal intonation; taking turns in conversation or tendency towards monologue; making small talk or maintaining a conversation; reading between the lines or picking up hints; seeing things from another person’s perspective; resolving conflict; anticipating what might offend others; keeping track of what the listener or reader needs to know; making or keeping friends; understanding other people’s expectations; conforming; judging what might be relevant or irrelevant to others; coping with or interacting in social groups; and coping with ambiguity in language.
  • Stereotypic (rigid and repetitive) behaviours, resistance to change, or restricted interests may include:
    • Avoiding crowded places.
    • Difficulties multi-tasking; doing one thing at a time.
    • Narrow, deep interests rather than broad superficial interests.
    • Preference for repetition and routine; need for sameness (eating the same foods, wearing the same clothes, taking the same routes, going to the same places) and avoidance of novelty
    • Anxiety in the face of change.
    • Preference for predictability and predictable events (watching washing machines spinning or trains going down tracks).
    • Being extremely passive if an activity of interest is not available or initiated by someone else.
    • Need for clarity and expressing a pedantic request for precision and avoiding ambiguity.
    • Attention to small details.
    • Development of ‘fixated interests’.
• ASD is strongly associated with a number of coexisting conditions that may significantly impact on the wellbeing of the person and their families, partners, and/or carer.
  • At least one associated mental health disorder occurs in approximately 70% of people with ASD [NICE, 2017]. These include [Howes, 2018; Hollocks, 2019; Huang, 2020; BMJ Best Practice, 2023; Hirota, 2023; NCCMH, 2023]:
    • Anxiety and depression.
    • Learning (intellectual) disability. 
    • Obsessive-compulsive disorder (OCD).
    • Attention deficit hyperactivity disorder (ADHD).
    • Tourette’s syndrome/tic disorder.
    • Dysexecutive syndrome.
    • Developmental coordination disorder.
    • Catatonia.
    • Eating disorders.
    • Gender identity disorder.
    • Personality disorder.
    • Psychosis.
    • Sleeping difficulties.
  • Other coexisting conditions associated with ASD include:
    • Sensory problems — occur in about 90% of adults with ASD without a learning disability [NCCMH, 2023].
    • Gastrointestinal problems — occur in almost 50% of adults with ASD and a learning disability [NCCMH, 2023]. These include inflammatory bowel disease, coeliac disease, chronic diarrhoea, and constipation [Buckley, 2017; Kim, 2022].
    • Epilepsy — there is an increased incidence of epilepsy (20–30%) in people with ASD [Buckley, 2017; BMJ Best Practice, 2023; Hirota, 2023].
• The autism spectrum is very wide, ranging from people with limited self-help, independence, academic, or verbal skills through to those who are fully independent but have significant social difficulties [BMJ Best Practice, 2023; NCCMH, 2023].
  • The features of ASD may range from mild to severe, and the presentation varies greatly in different people [NICE, 2021; NCCMH, 2023].
  • The severity and impact of ASD differs at different stages of life, in response to interventions, and with the presence of coexisting conditions [NICE, 2021; NCCMH, 2023].
• Historically, several clinical diagnoses have been used to describe a group of related conditions characterized by the delayed development of social interaction and communication skills (previously termed pervasive developmental disorders). These include:
  • Autism, autistic disorder, classic autism, or Kanner syndrome.
  • Asperger syndrome — People with Asperger syndrome are of average or above average intelligence and do not have the learning disabilities that many autistic people have (although they may have specific learning difficulties). They usually have fewer problems with speech but may still have difficulties with understanding and processing language [NAS, 2023; NCCMH, 2023].
  • Atypical autism or pervasive developmental disorder not otherwise specified (PDD-NOS) — These diagnoses have not been officially recognised since the fifth edition update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and the eleventh edition update of the International Classification of Diseases (ICD-11) [NAS, 2023].
• The recommended standard is to use the term 'ASD' to aid with the recognition that these conditions represent a single continuous clinical entity which varies in severity. People with a historical diagnosis of autistic disorder, Asperger's syndrome, or PDD-NOS should have their diagnosis updated to ASD [Hirota, 2023]. However, it is recognized that some people may prefer to retain and use their original diagnostic term [BMJ Best Practice, 2023].

What are the causes and risk factors?

• The precise cause of autistic spectrum disorder (ASD) is unknown. However, genetic factors, including genetic and chromosomal disorders, play a substantial role in the aetiology (estimates of heritability are between 40–90%) [Howes, 2018; Genovese, 2020; NCCMH, 2023]. A number of different environmental factors are also thought to play a role in development.
• Factors associated with an increased prevalence of ASD include:
  • Male sex — the proportion of males to females diagnosed with ASD varies across studies but always shows a greater proportion of males to females, mostly ranging from 3:1 to 5:1 [NCCWCH, 2022; BMJ Best Practice, 2023; NCCMH, 2023].
  • Family history of ASD — siblings of people with ASD have a 50 times greater risk of ASD, with a recurrence rate of 5–10% [Park, 2016; BMJ Best Practice, 2023]. The concordance rate reaches up to 82–92% in monozygotic twins compared with 1–10% in dizygotic twins [Park, 2016].
  • Genetic disorders, such as Fragile X, Angelman syndrome, tuberous sclerosis and Rett syndrome [Genovese, 2020].
  • Chromosomal disorders, such as Down's syndrome and Turner syndrome [Genovese, 2020].
  • Environmental factors, including prenatal, perinatal, and neonatal factors, such as [NICE, 2017; Howes, 2018; BMJ Best Practice, 2023; Hirota, 2023]:
    • Advanced parental age. 
    • Maternal use of sodium valproate during pregnancy.
    • Maternal vitamin D deficiency.
    • Maternal obesity.
    • Maternal preeclampsia.
    • Parental schizophrenia-like psychosis or affective disorder.
    • Maternal pre/postnatal infections (TORCH).
    • Prematurity (particularly gestational age less than 35 weeks).
    • Very low birth weight (less than 1500 g).
    • Perinatal hypoxia. 
    • Neonatal or epileptic encephalopathy.
    • Birth defects associated with central nervous system malformation and/or dysfunction, including cerebral palsy.
  • Neurodevelopmental conditions, such as [NICE, 2017; Howes, 2018; BMJ Best Practice, 2023]:
    • Learning (intellectual) disability. 
    • Attention deficit hyperactivity disorder.
    • Muscular dystrophy.
    • Neurofibromatosis.
    • Tuberous sclerosis.
• It is important to note that:
  • ASD is not caused by emotional deprivation or the way a person has been brought up [NCCMH, 2023].
  • There is no link between ASD and mumps, measles, and rubella (MMR) vaccine, based on all published research [NCCMH, 2023].

How common is it?

• Autism spectrum disorder (ASD) is one of the most common childhood-onset neurodevelopmental disorders. In the UK, the estimated prevalence in adults is about 1.1%, with relative consistency across studies [Huang, 2020; NCCWCH, 2022; BMJ Best Practice, 2023; NCCMH, 2023].
  • Comparing this estimated prevalence of ASD in adults with that of children (1-2%) suggests that ASD is underdiagnosed among adults [Huang, 2020].
  • One population-based cohort study sampled 10% of all GP records in England and found that adults aged 20–49 years and those over the age of 50 were less likely to have been diagnosed compared to people under 20 years of age. The authors projections suggest that up to 489,900 people aged 20–49 years, and that up to 591,600 people over the age of 50 may have undiagnosed autism. These projections suggest that the total autistic population in England could be over 1.2 million; nearly twice the widely-cited figure of 700,000 given for the entirety of the UK [O'Nions, 2023].
• The proportion of males to females diagnosed with ASD varies across studies but always shows a greater proportion of males to females, mostly ranging from 3:1 to 5:1 [NCCWCH, 2022; BMJ Best Practice, 2023; NCCMH, 2023].
  • ​​​​​This gender split is largely thought to be as a result of females being better at camouflaging their difficulties and ‘fitting in’ with society’s expectations [Buckley, 2017; McQuaid, 2022]. It is also thought that ASD traits in girls are under-reported and hence under-diagnosed [SIGN, 2016].
  • Camouflaging techniques, which may increase the possibility of underdiagnosis, may also be more common among those who are gender diverse or diagnosed with ASD in adulthood [McQuaid, 2022].
• Studies of autism in adults have shown that up to 80% of people have experienced a difficulty in obtaining a diagnosis, and many adults will not have received a formal diagnosis [NCCMH, 2023].

What are the complications?

• Complications of autism spectrum disorder (ASD) in adulthood include [Howlin, 2021; NCCMH, 2023; BMJ Best Practice, 2023]:
  • Failed relationships, including marriage(s).
  • Unemployment — approximately 30% of adults with ASD in the UK are in full or part-time paid employment, compared with 80% of non-disabled people.
  • Problems at work.
  • Inability to live independently (only a minority of affected people with lower levels of impairment manage to work and live independently).
  • Poor general health (because people with ASD often do not seek help for medical problems).
  • An increased vulnerability to mental health problems, such as anxiety and depression.
  • Social isolation.
  • Reduced quality of life [Ayres, 2018].
  • Premature mortality — the average age of death for people with ASD and no intellectual disability is 16 years younger than the rest of the population, and 30 years younger for those with ASD and an intellectual disability. The reasons for this disparity are multifactorial, but problems appropriately accessing healthcare and diagnostic overshadowing have been implicated [Hirvikoski, 2016; Buckley, 2017].
• The management and support of people with ASD and their families, partners, and/or carers incur substantial costs to the health and social care services and the wider public sector [NCCMH, 2023].
  • ASD costs the country an estimated £32 billion per year, making it the single most expensive health condition, exceeding cancer, heart disease, and stroke [Buckley, 2017].
  • The total cost, including accommodation, support, loss of earnings, and health care, for a person with ASD over their life span has been estimated to range between £1.5 million to £0.92 million for a person with or without intellectual disability, respectively [Howes, 2018].
• Autistic women may be more likely to experience poorer social and employment outcomes, increased mood and anxiety-related problems, and lower overall quality of life [Howlin, 2021]. This sex-based bias in the diagnosis of autism results in females who are more severely affected experiencing poorer outcomes. 

What is the prognosis?

• Autism spectrum disorder (ASD) is a lifelong disorder [NICE, 2021; NCCMH, 2023]. It varies greatly in terms of the level of impairment, which influences the prognosis.
  • The presence or absence of associated learning (intellectual) disability, language impairment, and additional mental health problems are the most important prognostic factors [Howlin, 2021]. Unaffected language development and the absence of an associated intellectual disability are associated with a more favourable prognosis [APA, 2022].
  • A minority of affected people with lower-level impairment live and work independently in adulthood [APA, 2022; Hirota, 2023]. It has been estimated that 15% of adults with ASD live independent lives, whereas 15% to 20% live alone with community support [BMJ Best Practice, 2023].
  • Premature mortality rates are approximately twice as high among those with ASD compared with the general population, with mortality risk increased by coexisting neurological disorders or psychiatric illness. The risk of death by suicide among people with ASD, after accounting for sex and age,has been estimated to be approximately 4 times higher than the background population [Hirota, 2023].
  • Although outcomes are highly variable, autistic people may experience improvements as they transition into adulthood, with reductions in symptom severity, less severe impairment from ritualistic behaviours or sensory sensitivities, and improvements in social, communication, adaptive functioning and independence skills [Howlin, 2021].
• The prognosis of ASD can be improved by early diagnosis and assessment. 
  • However, due to a wide variation in rates of identification and referral for diagnostic assessment, waiting times for diagnosis, models of multi-professional working, assessment criteria, and diagnostic practice for adults with features of ASD, many adults with suspected ASD have difficulties accessing a diagnostic assessment and subsequent access to appropriate services [NICE, 2021].
• It is important to recognise that there may be individual differences in what constitutes a good social outcome or quality of life for people autistic people.
  • The criteria that define these outcomes should not be benchmarked against the general population (such as having a high level of social engagement, being at work, or living independently).
  • It has been suggested that outcome assessments should be based on measures of within-individual growth over time and progress on a wide range of variables and domains identified as meaningful by those living on the autism spectrum [Howlin, 2021].

When should I suspect possible autism spectrum disorder in an adult?

• The identification, assessment, and diagnosis of autism spectrum disorder (ASD) in adults is challenging because ASD can coexist with a number of mental health disorders, such as depression. In addition, the differential diagnosis can present difficulties.
• Consider assessment for possible ASD when a person has:
  • One or more of the following:
    • Persistent difficulties in social interaction.
    • Persistent difficulties in social communication.
    • Stereotypic (rigid and repetitive) behaviours, resistance to change, or restricted interests.
  • And one or more of the following:
    • Problems in obtaining or sustaining employment or education.
    • Difficulties in initiating or sustaining social relationships.
    • Previous or current contact with mental health or learning disability services.
    • A history of a neurodevelopmental condition (including learning disabilities and attention deficit hyperactivity disorder) or mental disorder.

What else might it be?

• Conditions that may present with similar features to autism spectrum disorder (ASD) in adults include:
  • Neurodevelopmental disorders, including:
    • Learning (intellectual) disability or global developmental delay — the delay is likely to be across all areas of development with imitation present, and social intent and interest consistent with their developmental age.
    • Stereotypic movement disorder — stereotypic movements are among the diagnostic characteristics of ASD. The diagnosis of stereotypic movement disorder is not made if the behaviour is better explained by ASD unless the behaviour causes injuries, in which case both diagnoses may be appropriate.
  • Mental health and behavioural disorders, including:
    • Attention deficit hyperactivity disorder — a behavioural syndrome characterized by hyperactivity, impulsivity, and inattention. See the CKS topic on Attention deficit hyperactivity disorder for more information.
    • Mood disorder — usually episodic events with a history of 'normal' social behaviour when not depressed or severely anxious.
    • Anxiety disorder — anxiety can be associated with repetitive behaviour but is not typically stereotyped. The person will also have an interest in, and care about, the opinions of others. See the CKS topic on Generalized anxiety disorder for more information.
    • Obsessive-compulsive disorder — characterized by recurrent obsessional thoughts or compulsive acts or, commonly, both, which may cause significant functional impairment and/or distress. See the CKS topic on Obsessive-compulsive disorder for more information.
    • Personality disorder — characterized by difficulty with forming social relationships and empathy deficits, but not involving the narrow interests or resistance to change that are typical for people with ASD.
    • Schizophrenia — hallucinations and/or delusions are defining features of the condition. See the CKS topic on Psychosis and schizophrenia for more information.
    • Social (pragmatic) communication disorder — characterized by impairment in social communication and social interactions. There are no restricted and repetitive behaviour or interests.
  • Other conditions, such as:
    • Communication difficulties (for example, speech and language problems and selective mutism).

Scenario: Managing suspected autism

From age 18 years onwards.

Scenario: Managing confirmed autism

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of autism in adults. 

Search dates

May 2019 - May 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 7th May 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S3    S1 OR S2 
S2    AB ( autism or autistic or asperger* ) OR TI ( autism or autistic or asperger* ) 
S1    (MH "Autism Spectrum Disorder+") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.