Autism can be difficult to detect in very young children, although there is clear evidence that early detection and subsequent early intervention leads to a substantially better prognosis. This includes improved language and cognitive skills, social relationships and better adaptive functioning. There can also be less maladaptive behaviours, and an increased chance of successful inclusion in mainstream educational programmes.
Clearly, knowing when to refer a child for an evaluation is crucial. Due to modern recording technology there is more information available now than ever before, where retrospective videotapes of children diagnosed with autism are carefully examined and commonalities amongst these children aggregated (see Yirmaya & Charman, 2010 for a review). Diagnostic assessment for autism has become much more accurate in recent years, with children being reliably diagnosed from age 2 years old (Robins, 2008).
Recent retrospective data shows that parents of children with autism first reported concerns about their child’s social and communication skills within the child’s first year (Bolton, Golding, Emond & Steer, 2012) and the average age of diagnosis for classic autism is 4 years (Gray , Tonge & Brereton, 2006; CDC, 2014). To facilitate earlier diagnosis one of the most important things a GP can do is to learn the early signs of autism. The following “red flags” are reliable indicators that a full evaluation for the possibility of autism is warranted (Filipek et al, 1999; Yirmaya & Charman, 2010). For visual depictions of the early signs of autism and more information to facilitate early recognition: www.autismspeaks.org and www.firstsigns.org
RED FLAGS FOR AUTISM
- no babbling by 12 months
- no gesturing (pointing, waving, showing, reaching, etc) by 12 months
- no single words by 16 months
- no two-word spontaneous (not echolalic) phrases by 24 months
- any loss of any language or social skills at any age
Other important signs to look out for include:
- Diminished eye contact
- Diminished social engagement
- Limited interest in social games and turn taking exchanges
- Preference for being alone
- Visual attention more frequently to objects than people
- Limited range of facial expression
- Less sharing of affect (smiling and looking at others)
- Unusual hand and finger mannerisms
- Walking on tiptoes
- Difficulty adapting to new situations and coping with changes in routine
- Not orientating to name being called
- Not imitating facial expression or gesture
- Lack of seeking and enjoying cuddles
- Less likely to look at a parent to seek reassurance and approval
- Prone to intense distress
- Sensory over responsivity such as being afraid of every day sounds
- Unusual mannerisms to express emotions
- Extremes of temperament
Common medical reasons a child who may have autism may be brought to a GP include: problems with hearing, vision, sleep and/or feeding , macrocephaly , and ear infections.
There is not yet a screening tool deemed to be precise enough for blanket use in primary care settings. However the tool that comes closest to this is the Modified Checklist for Autism in Toddlers Revised (MCHAT- R; Robins, Fein, Barton & Green, 2001; Robins, Fein & Barton, 2009). The MCHAT-R is a 23 item yes/no parent report screener for autism in 16-30 month olds. Screening positive is defined as failing any three items, or any two of six critical items (2, 7, 9, 13, 14,15). The MCHAT-R is available as a free download at: www.m-chat.org.
If a positive screen results, it is highly recommended that referral is made to a developmental paediatrician who specialises in autism to further explore the unusual characteristics that could indicate a diagnosis of autism. A multidisciplinary team approach to diagnostic assessment is required. It is critical that the family is supported to discover an early intervention pathway that suits their family and means, should a diagnosis of autism be made. Psychologists specialising in autism are well placed to provide ongoing support and advice to the families, including case management to assist in devising an early intervention plan (see www.mindsandhearts.net).
Your State or Territory Autism Association
Bolton, P.F., Golding, J., Emond, A. & Steer, C.D. (2012). Autism spectrum disorder and autistic traits in the Avon Longitudinal Study of Parents and Children: precursors and early signs. Journal of the American Academy of Child and Adolescent Psychiatry, 51(3), 249-260.
Gray, K., Tonge, B., & Brereton, A. (2006). Screening for autism in infants, children and adolescents. International Review of Research in Mental Retardation, 32, 197-227.
Filipek, P.A. et al. (1999). The Screening and Diagnosis of Autistic Spectrum Disorders. Journal of Autism and Developmental Disorders, 29(6), 439-483.
Robins, D, Fein, D, Barton, M. & Green, J.(2001). The Modified Checklist for Autism in Toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31, 131-144.
Robins, D. (2008). Screening for autism spectrum disorders in primary care settings. Autism, 12 (5), 537-556.
Robins, D, Fein, D & Barton, M. (2009). Modified Checklist for Autism in Toddlers, Revised with Follow-Up. www.M-CHAT.org
Yirmiya, N & Charman, T. (2010). The prodrome of autism: early behavioural and biological signs, regression, peri- and post-natal development and genetics. J Child Psychol. Psychiat., 51(4), 432-458.
Author: Dr Michelle Garnett, MPsych(Clin), PhD (Psych), MCCP. Clinic Director and Clinical Psychologist, Minds and Hearts: A Clinic for Autism Spectrum Conditions, www.mindsandhearts.net