Assessing Autism Spectrum Disorders
Initial detection of autistic spectrum disorders (ASD) is a two-step process: developmental surveillance and
screening that begins at infancy with the child’s primary care provider.

Developmental surveillance is the routine monitoring and tracking of specific developmental milestones at well-
child visits. This includes the catering of information through reliable standardized instruments combined with
parent and professional observations and tracking developmental progress, compared with children of similar
age. All professional responsible for the care of the child should perform routine developmental surveillance to
identify children with atypical development.

Evaluation

Major advancements in the sciences of early identification and treatment of ASD have increased public
awareness and focused more attention on this class of neuro-developmental disorders. It has been clearly
demonstrated that ASD are identifiable and relatively stable in very young children. Evaluations, the identification
of risk factors for a disorder using specific tests. Screening the population of children from birth through age 5
for ASD seeks to identify those children most at risk of developing an ASD and/ or developmental delay.

Historically, it has been difficult to reliably detect ASD before the age of 3. In part, this is due to lack of
awareness of health care providers about the presentation of ASD in young children (including their more limited
skill development, particularly in language, cognitive, social behaviors). For example, it would be difficult to
judge developmental deviation in peer relationships in children of 18 months, an age at which these skills would
not be expected to have developed.

Advances have been made in identifying behavior indicators as well as atypical development in children less than
2 years of age who are later diagnosed with ASD. It has been demonstrated that autism can be reliably
diagnosed by an experienced clinician in children between the ages of 24 and 30 months. Since ASD early
intervention services are dependent upon early detection and formal diagnosis, it is imperative that young
children be screened for ASD, identified as being at risk and referred for comprehensive evaluation and
assessment in an efficient and timely manner.

Recently, researchers have begun to focus on the developmental precursors of communication, language and
social development in the first two years of life. Children with disorders on the autistic spectrum consistently
seem to demonstrate deficits in social-cognitive and social-communicative behaviors early in life. These include
failures of joint attention, nonverbal and pre-verbal communication, social reciprocity, affective understanding
and imitation.

Parental reports of behaviors of their young children with autism during the first two years of life. This research
was noteworthy in that it is one of the few to incorporate into its methodology a comparison group of typically
developing children. Parents of children with autism noted several features that were markedly deficient I their
child during the first two years of life. These included: poor eye contact and poor coordination of eye gaze with
vocalization or gesture, no pointing to or showing of objects and an inability to follow another’s focus of
attention through eye gaze or gesture. Children with autism also displayed less pre-verbal babbling and no
reciprocity in vocalizing and imitation. They also attended less to voice and had difficulty understand and using
nonverbal gestures.

The detection of young children with developmental and behavioral problems can be difficult due to the variety
of disorders and their manifestations at different ages. This is particularly apparent in young children with ASD
whose communicative and social difficulties are often poorly understood and are therefore frequently attributed
to normal variations in typical development. Many studies have demonstrated, however, that early detection and
early therapeutic intervention are associated with the beds developmental, behavioral and adaptive outcomes.

Most parents of children with autism expressed concerns regarding their child’s development before 18 months
of age. Until recently, a considerable gap existed between the time parents first reported concerns and
subsequent referral and definitive diagnosis. A lengthy referral and diagnostic process contributes to
considerable parental anxiety, places unneeded stress on parents and families and squanders valuable intervention
time. Research has supported the notion of parental accuracy with regard to developmental concerns with their
child. With the documented efficacy of early intervention in achieving optimal outcomes for young children and
their families, it is imperative that all concerns be taken seriously and addressed appropriately.

Parents’ concerns about their child’s development and behaviors are discussed at every health care provider
contact, including well and ill child visits. Some noteworthy clinical sings, or “red flags,” exist that can help
identify children at risk for developmental delay and/or ASD within a routine office or other health facility visit.
These indicators typically are tracked through routine developmental surveillance procedures, which should
occur at all well-child visits. The most powerful indicators is degree of language development. Any child not
using single words by 16 months of age are some two-word phrases by 2 years of age should be further
evaluated. Children who do not use gesture (i.e., pointing, waving, etc) or who cannot follow nonverbal
communication by 12 months should also be referred. Finally, any loss of skills at any age is a serious red flag
and warrants immediate referral to an appropriate diagnostic team.

Primary care providers are generally the first point of contact for parents with concerns and questions regarding
their child’s development. Parents expect their pediatricians and family physicians to offer guidance regarding
developmental issues; if no help is forthcoming, these parents may turn to other sources. Well-child visits are
the logical time and place for developmental surveillance and screening for specific disorders to occur.

Studies have shown that even when parents bring up developmental concerns, some PCPs respond by waiting
to see if the delays will resolve spontaneously or by discounting parental observations. They may be unaware of
the degree of accuracy often associated with parental concerns regarding their child’s development. While a
small number of children do “catch up” without formal intervention and achieve developmental milestones
somewhat later than same-age peers, this is the exception. A significant number of youngsters require early
intervention either on a transient ongoing basis to function within their family and community environment.
Presently, children are being referred for evaluation regarding suspicion of ASD at earlier ages. Although many
trained professionals are able to make a definitive diagnosis at a young age, the stability of diagnosis within the
spectrum may fluctuate. This is often the case with children who are very young (2 years and under) and for
those at extreme ends of the spectrum. It is not uncommon for a child to meet diagnostic criteria for autistic
disorder at age 2 and then be described at age 3 or 4 as PDD-NOS. Symptoms and behaviors may change
considerably with intervention, particularly as language and social skills progress. Because symptoms change
over time, a young child with an early diagnosis of ASD should be reexamined at least annually to confirm the
diagnosis and plan treatment.

Developmental and behavioral history of the child and current functioning are important in diagnosing ASD.
Developmental information such as developmental milestones, motor skills, eating and sleeping patterns etc. are
critical in the evaluation process.

The following are some specific domains in the diagnostic criteria.

∙        First concerns about the child’s development.

∙        Characteristics of the infant’s temperament.

∙        Social-emotional milestones. This includes engagement in typical baby games (pat-a-cake, peek-a-boo),
eye contact during feeding and games, shared attention, greetings and similar significant events. It is sometimes
helpful to provide a reference point (i.e., first birthday) to aid with recall.

∙        Sensory abnormalities. It is important for the clinician to provide examples to help discriminate atypical
patterns from typical development patterns. For example, arm flapping and jumping are common in many pre-
verbal children. For example, children respond to exciting stimuli such as the currently poplar children’s
characters, Barney and Elmo.

∙        Feeding and sleep problems or patterns.

∙        Fine and gross motor development and milestones.

∙        Atypical interests and activities.

∙        Interest in other children and/or siblings.

∙        Patterns of attachment to care givers.

∙        Ability to use nonverbal communicative means such as gesture and facial expression.

∙        Communication, including both verbal and nonverbal intent.

∙        Preferred activities and play.

∙        Other notable characteristics such as loss of skills or deterioration of behavior.
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