by Jeremiah Dickerson, MD
Autism and related disorders (autism spectrum disorders [ASDs]) are characterized by a constellation of impairments in the domains of communication skills and reciprocal social interactions that are accompanied by the presence of repetitive and inflexible behaviors. Children who exhibit these impairments and behavioral changes also may demonstrate challenges in a variety of other developmentally-informed areas of functioning. Literature has revealed that by twelve to eighteen months of age, children later diagnosed with ASDs may also exhibit impairments or delays in visual, motor, play, social-communication, language, and cognitive domains. In addition, abnormalities related to sleep, eating, attention, toileting, sensory tolerance, and affect regulation may be observed.
Given the complexity and extensive heterogeniety of ASD-related symptomology and the fact that ASDs are among the most common form of severe developmental disability, it is becoming increasingly important for clinicians to utilize certain tools to help screen and identify children and adolescents who are exhibiting concerning ‘red flag’ signs that may indicate an underlying ASD. Early recognition allows for the implementation of effective interventions which in-turn hopefully are associated with improved outcomes (for both the child and the family).
Most clinicians are well-versed in several of the ASD screening instruments developed for children less than three years-old, including the M-CHAT (Modified Checklist for Autism in Toddlers). This tool, along with other developmental screeners such as the Ages and Stages Questionnaire, the Child Developmental Inventory, and the Parents’ Evaluations of Developmental Status are commonly used devises used in primary care.
Some general questions that we ask parents about their child (regardless of age) that help to explore possible ASD-related behaviors include:
- How does (or did) you child respond to their name being called?
- Does (or did) your child make appropriate eye contact? Does (or did) he/she look in the same direction as an adult would look?
- Does (or did) your child imitate you doing certain activities?
- Does (or did) your child point to show interest in something?
- Does (or did) your child play in a pretend way (i.e. pretend to feed a doll)?
- Does (or did) your child bring you objects to show you?
- Does (or did) your child engage in babbling (back and forth) [by 12 months]?
- Is (or was) there any delay in speaking (words by 16 months)?
Some children, however, may not initially score high on the M-CHAT. Also, parents may not articulate textbook ‘red flag’ behaviors, the child may be exhibit more subtle ASD symptoms with relatively intact language and intellectual development (as may be characteristic of Asperger’s), or the ASD traits may not be recognizable until after early toddlerhood (particularly emerging in the context of schooling). Certainly, deficits in social reciprocity and communication skills may be continuous with a general population distribution and not readily identifiable at an early age. Given these considerations, clinicians should be aware that there are also other ASD-screening tools available for children 18 months and older (pre-schoolers, school aged, and older).
Some tools used in the VCCYF include The Social Communication Questionnaire and the Social Responsiveness Scale. Utilizing these instruments, along with the ASEBA family of instruments, can be very helpful in further evaluating a child’s functioning and symptom presentation as they relate to autism spectrum illness.
- Social Communication Questionnaire (Parent-Report)
- A quick (less than 10 minutes), easy, developmentally-sensitive, and inexpensive way to routinely screen for autism spectrum disorders
- Used with children over 4 years (with a mental age over 2) to evaluate communication skills and social functioning
- Social Responsiveness Scales (Parent & Teacher-Report)
- A quantitative scale that measures the severity and type of social impairments that are characteristic of autism spectrum conditions in children and adolescents (ages 4-18)
- Takes 15-20 minutes to complete and offers data on a variety of sub scales which can alert providers to sub threshold autistic symptoms that may be present in children who may have other emotional/behavioral struggles.
- ASEBA Instruments
- Using tools such as the Child Behavior Checklist, Teacher Report Forms, and the Language Development Survey (A feature of the preschool CBCL) helps to distinguish between problems that do versus do not warrant a more extensive clinical evaluation for autism.
- Also, many children with ASDs also have co-existing conditions that require screening and evaluation (ADHD, disruptive behaviors, anxiety, mood issues, etc). We use these instruments at all stages of assessment to include an evaluation of a broad spectrum of characteristics in order to avoid neglecting other aspects of children’s functioning that may deserve clinical attention.
Remember, screening tools are not diagnostic tests. One should confirm a positive or negative screening test result with a formal evaluation. Never make a diagnosis with only a screening test. If you suspect that a child may have an autism spectrum disorder, a more comprehensive assessment is warranted.
The VCCYF, under a pilot program through the state of Vermont, is now accepting referrals to the new Autism Assessment Clinic. In our inaugural year, we will be exclusively offering autism diagnosis and evaluation appointments to Medicaid supported families; to make a referral, please call our office at 847-2224.