Diagnosing autism in young children (Saving my Sons – A Journey With Autism by Ilana Gerschlowitz)
THE RED FLAGS OF AUTISM IN A DEVELOPING CHILD
Its important for parents, teachers and other people responsible for looking after children on a daily basis to be familiar with the typical developmental milestones all children should be reaching; and to learn about the early signs of autism.
The following checklist of autism red flags may indicate that a child is at risk of being diagnosed with autism. In some children, the early signs of autism may be observed by 12 months or even earlier. This is particularly important to note because, until very recently in South Africa, it was believed that you could diagnose autism only from three years of age.
If a child presents with any of the following, please don’t delay further investigation, and see a doctor or paediatrician:
- Lack of eye contact
- Not responding appropriately to greetings or when their name is called
- Not engaging in pretend play
- Preferring to play alone
- Not playing peek-a-b00 by eight months
- Not babbling by 12 months
- No back-and-forth gestures such as pointing or showing by 12 months
- No imitative behaviour such as waving bye-bye by 12 months
- No words by 16 months
- No meaningful, two-word phrases (not including imitating or repeating) by 24 months
- Any loss of speech at any age
- Losing previously acquired skills at any age
- No sharing of enjoyment or interest
- Becoming distressed by minor changes in routines
- Performing repetitive movements such as hand flapping or rocking
- Playing with toys in unusual ways, for example by spinning them or lining them up
- Having unusually strong attachments to particular objects
- Limiting conversations to very specific topics
- Exhibiting over sensitivity to sounds or textures
- Being a picky eater
- Experiencing plateaus or delays in skills development
- Displaying challenging behaviours such as aggression, tantrums and self-injury
- Appearing to be in their own world
- Not following any, or following too few, receptive instructions
- Repetitive movements with objects or posturing of body, arms, hands or fingers
- Being hyperactive
- Being unable to sustain their attention compared to their peers
THE MODIFIED CHECKLIST FOR AUTISM IN TODDLERS, REVISED (M-CHAT-R)
This checklist is a free, validated screening tool of 20 questions that assesses a child’s risk of autism. If you have concerns about your child’s development, tick the aspect(s) you see as concerning and contact your doctor or pediatrician. If you’re a teacher and have noticed possible signs of autism in a child, express your concerns tactfully yet immediately to the child’s parents. Show them the checklist and what you’ve ticked as concerning and advise them to take the list to a doctor or a paediatrician.
Please answer questions to reflect your child’s usual behaviors. If the behavior is rare (for example, you’ve seen it only once or twice), answer as if the child has not acquired the behavior.
1. If you point at something across the room, does your child look at it (for example, if you point at a toy or an animal, does your child look at the toy or animal?) YES/NO
2. Have you ever wondered if your child might be deaf? YES/NO
3. Does your child play pretend or make-believe? (For example, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?) YES/NO
4. Does your child like climbing on things? (For example, furniture, playground equipment, or stairs) YES/NO
5. Does your child make unusual finger movements near his or her eyes? (For example, does your child wiggle his finger or her fingers close to his or her eyes? YES/NO
6. Does your child point with one finger to ask for something or to get help? (For example, pointing to a snack or toy that is out of reach) YES/NO
7. Does your child point with one finger to show you something interesting? (For example, pointing to an airplane in the sky or a big truck in the road) YES/NO
8. Is your child interested in other children? (For example, does your child watch other children, smile at them, or go to them?) YES/NO
9. Does your child show you things by bringing them to you or holding them up to see – not to get help, but just to share? (For example, showing you a flower, a stuffed animal, or a toy truck) yes/no
10. Does your child respond when you call his or her name? (For example, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name? YES/NO
11. When you smile at your child, does he or she smile back at you? YES/NO
12. Does your child get upset by everyday noises? (For example, does your child scream or cry at noises such as that made by a vacuum cleaner, or loud music) YES/NO
13. Does your child walk? YES/NO
14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her? YES/NO
15. Does your child try to copy what you do? (For example, wave bye-bye, clap, or make a funny noise when you do) YES/NO
16. If you turn your head to look at something, does your child look around to see what you are looking at? YES/NO
17. Does your child try to get you to watch him or her? (For example, does your child look at you for praise, or say ‘look’ or ‘watch me’?) YES/NO
18. Does your child understand when you tell him or her to do something? (For example, if you don’t point, can your child understand ‘put the book on the chair’ or ‘bring me the blanket’?) YES/NO
19. If something new happens, does your child look at your face to see how you feel about it? (For example, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face) YES/NO
20. Does your child like movement activities? (For example, being swung or bounced on your knee) YES/NO
THE AUTISM SPECTRUM
In 2013, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistic Manual of Mental Disorders (DSM-5). The handbook is used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of autism. The DSM-5 replaced the DSM-4 which placed autism into categories including Pervasive Developmental Disorder (PDD), Pervasive Developmental Disorder Not Otherwise Specified (PDD NOS) and Asperger’s. With the new DSM-5 these categories have all been merged, and there is now one diagnosis called Autism Spectrum Disorder.
Understanding ASD in terms of the diagnostic criteria laid out in the DSM-5 is depicted below:
Autism Spectrum Disorder: Diagnostic Criteria
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Deficits in social- emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on social- communication impairments and restricted repetitive patterns of behavior.
Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g. simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food everyday)
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g. strong attachment to or preoccupation with unusual objects, excessively circumscribed or persevering interest.)
4. Hyper – or hypo- reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement
Specify current severity: Severity is based on social- communication impairments and restricted repetitive patterns of behavior.
- Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text):
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g. simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g. extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food everyday)
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g. strong attachment to or preoccupation with unusual objects, excessively circumscribed or persevering interest.)
- Hyper – or hypo- reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g. apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement
Specify current severity: Severity is based on social- communication impairments and restricted, repetitive patterns of behavior.
- Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life.)
- Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.
- These disturbances are not better explained by intellectual disability (intellectual-developmental disorder) or global developmental delay. Intellectual disability and ASD frequently co-occur; to make co-morbid diagnoses of ASD and intellectual disability, social communication should be below that expected for general developmental level.
Note: Individuals with a well-established DSM-4 diagnosis of autistic disorder, Asperger’s disorder, or PDD not otherwise specified should be given the diagnosis of ASD. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for ASD, should be evaluated for social (pragmatic) communication disorder:
Dr Doreen Granpeesheh