A common question new parents ask us at The Quirky Kid Clinic is ‘What do we need to look out for in relation to an Autism Spectrum Disorder (ASD)?’. The following article will discuss what ASD is, the diagnosis of ASD, and what to look out for if you have developmental concerns for your child.
What is ASD?
ASD is a developmental disability characterised by marked differences in social interactions, deficits in verbal and nonverbal communication skills, restricted and repetitive interests/behaviours, and sensory sensitivities. It appears in infancy and the symptoms and severity differ from individual to individual.
The severity of an ASD presentation can range from ‘Level 1 requiring support’, through to ‘Level 3 requiring very substantial support’. When ASD is diagnosed it includes the inclusion or exclusion or an accompanying intellectual disability (American Psychiatric Association, 2013, p. 52).
There is no known cure for ASD, and there is no current consensus amongst medical professionals on the precise cause of ASD. However what is clear is that quality individualised early intervention will support children to increase skill development, communication abilities and develop flexible adaptive behaviours (Dawson et al., 2010).
How is ASD diagnosed?
ASD has shown to be reliably diagnosed in a child as young as 18-24 months old (Charman et al., 2005). However, historically children have been more likely to have received a diagnosis closer to school age than during their toddler years (Mandell et al., 2005; Moore & Goodson, 2003).
Howlin & Moore (1997), who conducted a study of 1200 participants in the UK, reported that whilst the average age parents had any developmental concerns for their child was approximately 18 months old, for the majority of participants studied, the diagnosis did not actually occur until closer to the child turning 6 years old.
In response to ongoing research in the area of ASD diagnosis, in the United States, the American Academy of Pediatrics has now recommended that all children be screened for ASD at approximately 18-24 months old (Johnson & Myers, 2007).
In Australia, Williams et al. (2008) have concluded that currently, we have not matched initiatives occurring in other countries, such as the United States, in relation to early ASD diagnosis and early intervention support initiatives. However, the Autism CRC under the guidance of Professor Andrew Whitehouse and colleagues are currently developing a National ‘Best Practise’ Guideline document for the diagnosis of ASD within Australia. Whilst the document has not yet been finalised the draft submission cites the reliability of an ASD diagnosis for a child of 2 years old by a qualified professional. Although, it is still most common in Australia for children to receive a diagnosis between the ages of 3 and 5 years old (Whitehouse et al., 2017).
A reliable diagnostic process involves identifying the child’s strengths and weaknesses via a comprehensive formal assessment which includes a child observation, such as the Autism Diagnostic Observation Schedule (ADOS-2), a parent interview, such as the Autism Diagnostic Interview-Revised (ADI-R), and cognitive / developmental testing such as an IQ test or a general developmental assessment, completed by an experienced practitioner (Charman, 2010; Whitehouse et al., 2017).
Following diagnosis, access to individualised early intervention with the aim of increasing developmental deficits, and decreasing challenging behaviours can make a huge difference in your ASD child’s developmental pathway.
Early Signs to look out for in infants
Identifying characteristics of ASD in a child younger than two years old can be difficult. Concerns may arise due to the ‘absence’ of behaviours considered to be ‘normal’ development and the ‘presence’ of behaviours considered to be ‘abnormal’ development.
Developmental milestones occur across age ranges so your child may be ahead or behind their peers with respect to milestones such as crawling, walking, and early verbal and nonverbal language development.
Listen to your ‘gut instinct’ as a parent. Consider seeking help from your Child Psychologist or Paediatrician if your 12-month-old infant is not demonstrating the following behaviours, either as an emerging skill that is continuing to progress, or once learnt, does not demonstrate these behaviours consistently across multiple environments (Boyd et al., 2010; Charman, 1998):
- Responding to their name, or to the sound of a familiar voice, by turning their head and referencing the person who spoke or the direction from where the voice came from;
- Referencing a familiar person with eye contact, such as smiling in reciprocation to being smiled at, at times such as feeding, and or when playing ‘peek a boo’ like games;
- Demonstrating joint attention, such as referencing a favourite toy or food, then referencing a familiar person, then looking back towards the item of interest as if to say, “pass it to me”, or “can I have more”;
- Babbling or making noises to get a familiar adults attention;
- Developing an imitation repertoire such as waving and clapping, and or including the imitation of a familiar person’s facial expressions and movements;
- Demonstrating reciprocal interest and enjoyment in play, such as tickles, ‘peek a boo’ like games and cause and effect toys, coordinating eye contact to indicate “more”;
- Tracking objects or familiar people visually around the room and or following a familiar person’s gestures, such as pointing to an object;
- Coordinating gestures in order to communicate, such as pointing at an object to initiate a communication, or waving goodbye;
- Positively responding to cuddling, and or reaching out to be picked up.
Remember that your child may, like all individuals, experience good days and bad days. Your child’s development will occur in spurts and patterns, and it is best to evaluate your child’s development by considering the consistency and frequency of these emerging skills.
If you feel a particular skill is lacking spend the time to practise the behaviour with your child, ensuring that you are providing attention and praise for your child’s attempts at demonstrating the behaviour. If the skill does not start to develop or your child responds negatively to your attempts to model and teach the skill then seek help from your Child Psychologist or Paediatrician.
Commence an individualised early intervention program as soon as possible. Whether your child has a formal diagnosis or not it is advisable to start intervention as soon as you suspect that your child’s development is not progressing at the level expected for their age rather than following a wait and see approach.
Here at The Quirky Kid Psychology Clinic, our experienced team of Psychologists are more than happy to meet with you to discuss any concerns you have in relation to your child’s development and behaviour.
We always start with a parent only consultation to ensure that we get a thorough understanding of your child’s developmental history and a sense of your families identity, history and cultural dynamics. From here we provide an individualised case plan dependent on your child and families needs. Please don’t hesitate to contact our friendly reception on (02) 9362 9297.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Boyd, B. A., Odom, S. L., Humphreys, B. P., & Sam, A. M. (2010). Infants and toddlers with autism spectrum disorder: Early identification and early intervention. Journal of Early Intervention, 32, 75-98.
Charman, T. (1998). Specifying the nature and course of the joint attention impairment in autism in the preschool years: Implications for diagnosis and intervention. Autism, 2, 61-79.
Charman, T. (2010). Developmental approaches to understanding and treating autism. Folia Phoniatrica et Logopaedica, 62, 166-177.
Charman, T., Taylor, E., Drew, A., Cockerill, H., Brown, J. A., & Baird, G. (2005). Outcome at 7 years of children diagnosed with autism at age 2: Predictive validity of assessments conducted at 2 and 3 years of age and pattern of symptom change over time. Journal of Child Psychology and Psychiatry, 46, 500-513.
Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., & Varley, J. (2010). Randomized, Controlled Trial of an Intervention for Toddlers With Autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23.
Howlin, P., & Moore, A. (1997). Diagnosis in autism: A survey of over 1200 patients in the UK. Autism, 1, 135-162.
Johnson, C., & Myers, S. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120, 1183–1215.
Mandell, D. S., Novak, M. M., & Zubritsky, C. D. (2005). Factors associated with age of diagnosis among children with autism spectrum disorders. Pediatrics, 116, 1480-1486.
Moore, V., & Goodson, S. (2003). How well does early diagnosis of autism stand the test of time? Follow-up study of children assessed for autism at age 2 and development of an early diagnostic service. Autism, 7, 47-63.
Whitehouse, A.J.O., Evans, K., Eapen, V., Prior, M., & Wray, J. (2017). The diagnostic process for children, adolescents and adults, referred for assessment of autism spectrum disorder in Australia: A national guideline (Draft version for community consultation). Autism CRC Ltd.
Williams, K., MacDermott, S., Ridley, G., Glasson, E. J., & Wray, J. A. (2008). The prevalence of autism in Australia. Can it be established from existing data?. Journal of Paediatrics and Child Health, 44, 504-510.
Regularly checking if the stove is turned off before leaving home or pressing the car alarm button two or three times just to make sure it is turned on are some of the behaviours most people may display as part of everyday life. People with OCD, however, experience these types of behaviours and associated obsessive thoughts persistently and frequently. As a result, their day to day functioning is impaired and significant distress is caused.
Until recently, OCD was classified as an anxiety disorder due to the large role that anxious thoughts, feelings and behaviours can play. With growing research, OCD now stands alone as a diagnosis and related disorders such as hoarding and trichotillomania (hair pulling) are becoming increasingly recognised. OCD is characterised by obsessive thoughts such as contamination (germs), harm to self or others, symmetry, religion or sexual themes as well as compulsions such as excessive hand washing, checking, counting or praying. In OCD one or both of these will be present and will manifest in a cycle of symptoms. For example, thoughts about the house burning down (obsession) leads to anxiety which may be relieved by checking the stove repeatedly (compulsion). While completing a compulsion can lead some individuals to experience relief, this feeds into the unhelpful thinking pattern around the likelihood of the house burning down and thus increases the likelihood that the compulsion will be completed again and again. These thoughts and behaviours usually need to take up at least one hour per day before a diagnosis will be made.
Children can also suffer from OCD, in fact, most cases are diagnosed between the ages of seven and twelve. As with adults, the presence of some obsessions and compulsions are a typical part of development, however, for some children these can take over their life. About 0.2 – 1% of children will have OCD and about 3% of adolescents. A diagnosis of OCD will usually be considered if the thoughts and behaviours associated with the disorder continue for a long period of time, particularly if children do not seem to be deterred by the consequences of the compulsions such as getting in trouble. These children often tend to believe that performing a compulsion (e.g. excessively washing hands) will prevent a feared outcome (e.g. going to hospital). This is made more complicated by the fact that children generally have trouble distinguishing between healthy thoughts and behaviours and symptoms of OCD. When they do feel that something is wrong they are often too ashamed to tell an adult. For this reason we need to be aware of the warning signs and guide children through the recovery process. If concerned, you should always consult with a health professional like a Quirky Kid Psychologist.
Parents and other caregivers can look for signs that obsessions and compulsions are present. These signs will vary in different children and it is also important to be mindful that these experiences may occur for a number of reasons not related to OCD. They may include:
- Reported or observed feelings of ‘stress’
- Sleep deprivation
- Depression and/or feelings of shame
- Slowness in performing tasks (e.g. getting dressed)
- Seeming ‘manic’ or needing to be kept busy
- Decline in academic performance
- Angry outburst or challenging behaviour
- Avoiding social situations
- Family conflict over small things like setting the table
By being mindful of these signs and talking to your child you can determine if help is needed. A psychologist experienced in both child development and behavioural therapy will be most helpful and a psychiatrist can assist in deciding whether or not medication is appropriate and necessary. OCD is usually treated using Exposure and Response Prevention or ERP which involves exposing the individual to their feared situation (e.g. touching a garbage bin) and prevents them from completing their compulsion (e.g. washing hands). This allows them to learn to ‘sit with’ feelings of anxiety and change patterns of thinking which tend to overestimate the likelihood or severity of feared outcomes (e.g. getting sick). Just talking about the problem is usually not helpful and ERP is a highly effective form of therapy for OCD. Of course, this is best performed under the direction of a qualified professional.
OCD can put a strain on families and take the fun out of life for children who are affected so it is important to know how to help your child while also making sure that you have support for yourself. Although the behaviours can be difficult to deal with, children are not trying to misbehave or be annoying; they can’t help the way they are behaving and need support. On the other hand it is important not to participate in the rituals, for example, by constantly offering reassurance. Instead it is best to help your child to learn how to stop these rituals with the support of a professional. Also, many children find it helpful to externalise the symptoms or disorder of OCD by giving it a nasty nickname and treating it as something outside of them. They can then “boss back” the OCD and take charge of not letting the symptoms rule their life. Overall, it will be important to stick to family routines, avoid laying blame and be supportive of your child. Ensure that you have a support network in place for yourself and your family and that you are taking steps to manage your own stress levels while dealing with this challenge.
OCD in Kids. Centre for Emotional Health, Macquarie University (website)
Wilensky, A. (2006). When Your Child has Obsessive – Compulsive Disorder. PsychCentral (2013) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association.
Obsessive Compulsive Disorder. Australian Psychological Society (website)
Walitza, S., et. al. (2010) Genetics of Early-Onset Obsessive-Compulsive Disorder. European Journal of Child and Adolescent Psychiatry, 19 (227-235)
Ornstein, T. J., et. al. (2010) Neuropsychological Performance in Childhood OCD: A preliminary study. Depression and Anxiety, 27 (372 – 380)
Ivarsson, T. & Larsson, B. (2009) Sleep Problems as Reported by Parents in Swedish Children and Adolescents with Obsessive – Compulsive Disorder (OCD), Child Psychiatric Outpatients and School Children. Informa Healthcare UK ltd. DOI: 10.3109/08039480903075200
Calvo, R. et. al. (2007) Parental Psychopathology in Child and Adolescent Obsessive-Compulsive Disorder. Society of Psychiatry and Psychiatric Epidemiology, 42 (647 – 655).
What’s in a label? Should I get a diagnosis for my child?
‘Labelling a child’ is the term used to describe the process where a psychologist or psychiatrist assesses a child, resulting in a diagnosis or ‘label’. The diagnosis is based on a set of criteria defined in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).
About 10% of children and young people will have a mental health problem. The most common diagnoses for children include anxiety disorders; attention-deficit and disruptive behavior disorders; autism spectrum disorders; and eating disorders (for example, anorexia nervosa).
If you suspect your child may have a mental health condition, chances are you’ve wondered if it’s beneficial to obtain a professional opinion and perhaps a diagnosis. While professionals were traditionally hesitant to diagnose pre-adolescents with DSM-IV conditions, diagnoses have been on the rise since the 1980s, partly as a result of greater research into child mental health.
What is a diagnosis?
A reputable mental health professional will not give a diagnosis without a thorough evaluation of a person’s symptoms, behaviours, and developmental history. In the case of a child, specialists will usually consult with several other sources (for example, parents, teachers, and family doctors) before confirming a diagnosis.
What are the advantages of a diagnosis?
An accurate diagnosis will give parents and their child a clear and realistic sense of the limitations and challenges the child may face as a result of the disorder. Following a diagnosis, you should also have a good sense of what treatment plans are available, their pros and cons, and how effective they are. This knowledge can provide tremendous peace of mind for families who are struggling.
Other advantages of a diagnosis include:
- An accurate understanding of your child’s strengths and how to best harness them.
- Individual support from Specialists at your child’s school (for example, regular hours with a Learning Support teacher or funding for resources or appropriate training for teachers).
- Subsidized help for the family (for example, home-based intervention such as ABA for children with autism spectrum disorders).
- Effective collaboration between health professionals. For example, a Speech Pathologist, Occupational Therapist and Psychologist can work together to give your child comprehensive treatment.
What are the disadvantages of a diagnosis?
Most professionals agree: forming a diagnosis can be difficult. A child’s behaviour can change depending on their environment, their food intake and the people around them, which can impact the assessment process.
The disadvantages of a diagnosis may include:
- Stigma from other parents or peers.
- Difficulties reversing the diagnosis should behaviour change or improve.
- Children need support when discussing a diagnosis.
- Some families might find a thorough assessment and Diagnostic Report costly.
Finding more support:
Quirky Kid has offices in Sydney and Wollongong,
If you are concerned as to whether or not obtaining a diagnosis for your child is right for your family, you may find it helpful to talk through the decision with a professional yourself. Ask your health care provider about counselling or support services in your community or contact Quirky Kid on +61 2 9362 9297.
Parents may find useful resources at the Quirky Kid Shoppe.
National Institute for Mental Health in England (2008). The Mental Health Act: Essential Information for Parents and Caregivers.
Harakavy-Friedman, Jill M (2009). Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. American Journal of Psychiatry 166, 118-119
Kimberley O’Brien (2011). Interview on the advantages, disadvantages, benefits and challenges of diagnosing children.
The Cleveland Clinic (2005-2009). “Attention Deficit Hyperactivity Disorder.” http://my.clevelandclinic.org/disorders/Attention_Deficit_Hyperactivity_Disorder/hic_Attention-Deficit-Hyperactivity_Disorder.aspx. Retrieved September 24, 2011.}