Detecting the Early Warning Signs for Autism

The following is one of three articles on autism submitted by the Bucks County Autism Support Coalition. They will be published each Monday in April in recognition of Autism Awareness Month.

If you are reading this article, it is very possible that you already have a child who has been diagnosed with autism. Perhaps you are just looking for information or, you might have questions about the diagnosis. You may also being wondering how the professional who recently evaluated your child came to that conclusion. 

As a professional psychologist who has conducted literally hundreds of evaluations on children, I would like to provide you with some insight into how I go about making a diagnosis.

How many of you have had this experience? “Hello, Dr. Sebastian. My name is Jane Doe. I have some concerns about my son Johnny’s behavior and my pediatrician recommended that I have him ‘evaluated.’ What does that mean exactly?” 

Parents are often confused when they walk in my door for the first time and many times they are frustrated by their child’s behavior. Many of you might have felt all along that there was something just “not quite right” about your child’s development or behavior, but perhaps your pediatrician has reassured you that nothing is wrong and that Johnny is developing just fine.  

On the other hand, Johnny’s teacher might be telling you that she sees problems at school and you are bewildered because you don’t see it at home and Johnny seems to act like all of the other kids you know. So how does one come to this diagnosis? 

First of all, it is not an exact science. There is no blood test for autism and no obvious physical signs.  If your child exhibits significant developmental delays in infancy, it is likely that he/she will come to the attention of medical professionals at an early age. In these cases, the diagnosis is made fairly easily by looking for hallmark symptoms of autism.  

Specifically, the symptoms (just to name a few) include:

• lack of age appropriate language development
• delays in gross or fine motor skills
• lack of eye contact,
• isolation and avoidance of other children
• “fixations” on particular objects or parts of objects

The more severe the autistic symptoms, the more likely it is that the child will be diagnosed earlier, and there will be less confusion about the diagnosis.  I would, however, like to discuss case scenarios where it is less clear because the child might not have exhibited any obvious delays. These are the kids who are often diagnosed with Asperger’s Disorder or perhaps PDD NOS. 

Generally, the child is brought to my office because of behavioral concerns and/or academic concerns. So you might ask, how are these more subtle cases diagnosed? 

I typically begin the interview by obtaining a complete developmental history of the child, as well as a family history. Some people have become offended when I ask about the family’s mental health history because they wonder what that has to do with anything. Well, in my experience, family history is extremely relevant. 

It is my belief that autistic spectrum disorders (ASD) run in families and are also common in families with significant mental health issues. The child’s developmental history is important because even if he/she did not exhibit major delays in speech etc., there may be other less obvious delays.

For example, I am interested in the child’s early social and educational experiences. I want to know if they attended preschool, and if there were behavioral or learning issues in school, or whether the child had trouble separating from the mother.  

Social development is, of course, extremely important, since difficulty in socialization is one of the hallmark symptoms of ASD. Sadly, I have been told countless times by parents and by other professionals, such as teachers or physicians, that there is no way the child has autism/Asperger’s because “he has friends, he is too social, or he loves being around other children.” 

Whereas this might be true, the fact that the child is interested in socializing does not rule out a diagnosis of ASD. In fact, many of the children I see are quite interested in interacting with others and desperately want to make friends. 

What I look for is the “quality” of the child’s interactions with others, not so much the quantity. For example, some ASD children are “too social.” They want so badly to have friends that they might “hound” a peer at school to try and develop a friendship. 

Unfortunately, the ASD child fails to read the social cues and they often will continue to pursue a relationship with a peer even though that child has rejected them and made it clear that they do not want to be friends. ASD children also have trouble with boundaries and they have a tendency to “get in your face” rather than being avoidant.  

The ASD individual’s lack of “social awareness” can be manifested in many different ways with other children, adults, and even animals.  Many a parent has described to me that their ASD child “won’t leave the dog alone. I’ve told him a hundred times to stop pulling the dog’s tail and the dog has growled at him but he continues to do it.” This can be a sign of a lack of empathy or as we often say “inability to put yourself in someone else’s shoes.”

So what else do I look for?  When the child comes into my office, I try to engage him/her in conversation. Many ASD children will not engage with me and will often look away when I am speaking to them. Lack of eye contact is a red flag, as it is very common in ASD. Also, I find that ASD children have trouble answering simple questions about their friends and their favorite activities.  

For example, I often ask who they are friends with or who they play with at school. Instead of listing one or two peers that they regularly interact with, these children will often reply something like, “I play with everybody” and “everyone is my friend.” 

Similarly, I often ask parents if their child talks about what they did at school that day and the majority of parents will say, “No.  I can’t get a word out of him unless I ask and then I get a one-word answer.”  This represents a lack of spontaneity in language and trouble “sharing” information with others.  

In contrast, there are ASD children who talk excessively and ask questions excessively even after the question has been answered. The problem is that these children talk excessively about a certain topic that interests them and they do not get involved in the “give and take” of conversation. They may continue talking without letting the other person take a turn and they might not ask the other person’s opinion or be interested in their thoughts.

Additionally, I ask questions about play skills and preferred activities. Also important is information about sensory integration issues, such as whether the child is sensitive to noise, touch, light, or movement.

Many of these topics are covered on standardized behavior rating scales, and I often ask parents to complete a behavior scale. Some of the more common ones are the Childhood Autism Rating Scale (CARS), the Gilliam Autism Rating Scale (GARS), and the Gilliam Asperger’s Disorder Scale (GADS). These instruments provide an objective measure of autistic symptoms, though the scoring is not black and white. That is, the score provides a range or “probability” that the child has ASD, but it is certainly not definitive. 

As I mentioned earlier in the article, there is no one test for autism and much of my diagnosis is based on my observations and impressions of the child as well as objective measures.

Some parents have become upset by this and have remarked, “How could you diagnose my child with autism when you only spent about an hour with us?” 

All I can say is that I have years of experience and I have seen hundreds of autistic children, so I know what to look for. If a parent disagrees with a diagnosis it is certainly their right and responsibility to seek out a second opinion. 

What I often tell parents when I suspect this diagnosis is to research it themselves. There is a multitude of information on the Internet, so I suggest that parents read about the various forms of autism and its symptoms, and see if the symptoms “fit” their child. 

People are often surprised when they begin reading about it and they might say, “That sounds just like my child.” It is my hope that when that occurs, parents will begin to accept the diagnosis and become more comfortable with it. 

In conclusion, I hope that this article has been helpful and informative. I know that receiving a diagnosis of autism can be very upsetting and frightening. Therefore, the more a parent can learn about the diagnosis, the more they will feel empowered and hopeful that their child can be helped. Please stay tuned for a future article on what to do and where to turn after you have received a diagnosis of autism or Asperger’s. 

Jeri Sebastian Ph.D. is a licensed clinical psychologist with more than 10 years’ experience diagnosing autism.  Jeri is a volunteer member on the BCASC Education Committee.