Jenny Gibbs, clinical psychologist and Altogether Autism consultant psychologist asks when should a parent be concerned enough to seek an assessment for their child?

Jenny Gibbs

6 July 2020 – Aotearoa New Zealand Autism Guideline, published by Whaikaha sets out clear guidelines about signs to look out for that would suggest a referral for assessment for autism is needed.

In children under three, the signs of autism involve the absence of typical behaviour, so they can be difficult to identify. The internationally recognised red flags of the early signs of autism are:

• Does not babble or coo by 12 months.
• Does not gesture (point, wave, grasp) by 12 months Does not say meaningful single words by 18 months.
• Does not say two-word phrases spontaneously (not just copying) by 24 months.
• Has any loss of any language or social skill at any age.

If you notice any of the above signs, see your GP or Plunket Nurse or Well Child Provider and ask for referral to a paediatrician or child development service. Do not be put off by reassurances such as “all children are different” or “let’s wait and see for six months”.

While there is no cure for autism there is very good evidence that early intervention is helpful in supporting communication and minimising the development of behaviour problems.

There is also an app available to parents of children under 2 1/2 years old which can tell you how likely it is that your child has autism. It is based on comprehensive research carried out at La Trobe University in Melbourne, Australia and includes videos of typically developing children and children with autism to help parents understand what they are looking for. Here is the link to the app.

The New Zealand ASD Guideline identifies key signs of autism in children aged 1-3; 4-8 and over nine. This is because autism is a developmental condition and looks different at different ages. There are many signs that can indicate autism. Every child or young person may have a few of these and it does not matter if they do not cause difficulties. However, if there are a lot of signs, and the child is having difficulty coping in their everyday life, it is important to discuss this with your GP and your child’s teacher, who can refer for further assessment.

The lists of signs below are adapted from the New Zealand ASD Guideline and from a resource developed by the Ministry of Health to help people know when to refer.

Signs in young children (1-3) that would suggest that an assessment for autism or another developmental problem is important are:

Social differences

• Lack of social smile and lack of eye contact.
• Lack of imitation of actions (e.g. clapping).
• Deficits in joint attention, such as lack of showing, lack of shared interest, or lack of involving others in joint play with toys or other objects.
• Lack of interest in other children or odd approaches to other children.
• Minimal recognition or responsiveness to another’s happiness or distress.
• Not wanting to be picked up and cuddled.
• Odd relationships with adults (either too friendly or distant).
• Limited variety of imaginative play.
• Lack of pretend play, especially involving social imagination (i.e. not joining with others in shared imaginary games).
• Appearing to be ‘in his/her own world’.
• Failure to initiate simple play with others or participate in early social games.
• Preference for solitary play activities.

Differences in language development, especially comprehension

• Unusual use of language (e.g. made up words; reference to self as ‘you’ or ‘she/he’ beyond 3 years, unusual vocabulary for child’s age or social group.
• Poor response to name.
• Limited non-verbal communication (e.g. lack of pointing and difficulty following the pointing of others).
• Failure to smile socially to share enjoyment and respond to the smiling of others.
• Unusual language development, including muteness, odd or inappropriate intonation patterns, persistent echolalia (“parroting”).
• Limited use of language for communication and/or tendency to talk freely only about specific topics.

Differences in interests, activities and other behaviours

• Over-liking for sameness and/or inability to cope with changes especially in unstructured setting.
• Repetitive play with toys (e.g. lining up objects or turning light switches on and off, regardless of scolding).
• Over-attentiveness to small visual details (e.g. fascination with spinning wheels).
• Repetitive motor mannerisms.
• Lack of flexible, co-operative imaginative play or creativity (although certain imaginary scenarios, such as those copied from videos or cartoons may be frequently re-enacted alone).
• Difficulty in organising self in relation to unstructured space (e.g. hugging the perimeter of playgrounds, halls).

Other factors that may support a diagnosis of autism

Over- or under-sensitivity to:

• sound (e.g. has trouble keeping on task with background noise, responds negatively to unexpected or loud noises).
• touch (e.g. discomfort during grooming, avoids getting messy, picky eater, especially regarding certain textures).
• movement (e.g. becomes anxious or distressed when their feet leave the ground, or twirls, spins, or rocks self frequently during the day).
• visual stimuli (e.g. prefers to be in the dark, feels discomfort or avoids bright lights).
• smells (e.g. seeks out certain smells).

Signs in children (4-8) that would suggest that an assessment for autism or another developmental problem is important tend to be subtler than those in younger children but include:

Social differences

• Inability to join in with the play of other children, or inappropriate attempts at joint play (may manifest as aggressive or disruptive behaviour)
• Lack of awareness of classroom ‘norms’ (criticising teachers; overt unwillingness to co-operate in classroom activities; inability to appreciate/follow current trends, e.g. with regard to other children’s dress, style of speech and interests)
• Easily overwhelmed by social and other stimulation
• Failure to relate normally to adults (too intense or no relationship)
• Showing extreme reactions to invasion of personal space and extreme resistance to being ‘hurried’.

Communication differences

• Unusual language development, including muteness, odd or inappropriate intonation patterns (e.g. “accented” speech); unusual vocabulary for child’s age or social group.
• Limited use of language for social communication and/or tendency to talk freely only about specific topics of interest.
• Differences in interests, activities and other behaviours.
• Lack of flexible, co-operative imaginative play/creativity (although certain imaginary scenarios, for example, copied from videos or cartoons, may be frequently re-enacted alone).
• Difficulty in organising self in relation to unstructured space (e.g. hugging the perimeter of playgrounds or halls).
• Inability to cope with change or unstructured situations, even ones that other children enjoy (such as school trips or teachers being away).
• Intense or unusual patterns of interest

Identifying autism for the first time in young people and adults is usually triggered by things such as:

• symptom changes and diagnostic dilemmas – where children formerly diagnosed with other conditions have matured, their behavioural and emotional characteristics have altered, and, consequently, the original diagnosis is being reconsidered.
• social differences – where the differences in social behaviour between the person and their same-age peers has become more obvious and is causing distress.
• difficulty meeting academic expectations – where the person’s response to the increasing demands of the educational system is of concern. For example, there may be an unusual profile of skills/deficits (e.g., social and motor skills very poorly developed, whilst general knowledge, reading or vocabulary skills are well above chronological/mental age).
• Sensory differences including over- or under-sensitivity to sound, touch, movement, visual stimuli or smells that mean the person has difficulty coping with everyday life.
• The loss of an elderly parent who has supported their adult child.

References/Sources:

• Aotearoa New Zealand Autism Guideline.
• This article was first published in Altogether Autism Journal Issue 4, November 2016 read the latest edition.
• Updated Monday 6 July, 2020.