Changes in the diagnosis of autism: how parents and professionals act and react in France

The category of autism has undergone huge changes over the past 20 years. This study was undertaken to analyze the changes and how parents have experienced the diagnostic process in France. Data were obtained from in-depth interviews with parents and psychiatrists, and from 248 questionnaires with open-ended questions filled in by parents. We compared the experiences of parents with adult autistic children to those of parents with young autistic children. Progressively earlier age at diagnosis was evidenced. These changes occurred later than in North America and the UK, due to the reluctance of French professionals to adopt the new classifications of diseases which they viewed as undervaluing both the physician's holistic clinical skills, and psychoanalytical interpretations. Parents' experiences and interviews with psychiatrists were analyzed in order to document changes over time in the diagnostic process following tensions between parents and professionals, and intra-professional debates in psychiatry. Our data support the notion that the diagnosis of autism is historically and nationally contingent. The interactions between changes in the diagnostic process, policy, and parental experiences have led to changes in the way autism is defined, understood, and experienced.

Prospective examination of visual attention during play in infants at high-risk for autism spectrum disorder: a longitudinal study from 6 to 36 months of age

Regulation of visual attention is essential to learning about one's environment. Children with autism spectrum disorder (ASD) exhibit impairments in regulating their visual attention, but little is known about how such impairments develop over time. This prospective longitudinal study is the first to describe the development of components of visual attention, including engaging, sustaining, and disengaging attention, in infants at high-risk of developing ASD (each with an older sibling with ASD). Non-sibling controls and high-risk infant siblings were filmed at 6, 9, 12, 15, 18, 24, and 36 months of age as they engaged in play with small, easily graspable toys. Duration of time spent looking at toy targets before moving the hand toward the target and the duration of time spent looking at the target after grasp were measured. At 36 months of age, an independent, gold standard diagnostic assessment for ASD was conducted for all participants. As predicted, infant siblings subsequently diagnosed with ASD were distinguished by prolonged latency to disengage ('sticky attention') by 12 months of age, and continued to show this characteristic at 15, 18, and 24 months of age. The results are discussed in relation to how the development of visual attention may impact later cognitive outcomes of children diagnosed with ASD.

Preserved imitation of known gestures in children with high-functioning autism

It has been suggested that children with autism are particularly deficient at imitating novel gestures or gestures without goals. In the present study, we asked high-functioning autistic children and age-matched typically developing children to imitate several types of gestures that could be either already known or novel to them. Known gestures either conveyed a communicative meaning (i.e., intransitive) or involved the use of objects (i.e., transitive). We observed a significant interaction between gesture type and group of participants, with children with autism performing known gestures better than novel gestures. However, imitation of intransitive and transitive gestures did not differ across groups. These findings are discussed in light of a dual-route model for action imitation.

The relationship of early communication concerns to developmental delay and symptoms of autism spectrum disorders

OBJECTIVE

Parental concerns related to communication are an oft-cited reason that children present to early intervention clinics. We examine the relationship between early communication first concerns (FCs) and symptoms of ASD.

METHODS

The present study included 3173 toddlers at risk for developmental delay. The Battelle Developmental Inventory, 2nd edition and the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) were used to examine developmental quotient scores and autism symptoms.

RESULTS

Significant results were observed with respect to FC group and gender. A significant effect of FC-Communication group was observed with respect to developmental quotient overall and subscale scores, as well as autism symptom scores.

CONCLUSION

Those with communication disorders are a heterogeneous population and do not account for all children who will meet criteria for a diagnosis of an ASD.

Communicating a diagnosis of Autism Spectrum Disorder - a qualitative study of parents' experiences

Not enough is known about parents' experiences of receiving the news that their child warrants a diagnosis of Autism Spectrum Disorder (ASD). Sharing this information with parents is an important and difficult part of Child and Adolescent Mental Health (CAMH) practice. Qualitative methodology was used to explore the experiences of the 'feedback session' with nine sets of parents in a community Child and Adolescent Mental Health Service (CAMHS) in North East England. Parents gave vivid accounts of their experiences and described issues relating to the structure, style and content of the session. The experiences of CAMHS users should inform the development of good practice in this important area.

Explaining differences in age at autism spectrum disorder diagnosis: a critical review

The diagnosis of autism is often delayed, which translates into a missed opportunity to provide treatment during a critical developmental period. This study reviews studies that assessed factors associated with age at autism spectrum disorder diagnosis and provides recommendations on future research, programs, and policies to improve early detection. A search for all peer-reviewed articles containing the words autism, age, and diagnosis in either the title or abstract was performed. A total of 42 studies published from January 1990 through March 2012 were identified. Mean age at diagnosis for all autism spectrum disorders ranged from 38 to 120 months and has decreased over time. Factors associated with earlier diagnosis included greater symptom severity, high socioeconomic status, and greater parental concern about initial symptoms. Family interactions with the health and education systems prior to diagnosis also influenced age at diagnosis. Geographic variation in age at autism spectrum disorder diagnosis was identified in a number of studies, suggesting that community resources and state policies play a role in early identification. Early detection efforts should include enhanced parental and provider education on the early recognition of developmental problems, interventions aimed at streamlining the process from first concern to eventual diagnosis, and strategies that target underserved populations.

Children with developmental disabilities in India: age of initial concern and referral for rehabilitation services, and reasons for delay in referral

This study aimed to identify the age at first concern and age at referral for rehabilitation services in children with developmental disabilities in India. Two hundred fifty-nine children were included and data were collected from the parents. In children with developmental disabilities (excluding autism spectrum disorders), median age at initial concern was 7 months and age at referral for rehabilitation services was 13 months. In children with autism spectrum disorders, median age at initial concern was 24 months and age at referral was 42 months. Physician's recognition of the condition, single child, institutional delivery and neonatal admission ≥4 days were associated with early referral. The common reasons cited by the parents for delay in services were reassurance by physicians or family members and nonreferral by the physicians. Thus, routine screening for developmental problems (including autism) and improving the awareness of these conditions among physicians and society would lead to early referral.

Developmental trajectories in children with and without autism spectrum disorders: the first 3 years

Retrospective studies indicate 2 major classes of autism spectrum disorder (ASD) onset: early and later, after a period of relatively healthy development. This prospective, longitudinal study examined social, language, and motor trajectories in 235 children with and without a sibling with autism, ages 6-36 months. Children were grouped as: ASD identified by 14 months, ASD identified after 14 months, and no ASD. Despite groups' initial similar developmental level at 6 months, ASD groups exhibited atypical trajectories thereafter. Impairment from 14 to 24 months was greater in the Early-ASD than the Later-ASD group, but comparable at 36 months. Developmental plateau and regression occurred in some children with ASD, regardless of timing of ASD diagnosis. Findings indicate a preclinical phase of varying duration for ASD.

Effectiveness of developmental screening in an urban setting

OBJECTIVE

To determine the effectiveness of developmental screening on the identification of developmental delays, early intervention (EI) referrals, and EI eligibility.

METHODS

This randomized controlled, parallel-group trial was conducted from December 2008 to June 2010 in 4 urban pediatric practices. Children were eligible if they were <30 months old, term, without congenital malformations or genetic syndromes, not in foster care, and not enrolled in EI. Children were randomized to receive 1 of the following: (1) developmental screening using Ages and Stages Questionnaire-II (ASQ-II and Modified Checklist for Autism in Toddlers (M-CHAT) with office staff assistance, (2) developmental screening using ASQ-II and M-CHAT without office staff assistance, or (3) developmental surveillance using age-appropriate milestones at well visits. Outcomes were assessed using an intention-to-treat analysis.

RESULTS

A total of 2103 children were enrolled. Most were African-American with family incomes less than $30,000. Children in either screening arm were more likely to be identified with delays (23.0% and 26.8% vs 13.0%; P < .001), referred to EI (19.9% and 17.5% vs 10.2%; P < .001), and eligible for EI services (7.0% and 5.3% vs 3.0%; P < .001) than children in the surveillance arm. Children in the screening arms incurred a shorter time to identification, EI referral, and EI evaluation than children in the surveillance arm.

CONCLUSIONS

Children who participated in a developmental screening program were more likely to be identified with developmental delays, referred to EI, and eligible for EI services in a timelier fashion than children who received surveillance alone. These results support policies endorsing developmental screening.

Autism awareness and attitudes towards treatment in caregivers of children aged 3-6 years in Harbin, China

OBJECTIVE

To (1) estimate the proportion of people in the community who could correctly recognize autism spectrum disorders (ASD); (2) describe the attitudes towards various treatments for ASD; and (3) identify factors associated with ASD recognition.

METHODS

A population-based cross-sectional survey was conducted in Harbin, China (n = 4,947). We estimated the proportions of participants who were at different levels of knowledge about ASD and of their attitudes towards mental health service use. Multivariate logistic regression modeling was used to identify factors associated with the recognition of ASD.

RESULTS

Overall, 2,786 (57.8%) of the respondents could recognize the ASD. Recognition of autism depended on gender, residing areas, age and educational levels. With respect to the attitudes towards mental health service use for ASD, 4,007 respondents (84.6%) chose to visit a health organization for treatment; 2,470 (68.2%) made the choice of consulting a psychotherapist.

CONCLUSIONS

There is a large room for improvement in awareness about ASD and treatment in the Chinese communities. Insufficient knowledge about ASD and inappropriate attitudes towards mental health service use may impede the efforts of early identification and intervention. Health education and promotion are needed to improve people's knowledge about ASD and available mental health services.

The First Year Inventory: a longitudinal follow-up of 12-month-old to 3-year-old children

The First Year Inventory is a parent-report measure designed to identify 12-month-old infants at risk for autism spectrum disorder. First Year Inventory taps behaviors that indicate risk in the developmental domains of sensory-regulatory and social-communication functioning. This longitudinal study is a follow-up of 699 children at 3 years of age from a community sample whose parents completed the First Year Inventory when their children were 12 months old. Parents of all 699 children completed the Social Responsiveness Scale-Preschool version and the Developmental Concerns Questionnaire to determine age 3 developmental outcomes. In addition, children deemed at risk for autism spectrum disorder based on liberal cut points on the First Year Inventory, Social Responsiveness Scale-Preschool, and/or Developmental Concerns Questionnaire were invited for in-person diagnostic evaluations. We found 9 children who had a confirmed diagnosis of autism spectrum disorder from the sample of 699. Receiver operating characteristic analyses determined that a two-domain cutoff score yielded optimal classification of children: 31% of those meeting algorithm cutoffs had autism spectrum disorder and 85% had a developmental disability or concern by age 3. These results suggest that the First Year Inventory is a promising tool for identifying 12-month-old infants who are at risk for an eventual diagnosis of autism spectrum disorder.

High-functioning autism and Asperger's disorder: utility and meaning for families

We used framework analysis to investigate the utility of pervasive developmental disorder diagnoses, interviewing young people (aged 9-16 years) with high-functioning autistic disorder (AD) and Asperger's disorder (AsD), and their parents. Twenty two participants from ten families described both gains and costs resulting from diagnosis. Perceived advantages of AD and AsD diagnosis were increased understanding and practical support, and parental empowerment. Disadvantages included the effects of stigma and concerns about validity. Participants tended to consider AsD and AD as interchangeable terms. Findings suggest that the utility of AD and AsD depends upon both their validity and how these diagnoses are received in their cultural, economic and legislative context. Improvement of post-diagnostic services will improve the utility of AD and AsD.

Working with families living with autism: potential contributions of marriage and family therapists

This article introduces marriage and family therapists (MFT) to some of the common issues faced by families that have a child with autism spectrum disorder (ASD). First, autism is defined and common myths surrounding it are discussed. Next, relational challenges are presented that families report experiencing during early childhood through the elementary school years, adolescence and the transition into adulthood, and the later years of the family life cycle. Real-life stories are included to illustrate the potential contributions that MFTs can make to families that have a child with ASD.

Outcomes of a behavioral education model for children with autism in a mainstream school setting

The authors report 1-year outcomes for 11 children (3-7 years) with autism who attended an "Applied Behavior Analysis (ABA) classroom" educational intervention in a mainstream school setting. The children learned new skills by the end of 1 year and learned additional skills during a 2nd year. Group analysis of standardized test outcomes (IQ and adaptive behavior) showed moderate to large effect size changes over 1 year, with further changes during a 2nd year. Standardized test outcomes for nine children after 2 years were also analyzed against a comparison group (n = 18) of children with autism receiving "education as usual." These controlled comparisons were associated with statistically significant large effects in favor of the ABA group for adaptive skills. Exploratory analysis also showed that increases in language and learning skills in the ABA class group were generally associated with positive changes in standardized test scores. A comprehensive behavioral intervention model can be successfully implemented in a mainstream school setting.

Autism in Vietnam: the case for the development and evaluation of an information book to be distributed at the time of diagnosis

Autism is not generally well understood by the community in the West or in Asia. A diagnosis of autism is distressing for all families. When families receive the diagnosis they are often not able to fully appreciate what it means or process the information given to them. Booklets exist in English that contain relevant autism related information but few have been evaluated. In Vietnam, parents do not have ready access to autism related information. This paper makes the case for offering a Vietnamese language information resource/booklet for parents to be distributed at the beginning of the diagnostic process and evaluating its usefulness. In developed countries autism has been recognised since the 1940s (Kanner, 1943). More recently it is being increasingly recognised in children with average and above intelligence. In Vietnam, a Western view of autism is just developing. Consequently community resources are undeveloped. The community, in general, and health services for children, in particular, have a rudimentary understanding of autism. This paper discusses a Western understanding of autism, autism in Vietnam, and suggests one possible strategy for addressing the educational needs around autism in Vietnam.

Dilemmas, diagnosis and de-stigmatization: parental perspectives on the diagnosis of autism spectrum disorders

Many children who display autistic behaviours at clinical levels do not receive a formal diagnosis. This study used qualitative methods to examine parental influence in pursuing or avoiding a diagnosis of autism spectrum disorder (ASD). The aim was to explore the function of ASD diagnosis for parents, and examine whether a diagnosis affected how parents perceived ASD. Seventeen parents participated in in-depth semi-structured interviews, which were analyzed using thematic and grounded theory approaches. Data analysis revealed dilemmas faced by parents: whether to act to retain the 'normal' status of the child or to 'normalize' the child through diagnosis and subsequent remediation. Parents who had received an ASD diagnosis for their children became proactive in trying to reduce stigmatization of ASD more widely, and in some cases actively advocating ASD diagnosis to other parents. Thus their actions may make it more likely that others will opt for diagnosis in the future.

Optogenetic investigation of neural circuits underlying brain disease in animal models

Optogenetic tools have provided a new way to establish causal relationships between brain activity and behaviour in health and disease. Although no animal model captures human disease precisely, behaviours that recapitulate disease symptoms may be elicited and modulated by optogenetic methods, including behaviours that are relevant to anxiety, fear, depression, addiction, autism and parkinsonism. The rapid proliferation of optogenetic reagents together with the swift advancement of strategies for implementation has created new opportunities for causal and precise dissection of the circuits underlying brain diseases in animal models.

Developmental surveillance of infants and toddlers by maternal and child health nurses in an Australian community-based setting: promoting the early identification of autism spectrum disorders

Although signs of autism spectrum disorders (ASDs) are evident during the first year of life, few children are diagnosed prior to 3 years. The objective in this article is to highlight the role that primary health care professionals can play in the early identification of ASDs by briefly outlining the successful implementation of The Social Attention and Communication Study. Maternal and child health nurses were trained on the early signs of ASDs, which enabled them to identify these children prior to 2 years. The training procedure used will be outlined, and the early signs that were monitored will be explained in detail. It is recommended that routine monitoring for ASDs in infancy and toddlerhood become standard practice among all primary health care professionals.

Parents' first concerns of their child's development in toddlers with autism spectrum disorders

OBJECTIVE

Investigations about first concerns among parents of toddlers with ASD and comparisons of the same with children diagnosed with other developmental disorders are scarce.

METHOD

The current study utilized a sample of toddlers diagnosed with an ASD or other developmental delay and examined the nature of parents' first concern and the age of first concern compared to the age of first assessment.

RESULTS

The majority of parents of both toddlers diagnosed with ASD and non-ASD related developmental delays indicated that the area of first concern was in communication. However, the age of first concern was significantly younger for toddlers with an ASD diagnosis. In addition, there was a significant positive correlation between the age at which concerns were first noted and the age at which assessment was sought.

CONCLUSION

The implications of these findings are discussed as they relate to early assessment and intervention.

Factors affecting age at initial autism spectrum disorder diagnosis in a national survey

Entry into early intervention depends on both age of first parent concern (AOC) and age at initial autism spectrum disorder (ASD) diagnosis (AOD). Using data collected from a national online registry from 6214 children diagnosed with an ASD between 1994 and 2010 in the US, we analyzed the effect of individual, family, and geographic covariates on AOC and AOD in a multivariate linear regression model with random effects. Overall, no single modifiable factor associated with AOC or AOD emerged but cumulative variation in certain individual- and family-based features, as well as some geographic factors, all contribute to AOC and AOD variation. A multipronged strategy is needed for targeted education and awareness campaigns to maximize outcomes and decrease disparities in ASD care.

Immunization and children at risk for autism

Possible connections between immunization and developmental disorders, most notably autistic disorders, have been the subject of a great deal of debate and have caused much concern for parents who want to make the safest choices for their children. Anxiety has risen steadily since the mid-1990s, when a medical investigative team led by A Wakefield postulated that the measles-mumps-rubella (MMR) vaccine may be a causative factor in the development of autism spectrum disorder. Since this initial publication, immunization remains controversial for some parents and the uptake of the MMR vaccine has fallen in some countries, despite much discussion regarding the safety of MMR, a lack of evidence for an association between MMR and autism, and the risks of insufficient protection against wild measles virus infection. The Canadian uptake of MMR in 1998 was 95%, but data do not exist to document any change in Canada since that time. Many clinicians are concerned that the uptake in younger siblings of children with autism is considerably lower.Further anxiety for parents has been caused by the suggested association between developmental disorders and mercury toxicity due to thimerosal, which is used as a preservative in some vaccines. Many Canadian parents, while continuing to seek chelation therapy in response to this suggestion, are not aware that, in Canada, thimerosal has never been added to MMR, and has not been present in diphtheria-pertussis-tetanus-poliomyelitis or pentavalent vaccines since 1992. It is found in only Hepatitis B vaccine in some provinces.The present article is intended to be a guide for physicians as they counsel parents.

Early indicators of autism spectrum disorders at 12 and 24 months of age: A prospective, longitudinal comparative study

Prospective questionnaire data from a longitudinal population sample on children with autism spectrum disorders (ASD), developmental delay, specific language impairment, or typical development (TD), were collected at ages eight, 12 and 24 months, via the Communication and Symbolic Behavior Scale Developmental Profile (CSBS) – Infant Toddler Checklist, and the Actions and Gesture section of the MacArthur-Bates Communicative Development Inventory (CDI):Words and Gestures. The four groups were compared at four years of age to identify whether any early behaviours differentiated the groups. While children with ASD differed from TD children on most social communicative measures by 12 months of age, the only social communication characteristic which could differentiate the children with ASD from the other groups were gesture scores on the CDI at 12 months and the CSBS at 24 months. Significant markers of ASD were identifiable in this community sample at an early age, although discrimination between clinical groups was rarely evident.

Communication deficits in babies and infants with autism and pervasive developmental disorder-not otherwise specified (PDD-NOS)

OBJECTIVE

To investigate if, and in what ways, communication impairments are present in toddlers (17-37 months) diagnosed with autism and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS).

METHODS

Study 1-The scores of 20 toddlers with autism or PDD-NOS (i.e. ASD group) were compared to those of 20 typically-developing infants on the Communication sub-scale of the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT)-Part 1. Study 2-These same scores were compared between 660 toddlers who fell into three groups: autism, PDD-NOS and non-ASD-related developmentally delayed.

RESULTS

Infants with an ASD exhibited greater communication impairments than did typically-developing infants overall and on all items. Additionally, significant differences were found in overall communication impairments and the majority of individual items between all three groups in Study 2.

CONCLUSIONS

Significant communication impairments are present in toddlers diagnosed with autism and PDD-NOS before 37 months.

Assessment of knowledge about childhood autism among paediatric and psychiatric nurses in Ebonyi state, Nigeria

BACKGROUND

There is increasing public and professional awareness of autism spectrum disorders with early recognition, diagnosis and interventions that are known to improve prognosis. Poor knowledge about childhood autism among paediatric and psychiatric nurses who are members of multidisciplinary teams that care for such children may be a major barrier to early interventions that could improve quality of life and prognosis in childhood autism. Factors that influence knowledge about childhood autism among these nurses are not known. This study assessed knowledge about childhood autism among paediatric and psychiatric nurses in Ebonyi state, Nigeria and determined the factors that could be influencing such knowledge.

METHODS

Forty specialist paediatric and forty psychiatric nurses, making a total sample of eighty, were randomly selected from all the health care facilities in Ebonyi state, Nigeria. A socio-demographic questionnaire and knowledge about childhood autism among health workers (KCAHW) questionnaire were administered to them and the study was a point survey.

RESULTS

The total mean score on the KCAHW questionnaire among the nurses that participated in the study was 12.56 ± 3.23 out of a total of 19 possible. The mean score for the paediatric nurses was 11.78 ± 3.64 while psychiatric nurses had mean score of 13.35 ± 2.58. The mean scores in Domain 1 were 6.17 ± 1.75 for the paediatric nurses and 6.52 ± 1.43 for the psychiatric nurses. The mean scores in Domain 2 were 0.65 ± 0.48 for the paediatric nurses and 0.80 ± 0.41 for the psychiatric nurses. Domain 3 showed mean scores of 1.97 ± 1.25 for the paediatric nurses while psychiatric nurses scored 2.62 ± 1.23. Domain 4 yielded the mean scores of 2.97 ± 1.54 and 3.42 ± 0.98 for the paediatric and psychiatric nurses respectively.There was significant relationship between the total mean score on the KCAHW questionnaire for the two groups and the area of specialisation of the nurses (t = -2.23, df = 78, p = 0.03) and there was also significant relationship between previous involvement in managing children with childhood autism as a specialist paediatric or psychiatric nurse and the total mean score on the KCAHW questionnaire (t = 6.90, df = 78, p = 0.00).

CONCLUSION

The scores reflect deficits in knowledge about childhood autism among the study cohorts. Paediatric and psychiatric nurses as members of multidisciplinary teams that care for children with childhood autism are expected to provide holistic care and adequate counselling to the families of these children. Unfortunately in this environment, they are not fully equipped with enough knowledge about childhood autism. Education on childhood autism is therefore needed and can be provided through continuing medical education and emphasizing childhood autism in their training curriculum. This will enhance early identification and diagnosis of childhood autism with early interventions that are known to improve prognosis.

Autism spectrum disorders

The term autism spectrum disorder refers to a constellation of symptoms involving impairments in social interaction and communication, and restricted, repetitive behaviours and interests. This article highlights the disorder among professionals who may come into contact with people with autism spectrum disorder.

A comparison of a specialist autism spectrum disorder assessment team with local assessment teams

BACKGROUND

Early diagnosis of autism spectrum disorders (ASD) is of crucial importance, but lengthy delays are common. We examined whether this issue could be reliably addressed by local teams trained by a specialist ASD assessment team.

METHOD

Four local teams were trained in diagnostic assessment. Their assessments of 38 children and young people using the Autism Diagnostic Observation Schedule-Generic (ADOS-G) were video recorded and independently assessed by the specialist team.

RESULTS

There was a high level of correspondence between the diagnoses of the local teams and of the specialist team. The number of assessments carried out increased and there was a considerable reduction in waiting times.

CONCLUSION

This study has demonstrated the potential feasibility of creating local, multi-agency ASD assessment teams, which will serve to reduce waiting times, improve clinical skills at a lower level of specialism and thereby improve the overall quality of ASD services.

The autism diagnostic experiences of French parents

This survey focused on French parents' views of the diagnostic process relating to their child with autism. Data were collected on the age at diagnosis, the time taken to obtain a diagnosis and the difficulties encountered. Questionnaires filled in by the parents (n = 248) and in-depth interviews (n = 43) were analyzed in order to obtain quantitative and qualitative results. The ages of the children ranged from 4 to 45. This approach enabled us to compare the practices of professionals now and in the past. The mean age of diagnosis was 10 ± 8 years from 1960 to 1990, 5 ± 3 years from 1990 to 2005 (3 ± 1 from 2003 to 2005). The results showed that the mean delays between first consultation and diagnosis were reduced. Regarding the way the diagnosis was announced, 63% of the parents of children with autism and 93% of the parents of adults with autism were dissatisfied. We discuss the parents' reactions and the changes in the diagnostic process.

Identification of children with the same level of impairment as children on the autistic spectrum, and analysis of their service use

BACKGROUND

Data from epidemiology have consistently highlighted a disparity between the true prevalence of childhood psychiatric disorders and their recognition as defined by receiving a clinical diagnosis. Few studies have looked specifically at the level of unidentified autistic spectrum disorder (ASD) in the population.

METHOD

Logistic regression was used to determine the behavioural traits associated with receiving a diagnosis of ASD using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). A composite score was derived to measure levels of autistic traits; undiagnosed children with scores matching those diagnosed with ASD were identified. Levels of educational provision beyond that provided by standard schooling were examined.

RESULTS

Fifty-five percent of children with autistic traits at the same levels as those who had an autism diagnosis had not been identified as needing extra support from education or specialised health services. Of those who were identified as having special needs, 37.5% had been formally diagnosed with an ASD. For children with impairment at the same level as that associated with Asperger's syndrome, 57% had no special provision at school, and were not accessing specialised health services. Twenty-six percent of those who did have special provision at school had an ASD diagnosis.

CONCLUSIONS

The results suggest that there may be a substantial proportion of children on the autistic spectrum who are never identified by services.

Evaluation of an Information Resource for Parents of Children with Autism Spectrum Disorder

This study sought to evaluate a newly created information resource book for parents of children newly diagnosed with Autism Spectrum Disorder entitled Autism Spectrum Disorder: Information for Parents. A purposive sample of 13 participants (comprised of mothers of children with ASD and ASD service providers) participated in 1 of 3 focus groups. Focus group participants provided their feedback regarding the accessibility, usefulness, content accuracy and tone of the resource book. Findings reveal that concise yet comprehensive and hopeful information targeted to parents at diagnosis, has been lacking in ASD practice. This supportive informational resource book addresses this gap in supporting family adaptation and mobilization at the key juncture of diagnosis. Suggestions for resource refinement and future development of similar diagnostic-related literature to support families of newly-diagnosed children are outlined.

Social influence and the autism epidemic

Despite a plethora of studies, we do not know why autism incidence has increased rapidly over the past two decades. Using California data, this study shows that children living very close to a child previously diagnosed with autism are more likely to be diagnosed with autism. An underlying social influence mechanism involving information diffusion drives this result, contributing to 16% of the increase in prevalence over 2000-2005. We eliminate competing explanations (i.e., residential sorting, environmental toxicants, and viral transmission) through seven tests and show that information diffusion simultaneously contributed to the increased prevalence, spatial clustering, and decreasing age of diagnosis.

Neurodevelopmental disorders: cluster 2 of the proposed meta-structure for DSM-V and ICD-11

BACKGROUND

DSM-IV and ICD-10 are atheoretical and largely descriptive. Although this achieves good reliability, the validity of diagnoses can be increased by an understanding of risk factors and other clinical features. In an effort to group mental disorders on this basis, five clusters have been proposed. We now consider the second cluster, namely neurodevelopmental disorders.

METHOD

We reviewed the literature in relation to 11 validating criteria proposed by a DSM-V Task Force Study Group.

RESULTS

This cluster reflects disorders of neurodevelopment rather than a 'childhood' disorders cluster. It comprises disorders subcategorized in DSM-IV and ICD-10 as Mental Retardation; Learning, Motor, and Communication Disorders; and Pervasive Developmental Disorders. Although these disorders seem to be heterogeneous, they share similarities on some risk and clinical factors. There is evidence of a neurodevelopmental genetic phenotype, the disorders have an early emerging and continuing course, and all have salient cognitive symptoms. Within-cluster co-morbidity also supports grouping these disorders together. Other childhood disorders currently listed in DSM-IV share similarities with the Externalizing and Emotional clusters. These include Conduct Disorder, Attention Deficit Hyperactivity Disorder and Separation Anxiety Disorder. The Tic, Eating/Feeding and Elimination disorders, and Selective Mutisms were allocated to the 'Not Yet Assigned' group.

CONCLUSION

Neurodevelopmental disorders meet some of the salient criteria proposed by the American Psychiatric Association (APA) to suggest a classification cluster.

Autism and Asperger's Syndrome

Autism and Asperger's syndrome are part of a range of conditions incorporated under the term autistic spectrum disorders (ASDs). This article will aim to define these conditions and explain the differences between them, clarify some of the myths about their aetiology and equip the reader with the specific knowledge to diagnose, refer and manage patients with ASDs as effectively as possible.

Autism spectrum disorders in infancy and toddlerhood: a review of the evidence on early signs, early identification tools, and early diagnosis

To date, the biological basis of autism spectrum disorders (ASDs) remains unknown. Thus, identification and diagnosis are reliant on behavioral presentation and developmental history. There have been significant advances in our knowledge of the early signs of ASD through the use of retrospective videotape analysis, parental report, screening studies, and more recently, studies on high-risk infant siblings. Despite behavioral markers being identified within the first year of life, the current average age of diagnosis for ASD remains at approximately 3 years or older. Consequently, these children are not receiving intervention in their early years, which is increasingly recognized as an important time to begin intervention. There remains little research on the prospective identification of these children in a community-based sample before 18 months. It is recommended that future prospective studies monitor behavior repeatedly over time, thereby increasing the opportunity to identify early manifestations of ASD and facilitating the charting of subtle behavioral changes that occur in the development of infants and toddlers with ASD.

How early do parent concerns predict later autism diagnosis?

OBJECTIVE

To study the relationship between parent concerns about development in the first year and a half of life and later autism diagnostic outcomes.

METHOD

Parent concerns about development were collected for infants at high and low risk for autism, using a prospective, longitudinal design. Parents were asked about developmental concerns at study intake and when their infant was 6, 12, and 18 months. Infants were then followed up until 36 months, when diagnostic status was determined.

RESULTS

By the time their child was 12 months, parents who have an older child with autism reported significantly more concerns in autism spectrum disorders-related areas than parents of children with typical outcomes. These concerns were significantly related to independent measures of developmental status and autism symptoms and helped predict which infants would later be diagnosed with autism or autism spectrum disorders. At 6 months, however, the concerns of parents who have an older child with autism do not predict outcome well.

CONCLUSION

Explicitly probing for parent concerns about development is useful for identifying children in need of closer monitoring and surveillance, as recommended by the American Academy of Pediatrics.

Autism Spectrum Disorders in Young Children

Retrospective research studies, videotape analyses of children later diagnosed with autism spectrum disorders (ASD), and recent studies on younger siblings of children diagnosed with ASD, at high-risk of ASD, provide evidence of the early signs of ASD in children as young as 12 months. This article provides a review of early identification, diagnostic assessment, and treatment for young children (0-5 years old) with ASD. Several screening tools as well as comprehensive assessment measures are described. The authors also discuss how the family context is affected by the diagnosis, in terms of adaptation to the diagnosis and to treatment. Finally, the authors present a brief review of interventions for young children with ASD.

Social and communication behaviours in infants and toddlers with autism and pervasive developmental disorder-not otherwise specified

PURPOSE

Autism Spectrum Disorders (ASD) are a group of conditions characterized by symptoms that onset in early childhood. Deficits in social skills and communication are two of the core features of ASD and, if not remediated, can lead to poor long-term outcomes. Few researchers have examined characteristics of social skills and communication in infants with ASD.

METHOD

The social skills and communicative ability of 886 infants and toddlers 17-37 months of age with autism, PDD-NOS or 'at risk' for other developmental delays were evaluated using the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT). A Kruskal-Wallis test with follow-up Mann-Whitney tests were used to test for significance.

RESULTS

Infants and toddlers with autism, followed by PDD-NOS, had greater social and communication deficits than children 'at risk' for developmental delays. Items which distinguished between these diagnostic groups were determined.

CONCLUSIONS

Outcomes suggest that social and communication deficits can be identified at early ages in a population of developmentally delayed toddlers. Implications are that pinpointing emerging social and communicative autistic traits earlier will allow for more accurate assessment and diagnosis in infants with ASD. This translates into earlier intervention and more effective treatment practices.

Early Identification of Autism: Early Characteristics, Onset of Symptoms, and Diagnostic Stability

In the first year of life, infants who later go on to develop autistic spectrum disorders (ASD) may exhibit subtle disruptions in social interest and attention, communication, temperament, and head circumference growth that occur prior to the onset of clinical symptoms. These disruptions may reflect the early course of ASD development and may also contribute to the later development of clinical symptoms through alterations in the child's experience of his or her environment. By age 2, developmental precursors of autism symptoms can be used to diagnose children reliably, and by age 3, the diagnosis is thought to be relatively stable. The downward extension of the autism diagnosis poses important questions for therapists in designing interventions that are applicable for infants who demonstrate early risk factors. We review current knowledge of the early signs of ASD in the infancy period (0-12 months) and the manifestation of symptoms in toddlerhood (12- 36 months), noting the importance of considering the variability in onset and trajectory of ASD. Finally, we consider the implications of this emerging research for those who work or interact with young children, including the importance of early monitoring and the development and evaluation of age-appropriate interventions.

Sensitivity and specificity of the Modified Checklist for Autism in Toddlers and the Social Communication Questionnaire in preschoolers suspected of having pervasive developmental disorders

This study assessed the psychometric properties of the Modified Checklist for Autism in Toddlers (M-CHAT) and the Social Communication Questionnaire (SCQ) in a sample of preschool children referred for possible pervasive developmental disorders (PDDs). The sample consisted of 82 children between the ages of 18 and 70 months (54 with a PDD diagnosis and 28 with non-PDD diagnoses). M-CHAT scores were analyzed for 56 children aged 18-48 months old and SCQ scores were analyzed for 65 children aged 30-70 months old. Optimal sensitivity and specificity were achieved using the cutoff score of any three items on the M-CHAT and lowering the cutoff score of the SCQ. The diagnostic agreement of both instruments was also compared in an overlapping subsample of 39 children aged 30-48 months. Overall, the M-CHAT and SCQ appear to more accurately classify children with PDDs who have lower intellectual and adaptive functioning.

Clinical assessment of autism in high-risk 18-month-olds

Earlier intervention improves outcomes for children with autism spectrum disorders (ASDs), but existing identification tools are at the limits of standardization with 18-month-olds. We assessed potential behavioural markers of ASD at 18 months in a high-risk cohort of infant siblings of children with ASD. Prospective data were collected using the Autism Diagnostic Observation Schedule (ADOS) and Autism Observation Scale for Infants (AOSI) on 155 infant siblings and 73 low-risk controls at 18 months. Infants were classified into three groups (ASD sibs, non-ASD sibs, controls) based on blind best-estimate diagnosis at age 3. Fisher's exact tests, followed by discriminant function analyses, revealed that the majority of informative ADOS items came from the social and behavioural domains, and AOSI items measuring behavioural reactivity and motor control contributed additional information. Findings highlight the importance of considering not only social-communication deficits, but also basic dimensions of temperament including state regulation and motor control when assessing toddlers with suspected ASD.

One-year change in repetitive behaviours in young children with communication disorders including autism

Repetitive behaviours are a relatively neglected area of study in autism. Previous research has concluded that repetitive behaviour is inversely related to ability and that it tends to increase over the preschool years. One-hundred and four children ages 24-48 months, with autism, autism spectrum disorder (ASD) or other disorders, were followed for 13 months. Twelve items from the Autism Diagnostic Interview (ADI-R) were analysed, as well as diagnostic algorithm scores. Ability was related to degree of repetitive behaviours, except for one cluster of relatively able children. ADI-R repetitive behaviour algorithm scores increased over time; however, when all 12 behaviours were considered, there was a general decrease in impact upon the child's and family's activities. Reasons for this decrease are discussed.

Parents' perceptions of communication with professionals during the diagnosis of autism

In order to obtain the views of parents concerning their perceptions of the process of getting a diagnosis of an autistic spectrum disorder (ASD) for their child, 15 focus groups were conducted across a range of locations in England. These groups were split into parents of preschool-, primary- and secondary-aged children who had recently received an ASD diagnosis. At the time of diagnosis, most of the parents wished for a quicker and easier process. In particular, they would prefer the procedure to have a more coherent structure and content. They also requested greater professional training about ASD, in particular, regarding the information that professionals possess, and the interpersonal skills of some professionals. The idea of broad information sheets to be provided to parents at the time of diagnosis would be of value, especially to combat negative information provided from other sources.

Diagnostic trends in autistic spectrum disorders in the South Wales valleys

This study provides an analysis of the diagnostic trends in autistic spectrum disorder (ASD) for children aged under 17 years in the Rhondda and Taff Ely districts of South Wales. In the period 1988-2004, 336 children received a diagnosis of ASD and represent the case registry data of one community paediatric team. For the period 1994-2003, the caseload of 267 comprised Asperger (58%), Kanner (20%) and ;other forms' of autism (22%). In comparison to the previous 5 year period, diagnosis of ASD in 1999-2003 increased for Asperger (2.9 fold) and ;other forms' (4.4) but decreased for Kanner autism (0.69). Male:female gender ratios and age at diagnosis fell for all subcategories of ASD. Prevalences per 10,000 children born in Rhondda Taff Ely are ASD 61.2, Asperger 35.4, Kanner autism 12.7, and 'other forms' 13.0. Detected prevalences and trends for ASD are in line with national standards and do not show an increase for Kanner autism.