Autism symptom presentation in toddlers during brief observations: what can we see in ten minutes?

Presentation of symptoms of Autism Spectrum Disorders (ASD) can vary within individuals and over the lifespan. This may make it difficult for a clinician with limited autism expertise to identify subtle signs of ASD at various ages. Furthermore, some individuals with ASD can exhibit appropriate social behaviors some of the time. There has been recent emphasis on ASD screening in primary care settings. However, the structure of a typical primary care appointment may not elicit an accurate sample of social behavior; this affects diagnostic impressions and subsequent referrals, which in turn can delay treatment during critical developmental periods. Typical primary care appointments are 10-20 minutes long, which may not be sufficient time to form an accurate clinical impression of need for referral. This study aimed to identify differences in symptom presentation during brief clinical observations among children with and without ASD. Participants included 3 groups of children between the ages of 15-33 months: (1) children with early signs of ASD, (2) children with suspected language delay, and (3) typically developing children. A clinical evaluation for early signs of ASD (including the Autism Diagnostic Observation Schedule [ADOS]) was videotaped. Social behaviors displayed by the children were measured across the first 10 minutes of the evaluation, and again 30 minutes into the evaluation for 10 minutes. Frequencies of atypical and typical behaviors and changes in behavior over time were compared among the 3 groups. Findings indicated low rates of atypical behavior relative to typical behavior in all three groups. Although the ASD group showed statistically higher rates of atypical behavior, and lower cognitive development and adaptive behaviors on standardized tests, expert clinical impressions based on 10-minute observations were incorrect in the ASD group 39% of the time. Brief observations likely do not provide enough of a behavioral sample to make a correct referral. Standardized screening identified more children correctly as needing referral for ASD evaluation than clinical impression alone.