When it’s time to refer for an autism screening?

Autism awareness has increased substantially in recent years. Most parents, school officials, and other adults that work routinely with children are familiar with the diagnosis, even if they do not completely understand it. There are many benefits to this increased awareness– more effort to make relevant accommodations, more access to services, etc. With this increased awareness, autism is closer to the forefront of people’s minds, and so we hear more parents, teachers, and related parties questioning whether a child may have autism when problems arise. This is good so that children who do meet criteria can be identified and connected with services earlier; however, it also creates many referrals for children who do not actually meet criteria. While there may be more awareness generally, there may still often be a lack of understanding of the specifics of autism spectrum disorder, especially after changes to the Diagnostic and Statistical Manual of Mental Disorder (DSM) in the fifth edition that combined autism and asperger’s disorder into autism spectrum disorder. This article aims to aid those who deliberate on whether or not to refer for autism evaluations by describing both signs that an autism screening or evaluation may be prudent as well as common symptoms that generate referrals for autism evaluations for children who do not get diagnosed with autism spectrum disorder.

Symptoms to watch for:

To meet the criteria for a diagnosis of autism, a child would need to display both pervasive social deficits and restricted repetitive behavior, and the child must experience impairment in some setting of life. These symptoms must be present from an early age, although the degree of impairment may be delayed, and symptoms in older children and adolescents become masked by learned strategies. The following are some examples of both types of symptoms. If some of these symptoms are observed from both categories in a child, it might be prudent to refer to an autism screening or evaluation.

Social symptoms:

• Deficits in social-emotional reciprocity
  • Some examples of this may be an awkward approach to conversations, inability to maintain typical back-and-forth conversation, reduced sharing of information, reduced initiation of conversation, etc.
• Deficits in non-verbal communication
  • This can include a lack of understanding, abnormal expression, lack of expression, or lack of integration of commonly used non-verbal communication, such as eye contact, body language, gestures, facial expressions, etc.
• Deficits in relationships
  • This may include symptoms such as not moderating behavior to match the context of the environment or situation, not engaging in imaginative play (when it is age-appropriate), difficulty making or maintaining friendships, lack of interest in peers or social relationships, etc.

Restricted and/or repetitive behaviors and related symptoms:

• Restricted, repetitive behaviors are unusual behaviors not usually seen in children in the frequency that you might see in a child with autism spectrum disorder. Some examples include:
  • Repetitive motor movements, such as flapping, spinning, etc.
  • Repetitive speech, especially if it is idiosyncratic speech or echolalia. These terms refer to speech that is repeated that is not coming from the child’s thoughts. For example, a child repeatedly asking for a toy, candy, saying ‘why,’ etc., may not fall into this category. Repetitive speech as seen in autism spectrum disorder is speech that is heard elsewhere. Examples include a child often repeating phrases heard in favorite movies or TV shows. Echolalia is a term specifically for when children repeat what someone has said to them.
• Insistence on sameness, which might manifest as engaging in an inflexible routine, becoming upset if that routine is disrupted, having difficulty with transitions, engaging in a set routine pattern of behaviors, etc.
• Having a restricted, fixated interest in abnormal intensity. This may be a hobby that the child is excessively interested in to that point that it causes social impairment, such as the child not being able or interested in engaging in conversation or activity with other people unless it is regarding this interest, child talks excessively about topic making it hard for others to talk to child or change subject once child has started talking about the interest, etc.
• Sensory sensitivities. This is a common symptom that creates referrals for autism spectrum disorder screenings or evaluations. This includes being especially sensitive to sensory stimuli, meaning the child is more bothered or aware of certain sensory stimuli than others, being attracted to certain sensory stimuli, in which the child wants more of this type of stimulation than is typical, or a lack of noticing sensory stimuli, in which the child is less aware of certain sensory stimuli than other children. Some examples include being sensitive to sounds, loud noises, textures in food or clothing, smells, lights, temperature, pain, touch, etc.

What may not be autism

As mentioned before, children are often referred for evaluations for autism spectrum disorder that ultimately do not meet criteria. To be clear, if in doubt, it doesn’t hurt to go ahead and refer for an evaluation or screening. However, it can be helpful to understand some common things that are referred that do not meet the criteria for a diagnosis of autism spectrum disorder. Being aware of these areas may allow you to be more informed when considering whether or not to refer to an autism screening or evaluation. Additionally, sharing this information can help families to be better educated and better prepared for potential evaluations.

1. Only social impairment or restricted and repetitive behaviors, but not both:
   1. We often see children referred for an evaluation for autism due to sensory sensitivities like the ones discussed above, or even related symptoms such as trouble transitioning, rigid routines, etc. All these symptoms fall under the restricted repetitive behaviors symptomology. Current diagnostic criteria require symptoms under this category as well as impairment from social symptoms. If children only have restricted and repetitive behavior symptoms, they will not meet the criteria for autism spectrum disorder. That being said, their symptoms may be better explained by another mental health disorder. For example, children with anxiety can also struggle with transitions or disruptions in routine, and even sensory sensitivities sometimes. It is also important to understand the converse of this scenario. If a child has a social impairment but not restricted and repetitive behaviors, they also will not receive a diagnosis of autism spectrum disorder. However, they may meet the criteria for what is called social pragmatic disorder, which is a diagnosis for solely social impairment.
2. Social impairment for other reasons:
   1. It is also helpful to understand that social functioning can also be impacted by other factors than autism spectrum disorder. For example, a common symptom that is reported when there are concerns about autism is a lack of eye contact. However, children with anxiety or even just children who are shy may make less eye contact than other children. In situations like this, it is important to know the child’s social functioning across settings. Generally speaking, children who meet the criteria for autism spectrum disorder are going to display their social deficits across settings, whereas children who may be shy or anxious may engage easily in some settings but withdraw in settings that arouse more anxiety. Anxiety is a common differential diagnosis for autism spectrum disorder, but this example applies to other issues that can impact social functioning, such as disruptive behavior. For example, a child that has trouble maintaining friendships and does not show interest in others could have these symptoms due to oppositionality and a poor reputation from the disruptive behavior rather than from autism.

This article discussed important symptomology to consider when contemplating referring to a clinician for an autism spectrum disorder assessment. Hopefully, this article has provided some clarity, but when in doubt, please consult a professional in diagnosing autism spectrum disorder.

Learn more about autism testing on the Arkansas Families First website. You can also feel free to reach out to one of our team members in North Little Rock or Conway over the phone or utilize our online chat feature or information request form.