Background
Early intervention in autism spectrum disorder (ASD) improves outcomes, but treatment access depends on early identification. Despite reliability of most autism diagnoses by age 24 months, the majority of children with autism do not receive comprehensive evaluations until after age 36 months. Although many possible reasons exist for delayed evaluations, the referral decision process itself is not clearly defined nor understood. In particular, little is known about how perceptions of early childhood symptoms of ASD interact with decision criteria to ultimately refer a child for comprehensive diagnostic assessment.

Method
To better understand pre-referral perceptions and decision factors involved, we provided multiple video clips from early comprehensive autism evaluations as prompts, then asked early childhood clinicians and educators (n = 346) to make decisions about autism referral, then to identify factors considered when making decisions.

Results
Decision factors cited most often were play, social interactions/engagement, and verbal behaviors, but none were cited by a clear majority. Some important early signs were infrequently mentioned: absence of joint attention, social reciprocity and gestures. Accuracy of referral decisions was similar across disciplines, indicating a broad range of professionals capable of identifying early signs of autism.

Conclusions
Autism training across early childhood professional disciplines should emphasize importance of early signs involving significant absences of behaviors, such as low joint attention, gestures, and social reciprocity in addition to odd social, verbal, and play behaviors. Such targeted training may encourage earlier referrals when autism is suspected in young children.

BACKGROUND: Pediatricians, neurologists, and geneticists are important sources for autism surveillance, screening, and referrals, but practical time constraints limit the clinical utility of behavioral observations. We analyzed behaviors under favorable conditions (ie, video of autism evaluations reviewed by experts) to determine what is optimally observable within 10-minute samples, asked for referral impressions, and compared these to formal screening and developmental testing results.

METHODS: Participants (n = 42, aged 15 to 33 months) were typically developing controls and children who screened positive during universal autism screening within a large community pediatric practice. Diagnostic evaluations were performed after screening to determine group status (autism, language delay, or typical). Licensed psychologists with toddler and autism expertise, unaware of diagnostic status, analyzed two 10-minute video samples of participants’ autism evaluations, measuring 5 behaviors: Responding, Initiating, Vocalizing, Play, and Response to Name. Raters were asked for autism referral impressions based solely on individual 10-minute observations.

RESULTS: Children who had autism showed more typical behavior (89% of the time) than atypical behavior (11%) overall. Expert raters missed 39% of cases in the autism group as needing autism referrals based on brief but highly focused observations. Significant differences in cognitive and adaptive development existed among groups, with receptive language skills differentiating the 3 groups.

CONCLUSIONS: Brief clinical observations may not provide enough information about atypical behaviors to reliably detect autism risk. High prevalence of typical behaviors in brief samples may distort clinical impressions of atypical behaviors. Formal screening tools and general developmental testing provide critical data for accurate referrals.

The purpose of this case report is to describe the conceptualization and treatment of comorbid anxiety diagnoses, selective mutism, and procedural anxiety in a young female presenting to a pediatric family therapy clinic with common variable immunodeficiency disease (CVID) and behavioral concerns. Treatment included a comprehensive interview assessing domains of functioning. Treatment plans for both selective mutism and procedural anxiety were informed by behavior learning theories. In collaboration with parents and teachers, evidence-based interventions were implemented concurrently across the clinic, home, and school settings to facilitate generalization. Over the course of 8 sessions, coping skills were successfully employed in the home setting to decrease procedural anxiety. Behavioral techniques implemented by clinician, parents, and the patient’s teacher to reinforce functional communication resulted in the reestablishment of speech in the school setting. Comorbid treatment of anxiety disorders proved successful and was effectively applied within an academic medical setting in a child with CVID. Application of evidence-based interventions informed by behavioral learning theories brought about improvements in both functional communication and procedural anxiety. Close collaboration among pediatric psychologists, school personnel, and parents was critical to achieving positive treatment outcomes across multiple settings. (PsycINFO Database Record (c) 2013 APA, all rights reserved)