Is it autism, or something else?

• August 23, 2024
• The REACH Institute
• Autism

With Autism Spectrum Disorder, early screening and intervention are essential—with diagnosis ideally made in early childhood. But as shared in our recent article about how autism may present at different ages, less severe cases may not be detected until children are school-aged or adolescents, especially among girls. 

We asked REACH faculty member Ron Marino, DO/MPH, how pediatric primary care providers might approach making—or ruling out—an autism diagnosis among higher-functioning older children and adolescents.

Distinguishing Symptoms from Functional Impairments

“We can be quick to want to label things,” explains Dr. Marino. “But in between normal behavior and diagnosable disorders, there is also a range that includes normal developmental variation and problematic behavior, which doesn’t meet the criteria of a disorder.” 

What sets a diagnosable disorder apart is the presence of significant impairments in social, educational, or other areas of functioning. Not every symptom that may be typical of autism spectrum disorder—such as a child or adolescent who is extremely quiet, doesn’t make eye contact, or is slow to pick up on social cues—causes functional impairment. 

Dr. Marino recommends several strategies to tease out the differences: 

Ensure early ASD screening. Clinicians should ensure children are screened for autism in the early toddler and preschool years using research-backed diagnostic tools like the Modified Checklist for Autism in Toddlers (M-CHAT-R/F). This can enable early intervention, especially for more severe cases of autism spectrum disorder. If there was no formal early screening done, clinicians, as always, should do a detailed history searching for clues that this was a missed diagnosis and employ other screening devices appropriate for the age of the child they are seeing.

Understand symptoms and their impact. Like with all mental health disorders, motivational interviewing is key to understanding the context in which symptoms or behaviors are occurring and how they are affecting the patient. For example, is a school-aged child’s withdrawn or socially awkward behavior getting in the way of relationships with peers or success in school? Or is the child simply more shy and quiet than their peers? 

Get specific about concerns. Clinicians should also identify who is concerned about the behaviors and symptoms—whether it is the parent, the child, or the school. For example, if a parent is concerned about a specific behavior, a conversation with other adults, such as teachers, can help clarify if the behavior is taking place in more than one setting. Sometimes a personality trait such as being shy does not meet a parent’s expectations and yet the child still falls within the developmental norms when observed by other skilled individuals who may have a better sense of the range of normal.

Consider context. Understanding context is critical. Stress in the family or other negative situations at home or school may be triggering the symptoms or behaviors that look like autism. For example, a clinician might notice that a child is very withdrawn and not making eye contact. But the root cause could be that, whenever they make eye contact at home, they are experiencing physical abuse. 

Evaluate for other mental health conditions. Clinicians should also evaluate for other mental health conditions—both because people with autism have higher rates of conditions like depression and ADHD and because some mental health conditions may mimic certain symptoms of autism. For example, depression may share some qualities of autism such as a deficit in social emotional reciprocity or diminished eye contact. However these qualities are generally present when the depression is active, did not precede the depressive episode, and respond to appropriate therapeutic interventions. 

Be prepared for next steps. “Autism can be a very charged word,” explains Dr. Marino. How patients and families react to a potential diagnosis can vary widely. If after going through the steps above, a clinician strongly suspects an autism diagnosis, Dr. Marino recommends having referrals and resources ready for patients and families. This includes referrals to psychiatrists and others certified to make an autism diagnosis as well as community resources that may help patients and families while awaiting a diagnosis. 

 

RESOURCES

• For children 18-24 months, the Modified Checklist for Autism in Toddlers (M-CHAT-R/F) is a research-backed diagnostic tool. If a child screens positive on the M-CHAT, they should be referred to specialists for additional diagnostic tests like the ADOS-2. 
• Read this article to learn more about depression in youth with autism spectrum disorder.
• Wait times for a formal autism diagnosis range from six months to two years. REACH’s recent article on how to support patients and families awaiting an autism diagnosis provides helpful resources for clinicians.