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As children develop, parents, teachers, or medical professionals may begin to notice signs or indicators of ASD. It is important to discuss these concerns with a medical professional in order to screen for the disorder and obtain a diagnosis, if appropriate, so that the individual may start receiving services and accessing necessary treatment options as soon as possible. The information below outlines general characteristics of ASD, the steps for pursuing an ASD diagnosis, and the differences between diagnoses within the medical versus educational setting.

What are the General Symptoms of ASD?

As specified within the current diagnostic criteria (DSM-5), ASD is characterized as affecting individuals across their lifespan in two functional areas: (1) challenges related to social communication and social interactions and (2) restricted repetitive behaviors, interests, or activities. These core features of ASD are typically qualitative in nature, meaning the characteristics related to ASD are different from those observed in children of the same developmental age; they are not necessarily quantitative (i.e. more or less frequent in individuals with ASD than in others).

Challenges Related to Social Communication and Social Interactions

Communication challenges vary among individuals with ASD, as some individuals may be completely nonverbal while others may speak but struggle to use language to communicate effectively with others. Similarly, social challenges among individuals with ASD can vary greatly, but individuals frequently experience difficulty in using and recognizing nonverbal cues such as eye contact, facial expressions, body posture, and gestures. Many individuals also have trouble understanding social cues and rules, which can make social situations uncomfortable and lead to anxiety and challenging behaviors. Children with ASD may also experience a delay in the development of language, or even the absence of language entirely. When language is used, individuals may demonstrate echolalia, or the repetition of words or phrases without meaning to the context of the social interaction (for instance, an individual may repeat phrases he or she has just heard or heard in a movie in the middle of a conversation). They may also have difficulty starting or maintaining a conversation, hold one-sided conversations, or choose to only talk about their own interests when interacting with others.

Individuals with ASD sometimes avoid eye contact and refrain from making certain nonverbal gestures or facial expressions. Children with ASD may struggle with engaging in make-believe play and prefer to play by themselves than with other children, sometimes demonstrating a limited desire to share toys or other items when interacting with others.  An additional social-communication challenge for individuals with ASD includes difficulty recognizing social rules and personal space, making interactions problematic and sometimes provoking anxiety.

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Restricted Repetitive Behaviors, Interests, or Activities

Some individuals with ASD may also demonstrate unusual interests and repetitive behaviors. For instance, an individual may be intensely focused on a particular cartoon character, historical event, toy, or animal to the extent that the interest interferes with his or her ability to socialize or engage in other activities. In addition, some individuals with ASD engage in repetitive motor movements, use of objects, or speech (repeating certain words or phrases). Examples of repetitive motor movements may include flicking fingers, walking on toes, holding fingers in odd postures, unusual facial grimacing, or even self-injurious behavior. Individuals with ASD may also engage in repetitive play with certain toys or objects, such as arranging toy cars in a certain order, turning lights on and off repeatedly, or re-watching the same segment of a television show multiple times in a row.

Those with ASD also tend to seek out routines and sameness and may experience challenging behaviors when typical routines or their environment are changed. For example, an individual may get upset when a minor change is made to his or her bus route or when a classroom seating arrangement is adjusted. Additionally, individuals with ASD may be overly or under reactive to certain sensory experiences (such as the way things feel, taste, look, smell, or sound) within their environment, and as a result they may seek out certain sensory experiences or withdraw from them altogether. For instance, some individuals may choose to smell or lick their toys or other objects before using them, while others may be extremely sensitive to the volume of a movie or the feel of the fabric on their shirt and become upset at those sensory stimuli.

Because ASD is a spectrum disorder, the presence and intensity of these characteristics vary greatly from individual to individual, and some individuals may experience challenges and symptoms not listed above.

How Early Can ASD be Diagnosed?

Typically, concerns regarding the presence of ASD arise prior to three years of age. However, because ASD is a spectrum disorder, the early indicators of ASD may present themselves at different ages among different children. For some, delays or abnormal behaviors are observed early in infancy or toddlerhood, while others appear to be developing on track until around 18-24 months when regression or a loss of skills may occur. Most children with ASD are generally diagnosed around three years of age; this does not mean that a diagnosis must be given by age three, but rather that diagnostic criteria includes the fact that symptoms or indicators of ASD are present in the early developmental period.

What are the Early Indicators of ASD?

The challenges related to social communication and repetitive behaviors listed above are generally present early in a child’s development (oftentimes when a child is less than two years old). In children under two years of age, early indicators of ASD may include a child being limp or floppy when not seated upright or when being held, rarely crying in environments that would typically induce crying (such as pain, hunger, or discomfort), being difficult to comfort (or being comforted only by motion), and a limited understanding or use of specific gestures or other communication methods. A child with ASD may demonstrate a lack of babbling, pointing, or gesturing by 12 months of age, complete lack of speech by 16 months of age, and an inability to combine words by 2 years of age. In addition, children with ASD under the age of two may exhibit limited eye contact or social smiling, limited interest in or awareness of others in the environment, and unusual (high or low) sensitivity to the sensory features of an object or environment (sight, sound, smell, taste, feel).

Possible indicators of ASD in children over the age of two may have difficulty expressing wants or needs and have limited conversation skills or even lose the use of language. They may also experience high levels of stress related to minor changes within their environment, such as their favorite toy being put away in a different spot, and spend a significant amount of time seeking sensory input (such as spinning in circles or wedging themselves into tight spaces). In addition, children with ASD often engage in repetitive motor movements such as flapping their hands or even hurting themselves, and they oftentimes have a lowered sensitivity to pain. Sometimes, children with ASD have difficulty with imaginative play and the social rules or interactions of playtime, leading them to interact with others only to meet a particular need, such as asking a parent to fix a toy they were playing with alone or rewind their favorite scene from a movie repeatedly. Children over two years old are generally strong visual learners and react well to visual cues and routines.

Other possible early indicators of ASD in younger children may include a child not responding to his or her name, becoming attached to a particular toy or object, limited smiling, and a habit of playing with toys or objects in a different manner from typical peers.

Although the presence of these or any early indicators does not necessarily mean that a child has ASD, it may suggest that a child should be screened for ASD or other possible developmental delays by a medical professional.

Who Can Provide a Diagnosis of ASD?

Psychiatrists, developmental pediatricians, pediatric neurologists, and psychologists with expertise in childhood onset disorders and ASD can typically provide a medical diagnosis of ASD. Other disciplines, such as therapists social workers may screen and suggest further referral for ASD evaluation but are not qualified to make formal medical diagnoses.

 How is ASD Identified and Diagnosed?

For some children, signs and early indicators of ASD are apparent during infancy, with diagnoses occurring as early as 12 months. However, for others, the impact or appearance of symptoms may not be evident until later in their development when the challenges of social demands exceed the individual’s social abilities and capacities. The timeline of identification and diagnosis depend on the individual. There is no medical or biological test for ASD, so screenings and evaluations are important aspects of medical diagnosis process.

Once signs and indicators of ASD have become apparent, individuals may undergo a general developmental screening, hearing assessment, and, if needed, additional medical testing specific to parent and/or physician concerns.  Following the assessment and testing, if concerns regarding the presence of ASD remain, the physician or pediatricna would recommend a comprehensive evaluation by a multidisciplinary team to administer specific ASD diagnostic screening tools and possibly a referral to other specialists. Psychiatrists, developmental pediatricians, pediatric neurologists, and psychologists with expertise in childhood onset disorders and ASD can typically provide a medical diagnosis of ASD. Other disciplines, such as therapists social workers may screen and suggest further referral for ASD evaluation but are not qualified to make formal medical diagnoses.

During the comprehensive evaluation, one or more of the providers noted above would observe a child’s social skills and communication, cognitive ability (IQ), play skills, and everyday skills such as feeding and dressing to determine if the characteristics of ASD are apparent. In addition, the provider may conduct interviews with the child’s parents and other caregivers (such as teachers and therapists) or providers to learn about how the child behaves and interacts across settings and to obtain information about the child’s developmental, social, family, and behavioral histories. Additional testing may be undertaken to rule out other medical, mental health, and/or neurodevelopmental disorders.The medical professional may also utilize standardized diagnostic tools, such as the Autism Diagnostic Interview – Revised (ADI-R) or the Autism Diagnostic Observation Schedule – Generic (ADOS-G). A medical diagnosis of ASD is made according to diagnostic criteria as described in the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).

Medical Diagnosis vs. Educational Classification

In addition to a medical diagnosis, a student may receive an educational classification of ASD within the school setting. A medical diagnosis differs from an educational diagnosis, as explained in more detail below.

Obtaining a medical diagnosis of ASD, as outlined above, is an important step in identifying services that are determined by a provider to be a “medical necessity” for a child with ASD. These services may be covered by certain insurance providers and are related to the overall health of the child.

By contrast, within the school setting, a child may be eligible for special education services under ASD eligibility if the child meets diagnostic criteria for ASD as outlined within the current edition of the DSM-5 and if such symptoms or challenges result in a consistent and negative impact upon the child’s academic achievement and/or functioning performance as specified within the Individuals with Disabilities Education Improvement Act (IDEA) and the Indiana Department of Education Article 7. In order to determine special education eligibility, a multidisciplinary team comprised of qualified professionals (including school psychologists, speech-language pathologists, occupational therapists, and special education teachers, among others depending on the student’s unique needs) will conduct an educational evaluation of the student’s academic achievement, functional skills across settings, communication skills, motor and sensory responses, and developmental history. Following and based upon this evaluation, a case conference committee (CCC) comprised of various school professionals and the student’s parents will decide whether the student’s ASD symptoms result in a consistent and significant negative impact on his or her academic achievement or functional performance; if the CCC concludes that the student’s ASD does negatively interfere with learning, he or she would be determined to be eligible for special education services within the school setting.

A medical diagnosis of ASD may be used in consideration of eligibility decisions but is not necessary or sufficient to make the educational classification.  As such a medical diagnosis is not equivalent to a special education eligibility of ASD and vice versa. For more information about how medical diagnosis and educational determinations differ, refer to this guide by the Indiana Department of Education (IDOE).

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