Early assessment and intervention with autism and related developmental difficulties–benefits and challenges

Dr Joe McCleery

Autism is a neurodevelopmental condition characterised by pervasive difficulties and delays in social and communication skills, as well as restricted interests and repetitive behaviours. Current estimates suggest that autism is incredibly common, affecting approximately 1 in 100 children. Increasing awareness of autism has resulted in increased research activity on early diagnosis and early intervention. This, in turn, has resulted in social and political movements toward earlier and earlier diagnosis. In the most extreme cases, researchers in the USA have called for awareness of the “signs of autism” in the first 12-months of life.

The UK approach to healthcare is too financially savvy, and too sensible, to adopt such a call for very early detection of autism. There are no tools currently available, or on the visible horizon, that would allow for the accurate and effective detection, or diagnosis, of autism in the first year of life. Although research has identified some behavioural markers of risk for the possible later development of autism, such as not responding to one’s name being called at 12-months of age, such measures are a very long way from constituting effective diagnostic measures. Furthermore, there is currently insufficient evidence to support intervention with autism during the first 12- to 16-months of life. Together, these factors present serious practical and ethical dilemmas for the promotion of a policy of very early diagnosis.

At the same time as this, many parents of children with autism express reasonable and serious concerns about their child’s language development between approximately 18- and 30-months of age. In fact, approximately 70% of children with autism experience language-learning delays early in life, and delays in language skills are one of the most common initial signs that lead parents of children with autism to the clinician’s office. There is also evidence to support early behavioural intervention for increasing language and cognitive skills in toddlers with autism. This finding is important, because there is also evidence that strong language and cognitive skills measured at 5-years of age are positive predictors of critical cognitive and adaptive outcomes in adulthood in this population, ultimately increasing quality of life, options, and opportunity across the lifespan for these individuals.

A common response provided to parents first expressing concerns about their child’s language development is to re-assure them, telling them that children typically “grow out of” such language-learning difficulties. While research does generally support this notion at the level of groups of children, research also points clearly to important individual differences that need paying attention to. Specifically, in addition to autism, there are several other related conditions which, evidence suggests, are associated with sufficient long-term difficulties to warrant specialist evaluation and, often, early intervention. As a result, screening and examination of specific aspects of language difficulties, together with other aspects of development, is warranted for 18- to 30-month olds presenting with delayed language development.

First, one should screen or assess the child for autism-related features. These include evaluation of social engagement, interest in peers, presence of unusual sensory sensitivities, and presence of unusually repetitive behaviours.

Second, one should screen or assess the child for evidence of global developmental delay that includes not only language, but also cognitive and/or motor delays, which are often missed by both parents and professionals due to a focus on more obvious speech production delays.

Third, one should screen or assess the child for difficulties with language understanding/comprehension. Children whose language difficulties cut across language production and understanding are known to have, on average, more persistent and long-term language-learning and other difficulties, than children with delays which are specific to language production.

Finally, one should screen or assess the child for evidence of oral motor production difficulties, including evidence of laboured or severely “garbled” speech production attempts. These may be a sign of apraxia or dyspraxia, which also warrant further assessment and possible intervention.

Specialist assessment is warranted with children presenting with any of the above-described concerns. Although autism cannot currently be effectively diagnosed until 30- to 36-months of age in many cases, children presenting with clinical risk of autism or these related language-learning and other difficulties can, and should, be assessed for needs for intervention and support much earlier than that. Along with on-going efforts to develop better support programmes for adults on the autism spectrum in securing and maintaining the jobs they desire, early assessment and intervention has the potential to deliver long-lasting and critically valuable positive effects on individuals and society.