Relationship between age of recognition of first disturbances and severity in young children with autism

Baghdadli A, Picot MC, Pascal C, Pry R, Aussilloux C

European Child & Adolescent Psychiatry 2003; 12:122.

Question: Does the age at which parents or caregivers first notice symptoms of autism predict the severity of autism in children?

Background: Parents of children with autism often report that looking back prior to the formal diagnosis, they had noticed that their child wasn’t meeting his/her developmental milestones on time (e.g., first words), or that he/she wasn’t making good eye contact. Parents may be put off their concerns by relatives or even their physicians, so the diagnosis of autism may be delayed until after the child is two or three. This study looked at whether or not the age at which parents first noticed disturbances in their child’s development could be related to the severity of the child’s condition. That is, do children who show abnormalities earlier also show more severe symptoms of autism?

Design: Survey of a convenience sample, based upon parental consent.

Setting: 49 child psychiatry clinics in France.

Participants: The participants were 193 children formally diagnosed with a pervasive developmental disorder (PDD), ranging in age from 21 months to 7 years. 82.4% (158) of the children had a diagnosis of infantile autism, 14.6% (28) had atypical autism, 1% (2) had Asperger’s syndrome, and 2% (5) had another PDD. 81.3% were boys, and 18.7 were girls. 39% of the children had another medical condition in addition to their pervasive developmental disorder, most of which were neurological disorders or conditions that were genetic or present at birth.

Assessment of prognostic factors: Parents were asked at what age they first noticed there was something wrong with their child’s social and communication skills. A parent interview was used to get information on the child’s communication, social, and daily living skills. Parents also provided information about the severity of the child’s autistic symptoms, whether they had any co-existing medical conditions, and family social factors to see if any of these issues were predictive of the child’s later development. Children were grouped according to whether their developmental problems had been noticed prior to 18 months or after 18 months.

Main Outcome Measures: The Vineland Adaptive Behaviour Scale (VABS), and the CARS were administered and a speech assessment was conducted. The child’s medical history, age at the first psychiatric consultation, age at recognition of first disturbances (ARFD), birth order, and the parents’ social class were also determined.

Main Results: More than one third of the parents (37.6%) noticed developmental abnormalities in the child before his/her first birthday; 20.6% reported problems when the child was between 12 and 18 months, 19.4% saw difficulties between 18 and 24 months, 18.8% between 24 and 36 months, and 3.6% after 36 months. The severity of autistic symptoms was linked to the age of recognition of first abnormalities (ARFD), as was greater developmental delay and deficits in social adaptation, specifically independent living skills. The child’s sex, their birth order, and the family’s social class were not related to ARFD. Children who were recognized before 18 months had more severe symptoms than children who were recognized after 18 months. They also had lower social, communication and daily living skills levels. A strong association was seen between early recognition and neurological diseases and hearing impairment. The presence of social adaptation deficits and medical disease were most closely related to early recognition.

Conclusions: The authors caution that the age at first recognition is not necessarily indicative of when the symptoms first started, and that many of the symptoms are due to congenital conditions that may or may not be related to the autistic disorder but to developmental delay in general. Early recognition was more related to developmental delay and neurological problems than to the severity of autism. The best predictor of ARFD was daily living skills on the VABS and neurological problems or auditory difficulties.

The authors suggest that all children be screened for developmental disorders as part of usual care because of the importance of early intervention in reducing the deficits associated with an autistic disorder.