Spectrum Disorder: Insights From Studies of High-Risk Infants Clinical Assessment and Management of Toddlers With Suspected Autism

With increased public awareness of the early signs and recent American Academy of Pediatrics recommendations that all 18and 24-month-olds be screened for autism spectrum disorders, there is an increasing need for diagnostic assessment of very young children. However, unique challenges exist in applying current diagnostic guidelines for autism spectrum disorders to children under the age of 2 years. In this article, we address challenges related to early detection, diagnosis, and treatment of autism spectrum disorders in this age group. We provide a comprehensive review of findings from recent studies on the early development of children with autism spectrum disorders, summarizing current knowledge on early signs of autism spectrum disorders, the screening properties of early detection tools, and current best practice for diagnostic assessment of autism spectrum disorders before 2 years of age. We also outline principles of effective intervention for children under the age of 2 with suspected/confirmed autism spectrum disorders. It is hoped that ongoing studies will provide an even stronger foundation for evidence-based diagnostic and intervention approaches for this critically important age group. Pediatrics 2009;123:1383–1391 A DISORDER IS the most severe form of a spectrum of related disorders (autism spectrum disorders [ASDs]) characterized by impairments in reciprocal social interaction and communication and by the presence of repetitive, inflexible behavior.1,2 At an estimated prevalence of 1 in 150,3 the ASDs are among the most common forms of severe developmental disability. Parents of children with ASDs generally identify concerns by the age of 12 to 18 months.4–7 However, recent US data suggest that the average age of diagnosis remains at 4 years8,9 and possibly older in socioeconomically disadvantaged groups.10,11 In part to address the unacceptably long interval between parents’ initial concerns and confirmation of diagnosis, the American Academy of Pediatrics (AAP) and other groups have recently published clinical practice guidelines on the early identification, screening, and diagnosis of ASDs.12,13 With AAP recommendations that all 18and 24-month-olds be screened for ASDs,12,14 and active public awareness campaigns by the Centers for Disease Control and Prevention and other public and private organizations,15–17 there is increasing demand for diagnostic assessment of very young children. However, unique challenges exist in applying current diagnostic guidelines for ASDs to children under the age of 2, because standard criteria of the Diagnostic and Statistical Manual, Fourth Edition and International Classification of Disease, Tenth Edition, gold-standard diagnostic tools, and even the best judgment of experienced clinicians have rarely been applied to this age group. To address these challenges and www.pediatrics.org/cgi/doi/10.1542/ peds.2008-1606 doi:10.1542/peds.2008-1606 Drs Zwaigenbaum, Bryson, Rogers, and Lord contributed equally to this work.