Autism can present challenges to PCPs
Diagnosis, treatment elude 'magic bullet'

The average age of autism diagnosis in the U.S. is 8 years; in Boston, the average falls between 3 and 5 years. Children's Hospital Boston makes most of its diagnoses before age 3. The earlier autistic spectrum disorder is caught, the earlier intervention can begin. However, at very young ages there is no reliable way to determine how severe the problem is. Early evaluations can give false negatives, as mild disorders on the spectrum, such as Asberger's Syndrome, are easily missed at a young age. Autism is often misdiagnosed as a language disability, mental health issue, obsessive-compulsive disorder or ADHD.

On first impression, 5-year-old Peter does not seem to have special needs. His watchful eyes light up when he sees a toy rocket he likes, and he is perfectly agreeable as Ellen Hanson, PhD, invites him to play some games with her. Dr. Hanson, a psychology fellow in the Developmental Medicine Center at Children's Hospital Boston, is evaluating the progress of Peter's intensive therapy for autism†in part because officials at Peter's school insist, despite a clear diagnosis, that he suffers from ADHD or another disorder.

For schools and parents, it can be difficult to see the connection between behavior such as Peter's and autistic spectrum disorder. Peter functions on the high end of the autistic spectrum†well above the 80 percent of autistic children with co-morbid mental retardation, language disability or severe disconnection from the external world. Yet as Dr. Hanson and Janice Ware, PhD, associate director of the Developmental Medicine Center, conduct Peter's evaluation, they illuminate the subtle and not-so-subtle signs of high-functioning autism.

For example, although Peter is well behaved, he makes few social references such as seeking parental approval or making eye contact. He plays happily with Dr. Hanson, but fixates on the toy rocket and ignores every attempt by his playmate to develop an interaction. He learns a short story about a bird, but retells it without elaboration, gesture or inflection.

Diagnosing autism can be particularly difficult for primary care providers, who only see a snapshot of child behavior and interactions in a typical office visit. And unfortunately, there is no simple checklist of screening questions that can make the task any easier. "I've asked many pediatricians to name the top indicators for children on the autistic spectrum, and they've all had different answers," says Dr. Ware. "The fact is, there is no magic bullet. You can't simply count the number of words a child has acquired by a given age; you have to assess the quality of the child's social interactions."

Although autism was once primarily thought of as a communication disorder, the most reliable indicators relate to a child's inability to relate socially. On balance, says Dr. Ware, there should be predominantly positive interactions†including the ability to share attention with others, spontaneous initiation of social conversation, being flexible and transitioning easily between activities. Other behavioral indicators to look for include problems establishing regular sleep patterns, not eating a reasonable range of foods, and being late hitting language development milestones or not speaking at all.

Since evaluations are complex, time consuming and highly individualized for each patient, providers who suspect autism should refer to a developmental medicine specialist immediately. A specialist can make a diagnosis and determine what therapies†such as intensive applied behavioral analysis (ABA), relational intervention and speech pathology therapy†are appropriate for your patient.