The American Psychiatric Association defines autism spectrum disorder (ASD) as “a neurodevelopmental disorder characterized by impaired social communication and social interactions with unusual responses to stimuli, restricted interests, and repetitive behaviors.” According to the Centers for Disease Control, autism occurs in 1 of every 37 males and 1 of every 151 females, for an overall prevalence of 1 out of every 59 children.
With such a high occurrence, family nurse practitioners and other primary care providers will almost inevitably encounter children with autism—many of them not yet diagnosed. FNPs may therefore bear the responsibility for detecting autism in young patients. They should understand the indications of autism, understand how to use appropriate screening tools, and be comfortable talking to parents after an autism diagnosis occurs.
Family nurse practitioners can obtain the training to be successful in this task through academic programs such as Duquesne University’s Family (Individual Across the Lifespan) Nurse Practitioner online Master of Science in Nursing (MSN). Also offering Post-Master’s Certificate programs to meet the needs of RNs who already an MSN, Duquesne’s online master’s in nursing prepares students pursuing MSN careers to meet the challenges of the modern primary care environment.
Know the Signs
The first tool in every FNP’s arsenal is knowledge. FNPs must know the signs of autism in young children and be constantly on the lookout for suspicious behavior and characteristics. The website The Nurse Practitioner sorts the primary autism “red flags” into these categories:
- The FNP should look for social behavior, such as smiles and eye contact, in children as young as 2 months old. By 9 months, children should exhibit “joint attention,” or the desire and ability to interact with others. A lack of response to stimuli, such as the child’s own name, is concerning; so is overreaction to stimuli, such as tantrums or fear. Behavioral extremes of any sort are a cause for concern and further investigation.
- Speech delays are common in ASD. The FNP should therefore make sure that young patients are meeting appropriate developmental speech milestones, such as babbling by 12 months, use of one word other than “mama” and “dada” by 16 months, and use of two-word phrases by two years. Older children who are more vocal may display unusual pace, pitch, volume, or other qualities in their speech. Alternately, a child who has been vocal may suddenly stop speaking.
- Children with ASD may be over- or under-responsive to sensory stimuli. They may respond to these differences through extreme behavior, such as screaming with discomfort when clothing is too scratchy or putting their hands over their ears to block noise. They may also flap their hands, flick their fingers, or rock their bodies in an effort to self-soothe. Any unusual response to sensory input warrants consideration of autism.
- Most children with ASD meet major motor milestones, such as crawling and walking, on time. They may, however, display poor muscle tone, loose joints, and lack of coordination. Some children with ASD also walk on their toes, a habit that should viewed with suspicion.
Autism Screening
Along with simple observation, screening tools and techniques can help to identify autism in patients as young as 18 months. The American Academy of Pediatrics therefore recommends standard autism screening at 18 months and again at 24 months, as important clues can develop during this period.
The Nurse Practitioner identifies the important aspects of autism screening:
Risk factors.
The primary care provider should review a developmental history to look for autism risk factors. Known risk factors include low birth weight, prematurity, prenatal infections involving fever, polyhydramnios (excess fluid in the amniotic sac), in vitro fertilization, multiple births (twins and triplets are at greater risk), advanced maternal and paternal age, large difference between maternal and paternal age, and less than 18 months between the delivery of siblings.
Family history.
A review of family history will reveal if a child has siblings with ASD. This finding is cause for heightened concern because autism has a 10% to 25% recurrence rate within families. Close relatives who have developmental or psychiatric diagnoses are also cause for concern.
Parental concerns.
The primary care provider should explicitly ask parents if they have any concerns about their child’s behavior or development and pay close attention to any worrisome answers.
Standardized screening.
If the primary care provider sees any reason for concern, he or she may choose to administer standardized screenings. An example is M-CHAT, the Modified Checklist for Autism in Toddlers. Parents are asked a series of 20 questions, such as “Does your child point with one finger to ask for something?” and “Does your child look you in the eye when you talk to her?” A “fail” answer on any question leads to follow-up questions. Two failures are considered a positive screen, meaning the child should be referred for more extensive evaluation.
Talking to Parents
If all evidence points to an autism diagnosis, the primary care provider will need to have a difficult conversation with the child’s parents. Dr. Doris Greenberg has some words of advice for coping with this situation. “Don’t talk around the diagnosis—identify the elephant in the room and get on with it,” she says.
The provider should explain the diagnosis in clear terms and emphasize the need to start treatment right away. He or she should not act upset or say frightening things about the child’s future. With early intervention, children with ASD can make great strides and live full, happy lives—and not only can nurse practitioners diagnose autism, they can set families on the path to the best possible outcome.