Diagnosing autism in children during the pandemic

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We talk often in pediatrics about the importance of early identification and early treatment of autism spectrum disorder, with its hallmark issues of social communication problems and restricted repetitive behavior patterns. “Early” means paying particularly close attention to the behavior and development of children between ages 1 and 3, and checking in with their parents about any concerns.

But what does that mean for young children who have now spent half their lives — or more — in the special circumstances of the pandemic?

Dr. Heidi Feldman, a professor of developmental and behavioral pediatrics at Stanford University School of Medicine, said, “We don’t know what the impact of one year of very restricted social interaction is going to be on children.” Some of the behavior patterns that children are showing now may be the result of these strange living conditions, or they may reflect stress, trauma and the social isolation that many families have experienced, she said.

Dr. Feldman said that first-time parents who have been operating in the increased isolation of the pandemic may have very limited context for appreciating where their child’s behavior falls. They’re missing the input they might usually get from teachers and child care providers.

Dr. Eileen Costello, a clinical professor of pediatrics at Boston University School of Medicine and chief of ambulatory pediatrics at Boston Medical Center, said, “Especially for the really little ones, the only eyes that are on them are their parents’. They’re not seeing uncles and aunts and cousins, not in preschool.”

Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, said that because parents right now are at home more, sometimes they are more likely to notice unusual or concerning patterns — repetitive behaviors, or communications problems like echolalia, in which a child repeats words. This can be completely normal, and is in fact part of how children learn to talk, but it can be concerning if it’s the major part of a child’s language as the child grows.

Catherine Lord, a professor of psychiatry and education at the University of California, Los Angeles, said, “I’m doing diagnoses right now in my back yard, which is insane.” But with the protective gear that would have to be worn at the hospital, she said, “we look like we’re from outer space,” and could be too intimidating to small children.

Dr. Lord said. “We do remote interviews with parents, we try to see videos of the kid, then have them come — we have a big back yard.” And they continue to use the Zoom technology, even across the yard.

The standardized assessment for autism spectrum disorder can’t be done masked, because it depends on interpreting the child’s expressions and observing reactions to the examiner’s facial expressions. Dr. Lord said there is a shorter version that children can do with their parents — everyone unmasked — while the clinicians watch without being in the room.

Developmental assessments can include remote visits. “We have gotten quite good at doing telehealth evaluations,” Dr. Feldman said. “We get the kids in their own environments and their own toys, we get to see what they do at home.”

“Sometimes making the diagnosis of autism over telehealth in a very young child is incredibly challenging,” Dr. Spinks-Franklin said. “Families that don’t have access to consistent reliable high-speed internet are also impacted — a video visit may not be possible or may be interrupted.”

“Those who are vulnerable already are always going to be more severely affected — families who already had more limited access to primary care providers or are underinsured or uninsured already had a harder time,” Dr. Spinks-Franklin said.

Right now, because families are isolated or may not have good access to medical care, neurodevelopmental problems may be being missed in these critical early years, when getting diagnosed would help children get therapy. On the other hand, some children who don’t have these underlying problems and are just reacting to the strange and often anxiety-provoking circumstances of pandemic life may mistakenly be thought to be showing signs of autism.

Parents and even doctors may worry about autism spectrum disorder in children who have attention deficit hyperactivity disorder or anxiety, and who are being seen in unusual situations — in a parking lot, for example. “I’ve been undoing diagnoses,” Dr. Lord said. “It’s not surprising that a kid is looking a bit less relaxed.”

Dr. Spinks-Franklin said that the pressures of the pandemic may act on children as other stresses do, and show up as more extreme behavior, such as more frequent tantrums or increased irritability.

“All that bounces is not A.D.H.D.; all that flaps is not autism,” Dr. Spinks-Franklin said.