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Early detection and identification of the first signs of autism play an important role in the implementation of support projects and appropriate interventions. Our study aims, on the one hand, to study the variations of the age of detection of the first signs of autism by the parents and, on the other hand, to explore the nature of these signs. It also seeks to verify whether the age of detection of early signs depends on certain characteristics such as the socioeconomic level of the parents. To do this, an analysis of the data collected as part of a prospective study of a population of 120 children was carried out. The results obtained indicate that the average age of identification of the first signs is around 19 months; and that the most reported signs relate to the area of verbal communication. However, no significant relationship was found between the age of the detection of the first sign and the economic level of the parents.
*Address all correspondence to: mounabendiouis3@gmail.com
1. Introduction
Autism is a neurodevelopmental disorder that disrupts the early development of the child in different areas, namely social, emotional, cognitive, communicative, verbal, etc. The most up-to-date classification used to define autism is that of the DSM-V (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). Called ASD (Autism Spectrum Disorder), autism is currently classified in the category of Neurodevelopmental Disorders. It is a set of conditions that begin during the developmental period leading to an impairment of personal, social, school, or professional functioning. This alteration is mainly characterized by two symptomatic dimensions: A. “Persistent deficit in communication and social interactions observed in various contexts” and B. “Restricted and repetitive nature of behaviors, interests or activities” [1].
In Algeria, the Ministry of Health has identified a number that varies between 400,000 and 500,000 in 2018. The prevalence was estimated 10 years ago at 1 per 10,000 inhabitants, while it has currently reached 1 child per 100 inhabitants. It is therefore a growing phenomenon.
The journey of the child and his family begins as soon as the warning signs are identified. This is the first stage during which parents, family members, or any actor in the early childhood sector notices unusual signs in favor of one or more developmental particularities. The High Authority of Health [2] specifies that any parental concern regarding verbal development and social communication (absence of babbling and communicative gestures at 12 months, absence of words at 18 months, and absence of word association at 18 months) should be considered a major warning sign and should be the subject of a specialist consultation focused on identifying an ASD.
All research agrees that the signs of ASD appear during the first 2 years of life. There is currently no pathognomonic marker for progression to ASD. Indeed, the majority of parents begin to notice the first signs from the age of 6 months. However, this disorder can only be diagnosed from the age of 30 months [3]. Before the age of 1, the signs noted relate mainly to sensory reactivity (hyporeactivity, hyperreactivity, or search for sensory stimulation), the flexibility of attention, and the quality of the production of spontaneous movements (hypo or hypertonicity) [4]. This period can also be characterized by certain specificities relating to the level of alertness of the child (calm or irritable); its emotional regulation, exploration of the environment, but also on the quality of sleep and dietary diversity [5].
The current view of ASD baby-to-be-centered research methods is that there are three main methods [6]:
The retrospective method consists of retracing the history of the neurodevelopmental disorder on the basis of precursor clues to the domains or altered functions. It is mainly based on the use of family films and information collected during parental interviews.
The prospective method consists of targeting certain areas of development such as motor skills, language, the sensory or emotional area, and identifying the child’s development in these areas, while identifying the times when deviations from typical development appear.
The predictive method: a method currently being tested in psychopathology and child psychiatry, which has already brought results in certain areas such as the early detection of skin cancers for example. The experimental approach aims to first check whether the six entities that make up the neurodevelopmental disorders will be found or not, then to take into consideration the network of neurons with all the parameters that can influence this network as well as the trajectory of the child’s development, namely genetic, epigenetic, sociological, psychological, neuropsychological but also environmental and familial. Then in a last step, make predictions and deduce the evolution of the most relevant functional areas [6].
More and more studies are focusing on the question of identifying the first signs of ASD [7, 8]. This orientation is largely explained by the challenge of identification and early diagnosis in the implementation of support projects and interventions adapted to ASD, in order to reduce additional disabilities. It is therefore essential to follow very closely the development of children in whom communication is not established in an ordinary way in order not to delay a possible diagnosis and to allow early treatment [9] .
Adrien [10] uses the term “functional and developmental dysregulation” to describe the developmental characteristics of babies at risk because we notice at a very early age a disharmony concerning all psychological functions. Deegenne [11] and his collaborators conducted research on the early detection of autism, and more specifically on the interrelational sphere of the infant, focusing on the period from birth to 6 months, which they consider to be a little investigated period, yet it is fundamental for the subsequent development of the child. Compared with normal children, the analysis of home movies highlights the presence of an early interactive dysfunction in infants later diagnosed with autism, from the first month of life (commitment and visual attention, deficit in tonic-postural dialog, deficit in emotional expression) [11].
The concerns of parents appear in the majority of cases early. Indeed, DiLalla and Rogers [12] point out that 38% of parents of children with ASD worry toward the end of the first year, 41% during the second year, 16% identify abnormalities between the second and the third year, and finally, 5% from 3 years. De Giacomo and Fombonne [13] conducted a study on the nature of the first signs suspected by parents. They have indeed found that it is the delay in the appearance of language that is the anomaly most often identified initially (53.7% of cases) and that the particularities of interactive and social responses are identified in 17% of cases.
We hypothesize that the average age of recognition of the first signs by parents is around 18 months. Similarly, we assume that the nature of the first signs mainly concerns the sphere of non-verbal communication such as response to the name, eye contact, joint attention, etc. Finally, we expect the age of onset of the first signs to be correlated with the socioeconomic level of the parents. In other words, the higher the socioeconomic level of the parents, the earlier the age of detection of the first signs.
Our research was carried out in Tlemcen (Algeria) in a psychiatry and psychotherapy office. It is a private practice in which a psychiatrist, two psychologists, and a speech therapist practice. Consultations are conducted with adults with various psychiatric and psychological pathologies, but also with parents with children who have psychological developmental disorders and more particularly neurodevelopmental disorders (ASD, learning disabilities, ADHD, etc.)
The study therefore focuses on an analysis of data collected as part of a prospective study. The latter was carried out on the basis of evaluation files carried out in the context of consultations with parents who suspected an autistic disorder in their children. The study population is an Algerian population, which consists of 120 parents of children at risk whose chronological age varies from 15 to 60 months (Table 1).
Boys
Girls
Sex (N)
92
28
Chronological age (average in months)
48
38
Fathers
Mothers
Sex (N)
60
60
Average chronological age year month)
42 (504)
35 (420)
Table 1.
Population characteristics.
4.2 Tools
A data collection grid was designed for this research. This grid includes several parameters that can provide information on the child but also his entourage. Among these parameters, we can cite:
General information about the child.
Information about parents.
Anamnesis.
Information on screening or diagnosis.
The variables retained for this study are: the age of identification of the first signs by the parents, the nature of the signs observed, and the socioeconomic level of the parents.
For parents whose screening has not yet been carried out, we relied on two instruments used to identify signs related to Autism Spectrum Disorder: the M-CHAT and the ADOS-2.
The M-CHAT (Modified Checklist for Autism in Toddler) is an instrument that can detect the first signs of autism. It is aimed at parents with children aged 16–30 months and includes a set of questions (23) that cover several areas of development. A first screening test for autism, the CHAT (Checklist for Autism in Toddlers), was proposed and validated in the 1990s by a team of researchers including Simon Baron-Cohen. The M-CHAT is passed through a structured interview with the parents. The latter must answer yes or no, depending on the current behavior of their child. There are six key items in this test:
Item 2: Interest in other children.
Item 7: Proto-declarative pointing (pointing to indicate interest in something).
Item 9: Bringing objects to parents.
Item 13: Imitation.
Item 14: Child’s response to first name when called.
Item 15: Ability to follow the adult’s score.
If the child fails two or three of the items considered predictive of autism spectrum disorder, follow-up and further evaluation should be considered.
The ADOS-2 Autism Diagnostic Observation Schedule or Observation Scale for the Diagnosis of Autism developed by Catherine Lord in 1989 in the United States. This is the second version of a semi-structured tool, which makes it possible to observe the socio-communicative behavior of the child, and this, through a succession of playful scenes making it possible to evaluate the quality of the social openings but also the emotions and the level of imagination.
4.3 Procedure
The study took place over a period of approximately 2 years. The first year was devoted to data collection.
The procedure went through two main stages:
4.3.1 Reception of parents who have suspected abnormalities in their children
This process was carried out within the framework of consultations within a medical office of psychiatry and psychopathologies. It was about collecting through the grid we designed; information on the child, on his family and to trace the history of his development, and this, within the framework of a semi-structured interview with both parents.
4.3.2 Passing the M-CHAT and/or the ADOS-2
This step mainly focused on the child since a direct observation of his behavior was made, supplemented by a handover of ASD screening tools. The aim was to ensure that these were children at risk for Autism Spectrum Disorder and not another developmental disorder.
4.3.3 Data collection, tabulation, and analysis
Data from 120 children were collected, analyzed, and then categorized. The age in months of detection of the first anomalies by the parents was retained as well as the nature of these anomalies. Codes were assigned according to the altered domain. In other words, we have divided all the warning signs according to two main categories: negative signs, which include delays in the field of non-verbal communication, verbal communication, motor skills, sociability and emotions; and positive signs, which refer to behavioral particularities and sensory.
The socioeconomic level of both parents was also taken into consideration. Indeed, the professions of each parent were categorized according to (Table 2).
Remember that the main objective of this research is to first identify the average age of detection of the first signs of ASD by parents and then identify the nature of these signs. In other words, we seek to identify what is the area most identified by parents. Statistical analysis was performed using SPSS software. The results are presented in the following tables:
5.1.1 Average age of recognition of the first signs by the parents
Table 3 shows that the average age of identification of the first signs of autism by parents is around 19 months.
N
Minimum
Maximum
Average (Months)
Age of the identification of the first signs
120
0
48
18,96
Table 3.
Average age of detection of the first abnormalities by the parents.
5.1.2 Nature and percentage of signs reported by parents
Figure 1 shows that the highest number of parents report signs that relate to verbal communication with a percentage of 30.50%; 28.81% of them first identify signs related to non-verbal communication; 12.71% identify social and emotional abnormalities; 11.86% of parents identify sensory particularities; 11.2% are alarmed by behavioral particularities; and finally, 5.06% of them identify motor specificities.
Figure 1.
Percentage of different warning signs reported by parents.
5.1.3 Identification of warning signs of ASD and economic level of parents
An analysis of variance was carried out in order to know if a difference exists between the different economic levels of the parents in the age of the identification of the first signs.
5.1.4 Economic level of fathers
Table 4 shows that the p-value (0.48) is greater than 0.05. These results indicate that there is no significant difference between the economic levels of the fathers in the age of detection of the first signs of ASD. However, the descriptive analysis shows that fathers with a high socioeconomic level detect precursor signs earlier than parents with medium and low socioeconomic levels (mean, standard deviation 21 (8.78)).
N
Economic level of fathers Mean (standard deviation)
F test
P value
High level
Medium level
Low level
Age of detection of first signs
120
21 (8.78)
18.79 (10.3)
17.83 (10.01)
0.75
0.48
Table 4.
Economic level of fathers and age of detection of first signs.
5.1.5 Economic level of mothers
Table 5 indicates that the p-value (0.31) is greater than 0.05. This result reveals that there is no statistically significant difference between the economic levels of the mothers and the age of detection of the first signs of ASD by the parents. On the other hand, the descriptive analysis highlights that mothers with a low economic level detect the warning signs earlier than mothers with a higher and average level (mean, standard deviation (10.27)).
N
Economic level of fathers Mean (standard deviation)
F test
P value
High level
Medium level
Low level
Age of detection of first signs
120
15.23 (8.99)
8.55 (9.09)
19.70 (10.27)
1.17
0.31
Table 5.
Economic level of mothers and age of detection of first signs.
5.2 Discussion
There is a consensus on the question of the need to spot and identify early the developmental particularities that could evolve into a neurodevelopmental disorder. Pry [6] points out that this question of identifying signs is based on both theoretical and practical reasons. The theoretical reasons consist of saying that TND (neurodevelopmental disorders) in particular Autism Spectrum Disorder is of early and neurodevelopmental origin, the first behaviors tend to change in meaning but also in function with the advancement in age. The practical reasons relate primarily to aspects of early interventions that aim to change the developmental trajectory of these behavioral formulations.
Therefore, this study focused on the question of the identification of early signs by parents. This is therefore a “retrospective” study based on data from interviews with parents, the main objective of which was to estimate the average age at which parents identify the warning signs of ASD, but also to identify the signs most reported by parents (concerns relating to motor, verbal, emotional, social development, etc.).
The results of our study show that the first signs of ASD are on average identified by parents around 19 months. In other words, it is only from the age of one and a half that parents begin to observe particular behavioral formulations. Thus, the calculation of the percentage of signs indicates that the most reported signs concern the field of communication, first “verbal” (30.51%), then “non-verbal” (28.81%).
The results obtained are in agreement with certain studies, notably that of Rogers [14] according to which the majority of parents (41%) identify the first signs during the second year. Most of the research on this subject emphasizes that parental concerns appear around the second year Guinchat et al. [8].
Concerning the origin of the first concerns, it is mainly about the delay in the development of the language [7, 13, 15].
These results can be partly explained by the involvement of certain factors, in particular the cultural and social factor. Indeed, parents may not be sensitive to the typical development of intentional communicative acts addressed to the environment and its deviations such as gazing, sharing attention, or pointing. These acts of course precede the appearance of the first words. Therefore, the concerns are quite late because the parents mainly wait for the age when the expressive language (first words) is supposed to appear to be alarmed. The knowledge of the parents on the early psychological development of the child and more particularly, the sociocommunicative development, is probably not sufficient to be able to detect its anomalies, delays, or deviations.
We also note that only 5.08% of the signs relate to motor behavior, except that several studies confirm that the first manifestations relating to developmental disorders concern motor development with atypical ocular motor skills, asymmetrical postures, or even particularities of the spontaneous movements [16]. These relatively late concerns can also be explained by the number and position of the child among the siblings. Indeed, during the interviews within the framework of consultations with the parents, we noted that having only one child or when it was the first child in the siblings, the parents had difficulty in evoking information related to the early development of the child because of the lack of a possibility of comparison with children of the same age. This situation can lead parents to miss a set of early signs, including signs relating to motor or sensory development.
A third element that can be used for interpretation consists of taking into consideration the “regressive” process usually cited in research on the baby to become of ASD. Indeed, the data of the literature underline the presence in certain cases of a regression or even a loss of communicative and language skills between 16 and 20 months. This phenomenon may explain the relatively late identification of the first signs.
We have also sought to study the factors that may possibly influence the age of identification of the first signs, in particular the socioeconomic factor of the parents, first of the fathers and then of the mothers.
The statistical analysis reveals an absence of significant link between the socioeconomic levels of the parents and the age of the identification of the first signs. In other words, the social and economic level of the parents has no influence on the precocity or not of the identification of the first signs of ASD. Parents with a higher level are not necessarily able to detect the first anomalies early.
One way to interpret this result is to say that the profession of parents with a higher level leads them not to spend a lot of time with their children, and therefore, they have less opportunity to carefully observe the appearance of the first signs.
This observation was assessed during the interviews with the parents and confirmed by the descriptive analysis concerning the economic level of the mothers. Indeed, the results of our study tell us that mothers with a low economic level (generally inactive mothers) tend to spot the first signs well before mothers with a higher to average level.
Autism is an early-onset neurodevelopmental disorder, the first behavioral expressions of which are the subject of several studies. A broad consensus exists on the need to identify the first behavioral deviations as early as possible. The interest of this approach consists of answering the following problem: can early interventions (educational, developmental, behavioral, or others) possibly modify the evolutionary course of the child, but also what is the most that makes it possible to modify the child’s development as quickly as possible (before school age).
This work shows that Algerian parents detect the signs of autism during the second year of life (19 months) and that the signs reported relate mainly to nonverbal communication (pointing, gaze, gestures) language skills (delay appearance of language). Thus, the socioeconomic level of the parents is not linked to the age of detection of the first signs.
Parents should therefore be encouraged to carefully observe the child’s developmental sequences in order to be able to identify developmental deviations earlier, which may relate to a set of areas (other than the area of non-verbal communication and verbal) such as motor development but also emotional or sensory.
We would like to thank all the people who contributed to the realization of this work.
First of all, we would like to express our gratitude to the parents of children with autism for their patience and availability to answer our questions.
We would also like to thank Doctor Lotfi Bendiouis for giving us the opportunity to carry out this work in the field by welcoming us to his psychiatry and psychotherapy practice.
diagnostic and statistical manual of mental disorders, fifth edition.
HAS
high authority of health.
ASD
autism spectrum disorder.
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Written By
Yamina Hammas and Sarah Bendiouis
Submitted: 11 September 2022Reviewed: 12 September 2022Published: 14 November 2022
Open access peer-reviewed chapter
