Autism spectrum disorder (ASD) is a developmental disorder characterized by ongoing problems with social communication, social interaction, and restricted, repetitive behaviors, interests, and activities.1,2 While an experienced clinician can reliably identify ASD in children as young as age 2 years, many children do not receive the diagnosis until they are much older, which delays effective treatment.3 Parents may be able to spot signs and symptoms of ASD very early in their child's life, which can lead to earlier evaluation and treatment. This article describes what you should do to prepare for the initial evaluation if you suspect your child may have ASD, or if you think you might have ASD.
Prevalence of Autism Spectrum Disorder
In the United States, approximately 1 in every 36 children aged 8 years is estimated to have ASD.4 Boys are approximately 4 times as likely to be diagnosed with ASD than girls.4 Because ASD is a lifelong condition, an estimated 2.2% of U.S. adults (approximately 5.4 million people aged 18 years and older) are living with ASD.5
Early Signs of Autism Spectrum Disorder
Autism spectrum disorder can be diagnosed at any age.6 Symptoms of ASD are generally identified when a child is aged 12 to 24 months, though they may appear earlier than 12 months if severe, or later than 24 months if subtle.1 Parents or caregivers may be able to notice early signs of ASD before their child is 1 year old.2
Typical early symptoms of ASD include1:
A delay in language development;
A lack of social interest or unusual social interactions (such as pulling someone by the hand without trying to look at them);
Abnormal patterns of play (such as carrying toys around but not actually playing with them); and
Atypical communication (such as knowing the alphabet but not responding to their own name).
The 2 types of symptoms of ASD are difficulties with social communication/interactions and restricted, repetitive behavior, interests, or activities.1
Specific social communication/interactions problems include avoiding eye contact, having difficulty using nonverbal gestures, using stilted or scripted speech, interpreting abstract ideas literally, having trouble recognizing one's own emotions as well as the emotions of other people, and having difficulty making or keeping friends.2
A child who shows restricted interests is extremely focused on a specific subject to the exclusion of other subjects and expects others to be just as interested in that subject.2 A child with ASD has inflexible behavior and extreme difficulty dealing with change, particularly changes in routine or participating in new experiences.2 Repetitive behaviors might include movements such as hand flapping, rocking, or spinning, being hypersensitive to stimuli such as loud noises, and arranging toys or other items in a very particular pattern.1,2
Studies have shown that, with rare exceptions, a child with ASD will experience deterioration in their social and communication behaviors over the first 2 years of life. During the second year of life (aged 12 to 24 months) repetitive behaviors and abnormal play typically become more obvious. A small number of patients with ASD experience these behavioral declines in adolescence. Some people with ASD may not seek an evaluation for ASD until they are an adult, possibly prompted by an ASD diagnosis in a child in their family.1,2
Autism Spectrum Disorder Screening: Resources and Tools
While parents can informally assess their child for signs and symptoms of ASD, they also can use tools designed for that purpose. While these tools generally are intended to be used by clinicians, they rely at least in part on input from parents, so parents may find it helpful to explore them before their child is evaluated by a specialist.
The Modified Checklist for Autism in Toddlers (M-CHAT-R; available at www.mchatscreen.com) is a screening tool intended to be used by primary care providers, specialists, or other professionals to determine a child’s risk for ASD.7 It consists of 2 parts: the M-CHAT-R and the M-CHAT-R Follow-up (M-CHAT-R/F).
The M-CHAT-R consists of 20 yes/no questions about how a child usually behaves. Scoring of the M-CHAT-R is interpreted as follows7:
Total score 0 to 2: Low risk. Repeat screen after second birthday for children under 24 months of age.
Total score 3 to 7: Medium risk. A clinician should administer the M-CHAT-R/F to obtain further details about at-risk responses. If the score is still 2 or higher, the child has screened positive.
Total score 8 to 20: High risk. The child should receive immediate diagnostic assessment and early intervention evaluation from a clinician.
If a child screens positive on the M-CHAT-R, a clinician should administer the M-CHAT-R/F, which consists of 20 pass/fail questions and detailed instructions for how to interpret the results.7 Because the goal of the M-CHAT-R is to detect as many cases of ASD as possible, it has a high rate of false positives, which means that not every child whose M-CHAT-R results suggest they are at risk for ASD will be diagnosed with the disorder.7 However, children who screen positive on the M-CHAT-R are at risk for other developmental disorders and should be evaluated by an experienced clinician.7
In addition to M-CHAT, several other tools that include input from parents can be used to screen children for development delays that might suggest a diagnosis of ASD3:
Ages and Stages Questionnaires (https://agesandstages.com) is a general developmental screening tool to be completed by a parent or caregiver. It features 19 age-specific questionnaires that address communication, gross motor, fine motor, problem-solving, and individual adaptive skills.
Parents’ Evaluation of Developmental Status (https://pedstest.com) is a general developmental screening tool. It is a parent-interview form used to screen for developmental or behavioral problems that warrant further evaluation.
Communication and Symbolic Behavior Scales (https://brookespublishing.com/product/csbs) is a standardized tool to screen for communication and symbolic abilities in children up to age 24 months.
Screening Tool for Autism in Toddlers and Young Children (https://vkc.vumc.org/vkc/triad/stat) is an interactive screening tool for children with suspected developmental delays. It features 12 activities that evaluate play, communication, and imitation skills.
Screening tools such as these are used to help identify a child who might have a neurodevelopmental delay such as ASD, but they do not provide conclusive evidence of a delay and they do not establish a diagnosis.3 Parents who thinks their child might have ASD should express their concerns to their child's pediatrician. The American Academy of Pediatrics recommends that pediatricians conduct general developmental screening of all children at 9, 18, and 30 months of age, and screening specifically for symptoms of ASD at 18 and 24 months.8 If necessary, the pediatrician will refer parents to a specialist who will conduct a thorough evaluation using the appropriate diagnostic criteria.
Autism Spectrum Disorder Diagnostic Criteria
In order to receive a diagnosis of ASD, a child needs to meet the criteria established by the American Psychiatric Association and published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.1 Those criteria can be summarized as follows1:
A. Persistent deficits in social communication and social interaction as manifested by all of the following:
Deficiencies in social-emotional reciprocity (such as an inability to engage in normal back-and-forth conversation);
Deficiencies in nonverbal gestures used in social interaction (such as problems with eye contact, body language, or understanding or using gestures); and
Deficiencies in developing, maintaining, and understanding relationships (such as a lack of interest in peers).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least 2 of the following:
Repetitive motor movements, use of objects, or speech (such as body rocking, arm or hand flapping, lining up toys, repeating words just spoken by another person);
Insistence on sameness, inflexible adherence to routine, or ritualized patterns of behavior (such as difficulty with transitions, rigid thinking patterns, need to eat the same food each day);
Highly restricted, fixated interests that are abnormal in intensity or focus (such as a strong attachment to peculiar objects); and
Hypersensitivity or hyporeactivity to sensory input or abnormal interest in sensory aspects of the environment (such as indifference to pain or temperature, adverse response to specific sounds or textures).
To meet these criteria, a child must not only have the required number of symptoms but the symptoms must have been apparent early in the child's developmental period and must cause significant impairment in functioning.1 These symptoms must not be better explained by an intellectual disability or global developmental delay.1
Autism Spectrum Disorder Checklist for Parents
To best help a child who they suspect might have ASD, parents can be better informed about the condition and diagnosis. Some checklist items for parents to address include:
Keep track of your child’s developmental milestones through the Centers for Disease Control and Prevention (CDC) milestone tracker app (https://www.cdc.gov/ncbddd/actearly/milestones-app.html), which outlines incremental milestones for children from age 2 months to 5 years.9
Research the initial signs/symptoms and diagnostic criteria of ASD.1
Use a developmental screening tool, such as the M-CHAT-R or Ages and Stages Questionnaire, to prepare for your child's initial diagnostic evaluation with their pediatrician.3
Seek out an evaluation from a specialist such as a psychiatrist or psychologist.2
Autism Spectrum Disorder Checklist for Patients
An adolescent or adult who suspects they may have ASD can follow a similar checklist:
Research the symptoms and diagnostic criteria of ASD.
Express your concerns to your primary care provider.
Seek out a specialized evaluation from a specialist.
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The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) addressed new initiatives and voted on several vaccine recommendations in their first 2024 meeting, held from February 28 to 29.
The ACIP discussed several vaccines during the 2-day meeting, including those for protection against COVID-19, Chikungunya, diphtheria and tetanus (DT), Hemophilus influenzae type b (Hib), polio, respiratory syncytial virus (RSV), meningococcal disease, and pneumococcal disease. The updated recommendations for vaccination against COVID-19, RSV, and pneumococcal disease are available here.
DT Vaccine
The DT vaccine, which was previously recommended for children younger than 7 years with a contraindication to pertussis-containing vaccines, has been discontinued in the United States. The ACIP now recommends the tetanus and diphtheria (Td) vaccine for this group, particularly in those who develop encephalopathy within 7 days of DT vaccination.1 Current guidelines indicate the diphtheria, tetanus, and pertussis (DTaP) vaccine as the first dose in the vaccination series. Children aged 7 years and older with contraindications may now receive Td for all remaining doses. Although it remains a viable option, the Td vaccine contains a lower dose of diphtheria toxoid, suggesting a decrease in its efficacy.
The ACIP approved the vaccines for children resolution for coverage of the Td vaccine in children younger than 7 years who have contraindications to pertussis-containing vaccines.2 This update is anticipated to be included in the recommended immunization schedule. Guidelines regarding the administration of a single booster dose of the Tdap vaccine among children aged between 11 and 12 years remain unchanged.
"
Revisions to the schedule should optimize protection against meningitis.
Meningococcal Vaccination
The meningococcal conjugate vaccine (MenABCWY), a pentavalent formulation from Pfizer®, was approved by the Food and Drug Administration (FDA) in October 2023. The ACIP now recommends the MenABCWY vaccine among children and adolescents for whom both the MenACWY and MenB vaccines are indicated at a single visit. The approval of the MenABCWY vaccine provides multiple options for revising the meningococcal vaccine schedule, including the elimination of a MenACWY vaccine dose in children aged 11 to 12 years and a change in the recommended age group for MenB vaccination to increase protection at the time of college entry.
Evidence suggests that college-aged students have a 3.5-fold higher risk for serogroup B disease than noncollege-aged students, with disease incidence peaking at 19 years of age and declining after 20 years of age.3 According to the ACIP, "Revisions to the schedule should optimize protection against meningitis." They also noted that the approval of a pentavalent formulation will serve to lower the number of injections needed for protection against meningococcal disease.
The ACIP proposed several options to consider for revising the recommended meningococcal vaccine schedule, as shown in the table:3
Option
ACWY Dose #1
ACWY Dose #2
B Dose #1
B Dose #2
Current Recommendation
11-12 years
16 years
16-23 years (preferred 16-18 years) *SCDM
16-23 years (preferred 16-18 years) *SCDM
1
11-12 years
16 years
16 years
17-18 years
2
11-12 years
16 years
16 years risk-based
17-18 years risk-based
3
No dose
16 years
16 years risk-based
17-18 years risk-based
4
15 years
17-18 years
17-18 years
17-18 years
*SCDM = shared clinical decision making
There is ongoing discussion regarding these 4 options as the ACIP noted that the existing vaccination platform took years to implement and any revisions to the schedule may affect school requirements.
Chikungunya Vaccination
Chikungunya is a viral disease transmitted to humans by infected mosquitoes. The Chikungunya vaccine (IXCHIQ) was licensed in the US by the FDA in November 2023 for use among individuals at risk for exposure to the virus, including travelers, laboratory workers, and those residing in areas with increased transmission risk. The vaccine is available as a single-dose primary schedule for individuals aged 18 years and older.4
The ACIP recommends the vaccine for adults traveling to a country or territory where there has been an outbreak of Chikungunya.2
However, the vaccine may be considered for the following individuals in the event of planned travel to a country or territory where there is no outbreak but where substantial evidence of transmission has occurred within the past 5 years:2
Individuals aged 65 years and older with underlying health conditions likely to have mosquito exposure
Individuals scheduled to remain abroad an extended period (≥6 months)
In regard to laboratory workers, the ACIP recommends Chikungunya vaccination for those whose research or diagnostic work involves the use of live viruses. The ACIP noted that the virus is primarily transmitted through aerosol, as well as percutaneous and possibly mucosal routes.2
Individuals who are pregnant should avoid exposure to Chikungunya.6 The ACIP noted that Chikungunya vaccination should be deferred until after delivery but may be considered for individuals at increased risk for exposure. However, they recommend against vaccination during the first trimester as well as after 36 weeks’ gestation.
Polio Vaccination
The ACIP considered modifying the polio vaccine schedule for US children who have been vaccinated against polio in other countries. Six countries (Bangladesh, Cuba, Ecuador, India, Nepal, and Sri Lanka) include fractional inactivated polio virus (fIPV) vaccination in recommended routine childhood immunization schedules.8
According to the ACIP, 2 fIPV doses are considered valid and counted as one full intramuscular dose of IPV with respect to the US schedule. However, 1 fIPV dose is not considered a viable alternative to 1 IPV dose.8
Guidelines regarding children who have been vaccinated against polio in the US remain unchanged.
Hib Vaccination
There are ongoing discussions regarding the expansion of Hib vaccine recommendations for American Indian and Alaska Native (AI/AN) infants. Guidelines suggest the use of PedvaxHIB® (Hemophilus b conjugate vaccine) for AI/AN infants. However, the emergence of combination vaccines, such as Vaxelis®, may expand options for this population.
Vaxelis, initially licensed by the FDA in December 2018, is a hexavalent vaccine comprising DTaP, inactivated polio, Hemophilus influenzae type B conjugate, and hepatitis B virus vaccine formulations. Similar to PedvaxHIB, Vaxelis contains Hib conjugate at a lower dose.7 Combination vaccines provide an opportunity for fewer shots, reduce the risk for missed doses, and lower the burden of vaccine administration. Results of a phase 4 trial conducted among AI/AN infants (N=333) showed that Vaxelis was noninferior to PedvaxHIB with respect to Hib antibody levels 30 days following receipt of the first vaccine dose.8
Members of the ACIP will vote on additional vaccine recommendations at their next scheduled meeting in June of 2024.
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A 50-year-old woman requests removal of a growth on her nose that began as a small bump approximately 2 years ago and has slowly enlarged. The patient has no history of skin cancer, warts, or similar lesions elsewhere on the body and has no family history of genodermatoses. The lesion has never bled. Physical examination reveals a 0.4 cm dome-shaped, smooth, firm, flesh-colored papule of her right nares.
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Now that spring in the air, so is allergic rhinitis, with many affected patients streaming into clinician offices for relief. Yet for some patients, that need for relief goes beyond alleviating sneezes, itchy eyes, and stuffed noses. A growing body of research indicates a significant connection between allergies and mental health,1 especially among women.2
Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses. "Depression in and of itself is thought to be a pro-inflammatory state,” says David Gudis, MD, chief of the division of rhinology and anterior skull base surgery at New York-Presbyterian/Columbia University Irving Medical Center, New York City. “If your inflammatory mechanisms are already firing, and then you throw an allergic reaction on top of it, you're propelling that allergic reaction to an even greater degree. Dealing with these challenges can deplete your resilience, leaving you less equipped to handle the ways in which allergies might worsen your condition."
Seasonal allergies, in particular, have been linked to generalized anxiety.1 This is “no surprise to most practicing allergists,” says Ron Saff, MD, a practicing allergist and assistant professor of medicine at Florida State University College of Medicine in Tallahassee, FL. Allergy season typically worsens allergy-related conditions, such as asthma and urticaria, he notes, which adds to patients’ stress levels. “Many patients usually do well with their allergic rhinitis symptoms throughout the rest of the year, but when the spring rolls around and the trees start pollinating, they come in with sneezing and runny noses and watery eyes, and many of them just don't feel well. It seems like I see more of everything in the spring,” says Dr Saff.
Clinicians and patients alike need to be more aware of the potential for connection between seasonal allergies and mental health, so that patients’ needs can be fully addressed, Drs Saff and Gudis both stress. This is especially true given that allergy seasons are not only starting earlier but are also lasting longer and hitting harder; a 2020 study highlighted a 21% rise in pollen levels across North America between 1990 and 2018.3
"
Not only do allergies potentially worsen mood disorders, but the stress and anxiety from mood disorders can, in turn, amp up allergic responses.
Inflammatory Response as a Common Denominator
“For at least 75 years, doctors have identified and written about the association between depression and anxiety and allergic rhinitis,” says Dr Gudis. “It's been studied in different ways, using different scientific methodologies of investigation around the world. The reason that's important is that allergens are different in different parts of the world — meaning this is not unique to a reaction to a specific allergen. It's related more to the cascade of the inflammatory pathways that occur in the body during the allergic reaction.”4
Research delving into how our bodies react to allergens, such as tree pollen, shows a complex inflammatory response that transcends the initial point of contact. Upon encountering tree pollen, for instance, the nasal membranes react to these perceived microscopic invaders, fueling a reaction that travels through the airways and spreads through the body and brain.5
At the heart of this inflammatory response are cytokines, crucial chemical messengers that orchestrate the response.6 Pro-inflammatory cytokines can penetrate the central nervous system (CNS) and interact with critical neurological processes, thus influencing important brain functions, including how brain cells communicate, hormone regulation, and behaviors associated with mental health conditions like depression and anxiety.7
Allergy Symptoms and Mood
In severe allergic rhinitis, many of the physical symptoms that cause physical misery can also have a major effect on a patient’s mood. “Any illness or disorder, if it detracts from the enjoyment of the world around us, is a psychological stressor, and allergic rhinitis8 is no different,” says Dr Gudis. “Basically, the whole middle of their head is inflamed, impacting memory, attention, and fatigue," Dr Gudis adds.
The nasal congestion of allergic rhinitis in itself can have a major impact on mood, he stresses. “We don't even realize it but our sense of smell helps us connect to people around us,” Dr Gudis says. “When people have olfactory dysfunction, as a result of their noses being swollen and inflamed, they are more likely to feel depressed9and isolated,” he says.
This relationship was underlined by a 2016 study revealing a strong link between compromised olfactory function and depression.10 Of note, people who are depressed frequently have a diminished sense of smell compared to those who aren’t depressed. Moreover, individuals with a weaker sense of smell tend to be more prone to depression, especially if they've completely lost their ability to smell.
Allergies, Sleep Quality, and Mental Health
A growing body of research points to how inflammation from seasonal allergies can disrupt sleep,11 a major factor connecting allergic suffering to mood disorders, adds Dr Gudis.
A 2020 meta-analysis on the association between allergic rhinitis and sleep patterns found that although there is not a significant difference in sleep duration between people with and without allergic rhinitis, the condition was linked to poorer sleep quality, increased sleep disturbances, longer sleep latency, heightened usage of sleep medications, and lower sleep efficiency.11 Moreover, hay fever sufferers experience other sleep ailments, including insomnia, restless sleep, and obstructive sleep apnea, alongside daytime dysfunction, such as difficulty waking up and daytime sleepiness.
"When people have allergic rhinitis, one thing they experience is sleep dysfunction,” says Dr Gudis. "Allergic rhinitis, fundamentally, is defined by its underlying mechanism — its pathophysiology.” The inflammatory cytokines involved can disrupt normal and healthy sleep and increase fatigue, he explains.
“There's a shorter sleep duration... [and] a disruption of the normal sleep function and architecture.” Adequate sleep is critical to mental health, notes Dr Gudis, adding that research indicates that poor sleep “exacerbates symptoms of depression and anxiety.”
Allergy Medications and Mental Health
Some commonly used allergy medications can potentially worsen mental health conditions as well, says Dr Saff. While allergists are well-aware of this, patients and primary care providers often are not.
Older-generation decongestants present in antihistamines like those found in doxylamine or diphenhydramine can induce sedation12 and a feeling of disorientation. Pseudoephedrine and phenylephrine can cause anxiety, nervousness and insomnia13 without effectively treating allergic rhinitis.
Additionally, research suggests a connection between anticholinergics12 — such as Benadryl — and an increased risk of dementia in older adults.
“Benadryl [diphenhydramine] is frequently utilized in the emergency department,” says Saff. “And patients are frequently sent home on Benadryl, so I think there's certainly a lack of knowledge about the side effects of first-generation antihistamines.”
Additionally, Dr Saff notes that many patients resort to self-medication with these drugs before seeing him, often reporting adverse effects like drowsiness or ineffectiveness.
Dr Saff recommends that patients who wish to self-medicate use over-the-counter nasal steroids and antihistamines as safer alternatives, citing their minimal systemic absorption14 and fewer side effects. A protocol can be started before allergy season15 for more effective symptom management. Allergy eye drops also provide targeted relief without the systemic side effects associated with oral medications.16
Second-generation antihistamines in pill form, such as cetirizine, fexofenadine, and loratadine, are still a good choice for many, says Dr Gudis, as they cause less drowsiness than the first-generation drugs and last longer. Allegra is considered the least sedating of this group.17
Moreover, decongestants like oxymetazoline are useful for symptom relief but can have a rebound effect over a prolonged time. After a few days of using decongestants, the blood vessels in the nose become less responsive to the medication, reducing their effectiveness.
For patients seeking a medication-free option, Dr Saff suggests nasal irrigation — a time-tested, research-backed method using a saline solution to clear nasal passages.18 He recommends intranasal sodium chloride products over traditional neti pots for their ease of use and effectiveness.
Discussing the Allergy-Mental Health Connection With Patients
Many patients suffering with allergies who are also experiencing mood disorders may not be aware that the 2 problems could be connected, said Dr Gudis. "Patients might not realize they should mention changes in their mood to their ear nose and throat specialist, allergist, or pulmonologist," he notes. Given that, clinicians seeing allergy patients may want to open up this line of communication.
Dr Saff agrees. Although it is commonly assumed that depression screening is the responsibility of primary care providers, many patients — especially those without a regular primary care physician or detailed medical records — might miss crucial mental health screenings.
The US Preventive Services Task Force (USPSTF) mental health screening recommendations are useful guidelines for identifying and addressing depression, says Dr Saff, who advocates for their broader use across specialties. Dr Saff says he employs a holistic approach for those struggling with anxiety and depression, recommending reading materials, counseling, and exercise. When appropriate, he may also prescribe medications such as selective serotonin reuptake inhibitors.18
As a practicing allergist in a college town, Dr. Saff often sees students who are under stress, separated from their usual support networks, and who don’t have a local primary care physician. Getting an appointment with a mental health professional sometimes can take months for these students, he notes. “They need help and I'm happy to offer them the medication,” he adds. “Many take me up on the offer.” When they do, he has them come back for reassessment after a month. Many students will instead choose to contact their primary care physician in their hometown, consult another provider, or to just live with the stress. “It's always the patient's choice,” says Dr Saff.
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