a case study of autism spectrum disorder

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Autism Case Studies: Real-Life Examples and Insights

• Understanding Autism Spectrum Disorder (ASD)
• NeuroLaunch editorial team
• August 11, 2024
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Stepping into the shoes of individuals with autism spectrum disorder, case studies unlock a world of unique perspectives, challenges, and triumphs that reshape our understanding of neurodiversity. These real-life examples provide invaluable insights into the complex and diverse nature of autism, offering a window into the lives of those affected by this condition. By examining these case studies, we can gain a deeper appreciation for the experiences of individuals with autism and their families, as well as the various approaches to support and intervention that have proven effective.

Overview of Autism Spectrum Disorder and the Importance of Case Studies

Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social communication, restricted interests, and repetitive behaviors. Understanding Autism: Meaning, Spectrum, and Beyond is crucial for both professionals and the general public. The spectrum nature of autism means that individuals can experience a wide range of symptoms and abilities, making each case unique.

The prevalence of autism has been steadily increasing over the past few decades, with current estimates suggesting that approximately 1 in 54 children in the United States are diagnosed with ASD. This increase in prevalence has led to a growing awareness of the condition and its impact on individuals, families, and society as a whole.

Case studies play a significant role in advancing our understanding of autism. They provide detailed accounts of individual experiences, allowing researchers, clinicians, and educators to gain insights into the diverse manifestations of ASD. These studies help bridge the gap between scientific research and real-world applications, offering valuable lessons that can inform treatment strategies and support systems.

Understanding Autism Case Studies

Autism case studies serve multiple purposes in the field of autism research and treatment. They offer a comprehensive look at an individual’s life, including their developmental history, challenges, strengths, and responses to various interventions. This holistic approach allows for a more nuanced understanding of autism that goes beyond statistical data or generalized descriptions.

Typically, autism case studies include information such as:

1. Developmental milestones and early signs of autism 2. Diagnostic process and assessment results 3. Family history and environmental factors 4. Specific challenges in areas like communication, social interaction, and behavior 5. Strengths and special interests 6. Educational experiences and accommodations 7. Therapeutic interventions and their outcomes 8. Social and emotional development 9. Family dynamics and support systems 10. Long-term outcomes and quality of life

By examining these various aspects, case studies contribute significantly to autism research and treatment. They help identify patterns and trends across different individuals, highlight effective interventions, and reveal areas that require further investigation. Moreover, case studies often inspire new research questions and hypotheses, driving the field forward.

Autism Case Study Examples: Early Childhood

Early childhood case studies are particularly valuable in understanding the early signs of autism and the impact of early intervention. Let’s explore two examples that illustrate different aspects of autism in young children.

Case Study 1: Early Diagnosis and Intervention

Sarah, a 2-year-old girl, was brought to a pediatrician by her parents who were concerned about her lack of eye contact and delayed speech. After a comprehensive evaluation, Sarah was diagnosed with autism at 26 months old. Her case study highlights the importance of early detection and intervention.

Key points from Sarah’s case: – Early signs included limited eye contact, no babbling by 12 months, and no words by 16 months – Comprehensive evaluation included developmental screening, autism-specific assessments, and observations of behavior – Early intervention program started at 27 months, focusing on speech therapy, occupational therapy, and applied behavior analysis (ABA) – Significant improvements observed in communication and social skills by age 4 – Ongoing support and therapy continued as Sarah transitioned to preschool

This case underscores the potential benefits of early diagnosis and intervention in autism, as discussed in Could Autism Be Cured? Exploring Current Research and Future Possibilities . While a cure may not be currently available, early intervention can significantly improve outcomes for children with autism.

Case Study 2: Challenges in Social Communication

Alex, a 4-year-old boy, was diagnosed with autism at age 3 after his preschool teacher noticed his difficulties in social interactions. His case study focuses on the challenges in social communication often experienced by children with autism.

Key aspects of Alex’s case: – Demonstrated advanced vocabulary and memory but struggled with back-and-forth conversations – Showed intense interest in trains but had difficulty engaging in imaginative play with peers – Experienced sensory sensitivities, particularly to loud noises and certain textures – Intervention focused on social skills training, sensory integration therapy, and parent coaching – Progress noted in turn-taking and initiating interactions with peers after six months of intervention

Alex’s case highlights the complex nature of social communication difficulties in autism and the potential for targeted interventions to support skill development.

Autism Case Study Examples: School-Age Children

As children with autism enter school age, new challenges and opportunities arise. The following case studies illustrate some common experiences of school-age children with autism.

Case Study 3: Academic Challenges and Accommodations

Emma, a 9-year-old girl with high-functioning autism, excelled in mathematics but struggled with reading comprehension and writing. Her case study focuses on the academic challenges faced by many children with autism and the accommodations that can support their learning.

Key elements of Emma’s case: – Demonstrated exceptional skills in mathematical calculations and pattern recognition – Struggled with understanding abstract concepts in literature and expressing ideas in writing – Experienced difficulty with time management and organization – Individualized Education Program (IEP) implemented, including accommodations such as extra time for assignments, use of graphic organizers, and assistive technology for writing – Regular collaboration between teachers, parents, and special education staff to monitor progress and adjust strategies

Emma’s case underscores the importance of recognizing both the strengths and challenges of students with autism and providing appropriate support to help them succeed academically.

Case Study 4: Behavioral Interventions in the Classroom

Michael, an 8-year-old boy with autism, exhibited challenging behaviors in the classroom, including frequent meltdowns and difficulty transitioning between activities. His case study explores the implementation of behavioral interventions in a school setting.

Highlights from Michael’s case: – Displayed strong visual-spatial skills but struggled with verbal instructions and changes in routine – Experienced sensory overload in noisy or crowded environments, leading to meltdowns – Behavioral intervention plan developed, including visual schedules, social stories, and a token economy system – Quiet space provided in the classroom for self-regulation – Teacher and staff training on autism and positive behavior support strategies – Significant reduction in meltdowns and improved ability to transition between activities after three months of consistent intervention

Michael’s case demonstrates the effectiveness of tailored behavioral interventions and environmental modifications in supporting students with autism in the classroom.

Autism Case Study Examples: Adolescents and Adults

As individuals with autism transition into adolescence and adulthood, they face unique challenges and opportunities. The following case studies provide insights into the experiences of older individuals on the autism spectrum.

Case Study 5: Transition to Adulthood and Employment

David, a 22-year-old man with autism, navigated the transition from high school to employment. His case study focuses on the challenges and successes experienced during this critical period.

Key aspects of David’s case: – Graduated from high school with strong academic performance in computer science – Struggled with social anxiety and executive functioning skills – Participated in a transition program focusing on job skills, independent living, and social skills – Secured an internship at a local tech company through a supported employment program – Benefited from workplace accommodations, including a quiet workspace and clear, written instructions – Successfully transitioned to full-time employment after six months of internship

David’s case highlights the importance of targeted support during the transition to adulthood and the potential for successful employment outcomes for individuals with autism. Inspiring Autism Success Stories: Journeys of Triumph and Transformation provides additional examples of individuals who have overcome challenges to achieve their goals.

Case Study 6: Relationships and Social Support

Olivia, a 28-year-old woman diagnosed with autism in adulthood, focused on building relationships and developing a support network. Her case study explores the social aspects of autism in adulthood.

Key elements of Olivia’s case: – Late diagnosis at age 25 provided clarity and understanding of lifelong social difficulties – Joined an autism support group and found a sense of community – Engaged in social skills training and cognitive-behavioral therapy to address anxiety – Developed strategies for navigating social situations in personal and professional contexts – Formed meaningful friendships within the autism community and beyond – Advocated for autism awareness and acceptance in her workplace

Olivia’s case underscores the ongoing importance of social support and skill development for adults with autism, as well as the potential for personal growth and advocacy.

Key Findings and Patterns Across Autism Case Studies

Examining multiple case studies reveals several common themes and patterns in the experiences of individuals with autism:

1. Diverse presentations: Each case study demonstrates the unique combination of strengths and challenges experienced by individuals with autism, reinforcing the notion of autism as a spectrum disorder.

2. Importance of early intervention: Cases involving early diagnosis and intervention often show more positive long-term outcomes, highlighting the critical nature of early support.

3. Individualized approaches: Successful interventions are typically tailored to the specific needs, interests, and strengths of each individual, rather than following a one-size-fits-all approach.

4. Ongoing support needs: Many individuals with autism benefit from continued support and accommodations throughout their lives, albeit in different forms as they age.

5. Potential for growth and achievement: Case studies frequently demonstrate significant progress and accomplishments when appropriate support and interventions are provided.

6. Impact of environment: The role of supportive families, educators, and communities is evident in many successful cases, underscoring the importance of creating autism-friendly environments.

7. Comorbid conditions: Many case studies reveal the presence of co-occurring conditions such as anxiety, ADHD, or sensory processing difficulties, highlighting the need for comprehensive care.

8. Importance of self-advocacy: As individuals with autism grow older, the ability to self-advocate and communicate their needs becomes increasingly important for their success and well-being.

Effective interventions and support strategies that emerge from these case studies include:

– Early, intensive behavioral interventions – Structured teaching methods (e.g., TEACCH) – Social skills training and peer-mediated interventions – Assistive technology and visual supports – Sensory integration therapies – Cognitive-behavioral therapy for anxiety and emotional regulation – Vocational training and supported employment programs – Parent and family education and support

The importance of individualized approaches in autism treatment cannot be overstated. What works for one person may not be effective for another, and interventions often need to be adjusted over time as an individual’s needs change. This personalized approach is crucial for maximizing outcomes and quality of life for individuals with autism.

Autism case studies provide invaluable insights into the lived experiences of individuals on the spectrum, offering a nuanced understanding that goes beyond clinical definitions or statistical data. Through these real-life examples, we gain a deeper appreciation for the challenges faced by individuals with autism and their families, as well as the potential for growth, achievement, and fulfillment.

The case studies explored in this article highlight several key points:

1. The diverse nature of autism spectrum disorder and the unique combination of strengths and challenges each individual experiences 2. The potential benefits of early diagnosis and intervention 3. The importance of tailored support and accommodations across different life stages 4. The ongoing need for understanding and acceptance of neurodiversity in society

As we look to the future, autism research and case studies will continue to play a crucial role in advancing our understanding of the condition and developing more effective interventions. Exploring Autism: Key Research Questions and Discussion Topics for In-Depth Understanding provides insight into some of the critical areas that researchers are currently investigating.

Future directions for autism research and case studies may include:

– Long-term follow-up studies to better understand outcomes across the lifespan – Exploration of the impact of various interventions on brain development and functioning – Investigation of the experiences of underrepresented groups within the autism community – Development and evaluation of new technologies to support individuals with autism – Examination of the economic and societal impacts of improved support for individuals with autism

As our understanding of autism continues to evolve, it is crucial that we maintain a commitment to supporting individuals on the spectrum and their families. By fostering acceptance, providing appropriate interventions, and creating inclusive environments, we can help ensure that individuals with autism have the opportunity to reach their full potential and lead fulfilling lives.

Autism for Dummies: A Comprehensive Guide to Understanding and Supporting Individuals on the Spectrum offers additional resources for those seeking to learn more about autism and how to support individuals on the spectrum.

In conclusion, autism case studies serve as powerful tools for understanding, empathy, and progress in the field of autism research and support. By continuing to share and learn from these individual stories, we can work towards a more inclusive and supportive world for all individuals on the autism spectrum.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Baio, J., Wiggins, L., Christensen, D. L., et al. (2018). Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR Surveillance Summaries, 67(6), 1-23. https://www.cdc.gov/mmwr/volumes/67/ss/ss6706a1.htm

3. Dawson, G., Rogers, S., Munson, J., et al. (2010). Randomized, controlled trial of an intervention for toddlers with autism: the Early Start Denver Model. Pediatrics, 125(1), e17-e23.

4. Kasari, C., Gulsrud, A., Freeman, S., Paparella, T., & Hellemann, G. (2012). Longitudinal follow-up of children with autism receiving targeted interventions on joint attention and play. Journal of the American Academy of Child & Adolescent Psychiatry, 51(5), 487-495.

5. Landa, R. J. (2018). Efficacy of early interventions for infants and young children with, and at risk for, autism spectrum disorders. International Review of Psychiatry, 30(1), 25-39.

6. Lord, C., Brugha, T. S., Charman, T., et al. (2020). Autism spectrum disorder. Nature Reviews Disease Primers, 6(1), 1-23.

7. Magiati, I., Tay, X. W., & Howlin, P. (2014). Cognitive, language, social and behavioural outcomes in adults with autism spectrum disorders: A systematic review of longitudinal follow-up studies in adulthood. Clinical Psychology Review, 34(1), 73-86.

8. National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press.

9. Reichow, B., Hume, K., Barton, E. E., & Boyd, B. A. (2018). Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database of Systematic Reviews, (5).

10. Roux, A. M., Shattuck, P. T., Cooper, B. P., Anderson, K. A., Wagner, M., & Narendorf, S. C. (2013). Postsecondary employment experiences among young adults with an autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 52(9), 931-939.

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Case report: Transient symptoms of autism spectrum disorder in a 2‐year‐old boy

Devon n gangi, ramkumar aishworiya, monique moore hill, dan thu nguyen, chandni parikh, erika solis, sally ozonoff.

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Correspondence , Devon N Gangi, Department of Psychiatry & Behavioral Sciences, UC Davis MIND Institute, 2825 50 Street, Sacramento, CA 95817, USA. Email: [email protected]

Corresponding author.

Revised 2023 Apr 6; Received 2023 Feb 15; Accepted 2023 Apr 15; Collection date 2023 May.

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Key Clinical Message

Though early ASD diagnosis is highly stable, this case report describes a rare situation in which symptoms resolved without intervention over a 4 month period. We do not recommend delaying diagnosis in symptomatic children who meet criteria but when major behavioral changes are reported after diagnosis, reevaluation may be beneficial.

Keywords: autism spectrum disorder, diagnosis, screening, symptom resolution, transient

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by symptoms in two domains: social communication/social interaction and restricted, repetitive patterns of behavior, interests, or activities (RRB). For an individual to meet DSM‐5 diagnostic criteria, all three social communication/social interaction symptoms and at least two of four RRB symptoms need to be manifested. High stability of ASD diagnoses from 18 months of age onward and superior effectiveness of early intervention as compared to later in childhood has encouraged efforts to identify children at elevated probability of ASD as early as the second year of life. 1 , 2 , 3 , 4 , 5 A small group of children do lose their diagnosis of ASD, typically after a period of intensive early intervention. 6 , 7 , 8 Though they no longer meet the diagnostic criteria for ASD, many of these children have residual developmental concerns including attentional deficits, emotional/behavioral problems, and learning difficulties. 9 , 10 , 11 , 12 Spontaneous resolution of ASD symptoms without intervention is extremely rare. To our knowledge, only one such case has been reported, in which a 5.5‐year‐old boy had his ASD symptoms, present for at least 3 years, resolve over a period of 13 days, without any specific intervention for ASD. 13 In the current report, we present the case of a 24‐month‐old child who received an ASD diagnosis, meeting full diagnostic criteria (i.e., all three social communication symptoms and three of four RRB symptoms) following a telehealth‐based comprehensive diagnostic assessment but subsequently no longer met diagnostic criteria at reevaluation at 28 and 36 months of age (i.e., only one RRB symptom), without any specific intervention for ASD in the period between the evaluations.

1. CLINICAL CASE DESCRIPTION

1.1. medical, developmental, and family history.

Ian * is a two‐year‐old boy, conceived naturally, born shortly before the beginning of the COVID‐19 pandemic, at 42 weeks gestation with a birth weight of 10 pounds, 3 ounces. He is the first child of his parents; at the time of his birth, both parents were in their mid‐twenties. His mother's health during pregnancy was excellent, with no complications during birth reported. Ian has experienced good physical health throughout his life. His parents reported that he achieved developmental milestones within age expectations (see Table  1 ).

Ages at which developmental milestones were achieved

Ian lives with both birth parents, a younger brother (born when Ian was 22 months old), and his grandparents in a suburb of a medium‐size city. His family is middle‐class and parents are college‐educated. Both parents are highly involved in his care. Parents are attuned to his needs and provide a warm, loving home environment. He is taken care of in the home by one parent while the other parent works, as well as by grandparents living in the household. There was no evidence of abuse or neglect and parents did not report any trauma experienced by Ian. Ian is raised in a bilingual household. There is no known family history of ASD, ADHD, or any other psychiatric disorder.

1.2. Screening history

Before Ian was 6 months old, his parents enrolled him in a longitudinal online screening study that draws participants from across the United States. The purpose of the study was to compare the psychometric properties of several autism screening instruments in a large community sample of children. Participation in the study includes completion of screening instruments online at five time points between 6 and 36 months, including the Infant Toddler Checklist (ITC) 14 and Modified Checklist for Autism in Toddlers‐Revised (M‐CHAT‐R), 15 both widely used in clinical settings, with satisfactory psychometric properties (ITC, sensitivity of 0.88 and specificity of 0.88; M‐CHAT, sensitivity of 0.83, and specificity of 0.94). 16 , 17 A parent concerns questionnaire and the Video‐referenced Infant Rating System for Autism (VIRSA), 18 a screening measure that utilizes video examples rather than written descriptions of behavior, were also administered. Any child who screens positive on any instrument at any age is invited to complete developmental evaluations via telehealth at 24 and 36 months of age. In this study, screening positive was defined as M‐CHAT‐R initial scores ≥3 at 18 or 24 months, 15 ITC Total or Social Composite scores below the 10th percentile, 16 or VIRSA scores ≤3 at any age. 18

Ian's scores on each screening instrument, as well as parent concerns, from 6 to 24 months are presented in Table  2 . Ian screened positive on the VIRSA at 18 months and the M‐CHAT‐R at 24 months (score = 3). His parents did not endorse any worries about his development or behavior on the parent concerns questionnaire until 24 months, when they reported concerns about expressive language development (e.g., not yet talking regularly, vocabulary consisting of three words) and social development (e.g., lack of interest in other children).

Screening status from 6 to 24 months

Note : *Screened positive on instrument; On the VIRSA, scores of 3 or below are considered screening positive. On the ITC, composite standard scores are based on a mean of 10 and Standard Deviation (SD) of 3, and the Total standard score is based on a mean of 100 and SD of 15. On the M‐CHAT‐R/F, initial scores of 3 and above or follow‐up scores of 2 or higher are considered at‐risk for ASD at 16 months and older.

Abbreviations: ITC, infant‐toddler checklist; M‐CHAT‐R, Modified Checklist for Autism in Toddlers‐Revised; F/Up, Follow‐up; SS, Standard Score; VIRSA, Video‐referenced Infant Rating System for Autism.

1.3. Initial diagnostic evaluation

As part of the study protocol, Ian received a diagnostic evaluation via telehealth after screening positive. The evaluation included a review of his behavioral and medical history and development (via caregiver interviews) and direct observation of symptoms (via the TELE‐ASD‐PEDS and observation during the sessions) by specialists experienced in early ASD diagnosis, consistent with clinical guidelines. 19 At the time of the evaluation, Ian was 23 months, 28 days of age. The evaluation was completed via a secure video platform, with Ian and his parents in their home while the examiner observed, gave directions, and asked questions remotely.

The TELE‐ASD‐PEDS (TAP) 20 , 21 is an interactive tool used to assess behaviors associated with ASD in toddlers via 2‐way videoconferencing, in which Ian's parents followed examiner instructions to play with him and present a series of activities meant to elicit social interaction and communication. Ian's total score on the TAP was 16, over the threshold indicative of ASD (cutoff = 12; range 7–21). The examiner noted the following behavioral observations:

Ian demonstrated some encouraging behaviors, such as imitating his parents (e.g., when they were blowing bubbles), playing near them, seeking proximity when he was upset, and laughing during preferred activities. Ian also showed many behaviors consistent with ASD. His eye contact was very limited and he rarely used gestures (i.e., only pointed one time without eye contact). Ian did not respond when his parents called his name on multiple occasions or follow their points. He requested by taking his parents' hands and leading them to or placing their hands directly on desired objects, without making eye contact. Ian also used his father's hand to point when responding to questions (e.g., when his father asked where things were in a book). He did not use any words to communicate during the session. Ian's play was repetitive and sensorimotor in nature, often consisting of dropping objects off the table and watching them. He had difficulty transitioning between activities, often becoming upset when toys were removed .

The Developmental Profile, 4th Edition (DP‐4), 22 a parent interview about developmental milestones that can be used to quickly screen for developmental delays, was administered to Ian's parents. Ian's scores are presented in Table  3 . He scored in the Average range on the Physical and Cognitive subscales, in the Below Average range on Adaptive Behavior, and in the Delayed range on Communication.

Scores on the Developmental Profile, 4th Edition

Note : The Social–Emotional subscale was not administered at the 24‐ or 36‐month visit.

During a clinical interview focused on DSM‐5 symptoms, Ian's parents reported that he had regressed in several areas over a few months prior to the evaluation, such as less waving and pointing, responding to questions less often, no longer saying “mama,” and increased irritability, especially during transitions. They felt these declines coincided with the pregnancy and birth of his younger brother and an increase in screen time viewing (which had gradually increased from brief watching during care activities such as diaper changes to watching 2–4 h of videos per day). They felt that the evaluation was an accurate depiction of Ian's usual behavior. Based on the results of the evaluation, Ian was determined to meet DSM‐5 criteria for ASD (see symptom checklist in Table  4 ). His parents were surprised by the diagnosis, having expected only a speech‐language delay to be identified. They reported that they were not very familiar with ASD but once the diagnostic criteria were explained, they accepted the diagnosis and felt it fit Ian's current challenges.

DSM‐5 Symptoms of ASD present at 24 months of age

1.4. Interim time/events

Ian's parents began trying to access services for him after the initial evaluation through the state's early intervention (EI) system. As part of this process, the EI team conducted a brief telehealth screening for service eligibility. They told Ian's parents that he did not meet ASD criteria and suggested a reevaluation. No services were offered or received.

1.5. Follow‐up evaluations

Four months after the initial evaluation, Ian was enrolled in and assessed through a second independent study at the UC Davis MIND Institute. As part of that study's protocol, he was administered the TAP twice, 9 days apart, via telehealth with two independent examiners (both unaware of any prior evaluations or results). The DSM‐5 clinical interview and DP‐4 were also re‐administered and current parent concerns solicited. Ian's parents re‐completed the M‐CHAT‐R; his score at the follow‐up evaluation was 0.

1.5.1. First follow‐up evaluation

At the time of the first reevaluation, Ian was 28 months, 15 days of age. Ian's score on the TAP during the reevaluation was nine, below the cutoff indicative of ASD (cutoff = 12). The examiner noted the following observations:

Ian demonstrated many well‐developed social communication skills during this TAP administration. He frequently used eye contact to modulate social interactions and check in with his parents, directed consonant‐vowel vocalizations and some words to others (e.g., “no,” “mm‐kay” for “okay”) and used several non‐verbal gestures, paired with eye contact, to communicate, including pointing, shaking his head “no,” nodding “yes,” signing “more,” blowing to request bubbles, and using gestures associated with the “wheels on the bus” song. Ian responded immediately when his name was called, followed his mother's point to a distant object, made requests paired with eye contact and vocalizations, shared enjoyment with others, and initiated joint interactions. At times Ian scrambled toys during play and postured his hands in a slightly stereotyped manner. He resisted transitioning between some activities but responded well to redirection. Overall, he used fewer words than expected for a child his age .

Ian's scores on the DP‐4 at reevaluation are presented in Table  3 . Scores on all subtests showed improvement from the initial evaluation, with only Communication scoring below average for his age. Ian's parents continued to be concerned about his language development (i.e., small vocabulary size, only one multi‐word phrase). They no longer reported social concerns, noting that he had developed many skills in the 4 months since the initial evaluation, stating he was “like a different child.” The examiner's clinical decision was that Ian's presentation was not indicative of ASD during the reevaluation and he did not meet DSM‐5 criteria for a diagnosis, but did exhibit an expressive language delay.

1.5.2. Second (repeat) follow‐up evaluation

As part of the study protocol evaluating test–retest reliability of the TAP, Ian received a repeat TAP administration 9 days after the full diagnostic reevaluation, with an independent examiner. During the second repeat TAP administration, Ian again demonstrated well‐developed social communication skills. The examiner noted:

Ian initiated and responded to social interactions using eye contact and well‐integrated gestures. He consistently responded to his name and maintained age‐appropriate social–emotional reciprocity with his father. Ian directed his father's attention to different desired activities by pointing, nodding, and vocalizing. He smiled and directed many of his facial expressions to others. Ian demonstrated strong receptive language skills by successfully following his father's verbal instructions. His vocalizations were directed and communicative. Ian enjoyed turn‐taking activities, including puzzles, bubbles, and completing actions associated with the “wheels on the bus” song .

Ian's score on this administration of the TAP was eight, again below the ASD cutoff, and the examiner's clinical decision was also that he did not meet criteria for ASD.

1.5.3. Consensus and reliability

With his parents' permission, video of Ian's repeat TAP administrations and other evaluation results were presented at a clinical case conference attended by approximately 25 licensed professionals, ASD experts, and clinical trainees. As a standard procedure in these conferences, attendees are invited to complete a diagnostic “poll” indicating whether the child presented meets criteria for ASD. Based on the video review of the initial evaluation, 100% of attendees indicated that he had ASD, while after viewing the second TAP administration, 80% did not think he met criteria for ASD.

1.5.4. 36‐month evaluation

As part of the original screening study protocol, Ian was reevaluated at 36 months, including a TAP and DP‐4 administration, with an independent examiner unaware of the results of the three prior evaluations. Ian's score on the TAP at 36 months was nine, below the cutoff indicative of ASD (cutoff = 12). The examiner noted the following behavioral observations:

Throughout the assessment, Ian displayed warm social engagement with his father and well‐developed social skills, including frequent eye contact, shared smiles, requesting, giving and showing toys to others, pointing and using gestures, and age‐appropriate speech. He responded to his name immediately, enthusiastically showed his father toys he was playing with, and enjoyed interactions such as peek‐a‐boo. Ian easily transitioned between activities and regularly responded to and communicated with his father during the assessment. His language combined both multi‐word sentences and nonverbal gestures such as telling his father he wanted to blow bubbles by saying, “I want to do it” while patting himself on the chest. Some of Ian's vocalizations had a repetitive quality (e.g., repeatedly saying “you put the blocks in here” as he placed them in a toy dump truck), but were clearly communicative (e.g., paired with eye contact and shared smiles) and related to the context .

Ian's scores on the DP‐4 at 36 months are presented in Table  3 . His score on the Physical subtest remained stable, and scores on all other subtests showed improvement from the previous evaluation, including Communication (which now scored in the Average range). The examiner's clinical decision was that Ian's presentation was not indicative of either ASD or an expressive language delay.

1.6. Behavioral coding

Video of each of Ian's TAP administrations was coded by an experienced coder unaware of the order or outcome of the evaluations. The frequency of occurrence of the following behaviors was coded, and rates per minute were calculated: eye contact, social smiling, verbalizations, distress, and repetitive behavior (see Figure  1 ). Coding of the video documented in an objective manner the differences that the four independent examiners had noted across assessments. Between Ian's first and follow‐up evaluations, his rate of eye contact and smiling with his parents increased dramatically, and there was a slight increase in verbalizations. Ian's displays of distress and repetitive behaviors decreased. At 36 months, the dramatic increases in eye contact and smiling at others were maintained and verbalizations showed a remarkable increase (consistent with no longer being identified with a language delay). His level of distress stayed low, consistent with the follow‐up evaluations. Coding demonstrated that Ian showed more repetitive behavior at 36 months than during the follow‐up evaluations at 28 months, but the quality of this repetitive behavior differed from what was seen at the initial evaluation when he was diagnosed with ASD. Specifically, at 36 months there was no repetitive object use as observed at 24 months (repeated dropping of objects while watching them fall; use of parent's hand as a tool), only some repeated vocalizations that had a social‐communicative function and age‐typical intonation. The ratio of repetitive behavior/object use to functional and social play was much lower at 36 than 24 months. Overall, behavioral coding confirmed objectively the remarkable improvement in social behavior and decline in ASD symptoms reported by examiners from levels at the initial evaluation.

Rate of social, communication, and repetitive behaviors coded during each TAP assessment. At 24 months, no verbalizations were observed/coded; at both 28‐month evaluations, no repetitive behavior was observed/coded.

2. DISCUSSION

Evidence shows that ASD diagnoses made as early as 18 months of age are very stable. 2 , 4 , 5 This case report highlights that, in rare cases, it is possible for a child's early presentation of ASD symptoms to be transient. We do not, however, wish to imply that clinicians should interpret this case as an indication to be overly cautious in diagnosing ASD in young children–if symptoms are clear and present to support a diagnosis, it should be made to aid in securing intervention services as quickly as possible. Instead, this case is an indication that the first evaluation is not the end of every child's diagnostic journey. Ongoing monitoring of a child's symptoms and reevaluation, particularly when drastic changes in behavior are reported or observed, are crucial to ensuring that a child's treatment plan is tailored to provide the greatest benefit and support where needed most.

A counterargument often made is that it is prudent to employ watchful waiting and delay diagnosis for children under three displaying ASD symptoms. However, we do not recommend this strategy for several reasons. First, rapid resolution of symptoms without intervention is very rare. In fact, diagnoses made as early as 14–18 months are extremely stable. 2 , 3 , 4 , 5 Second, a wait‐and‐see approach hinders access to services. While this may be a reasonable strategy if a child demonstrates only a few atypical behaviors, it is not helpful for a child who meets full diagnostic criteria, as Ian did, given long waiting lists for services. Rather, our intent in presenting this case is to highlight that if caregivers are reporting major changes in behavior after diagnosis, further evaluation may be warranted.

Ian's parents made changes in their household at the time of the initial diagnosis. Specifically, they eliminated all screen time for him right before the initial diagnostic evaluation. At that time, right after the birth of his younger brother, he was viewing 2–4 h of videos per day. His parents reported seeing drastic improvements in his behavior within 2 weeks of eliminating access to videos/screens. Exposure to electronics and screens (e.g., phones, TV, videos) is common at Ian's age, with 3/4 of children under five across the world exceeding the recommended guidelines for screen time limits 23 and reported increases in screen time for children during the pandemic. 24 , 25 There are a few studies suggesting a link between screen time and ASD symptomatology. Dong et al. 26 reported that children with ASD tend to spend more time looking at screens than typically developing children, with those with more screen time tending to have higher ASD symptomatology. A longitudinal study found that higher screen time at 1 year of age was associated with a higher likelihood of an ASD diagnosis at 3 years among boys. 27 A small study reported that some children with excessively high digital exposure (over half of waking hours) demonstrated subclinical autism‐like symptoms but did not meet criteria for ASD. 28 A recent case report details two children with ASD who were receiving minimal intervention but demonstrated marked improvements in development and ASD symptoms when screen time was drastically reduced and replaced with social time. 29 These studies, small in size and not designed to determine the direction of causality, do suggest that some children may be particularly vulnerable to the impact of screen time on their development and behavior.

Ian was born just prior to the COVID‐19 pandemic but was not infected with the virus in utero or during his first years of life, which has been associated with neurodevelopmental delays in a small number of papers. 30 , 31 There are other reports of developmental delays in children born during the pandemic, 32 , 33 , 34 whether exposed to the virus or not, but no published reports of transient autism symptoms. Ian did not experience any significant changes in his exposure to other children or social situations in the short period over which the autism symptoms abated. Therefore, pandemic‐related exposures or restrictions do not readily account for either the development of his initial symptoms or their rapid resolution.

While the period of increased screen time and autism symptoms coincided with Ian's mother's pregnancy and the subsequent birth of a younger sibling, this is an adjustment experience common to many children and has never been associated with autism onset or transient symptoms in the literature. Ian's parents did not report excessively negative or unusual reactions to the new infant. While significant early deprivation and trauma have been associated with what has been termed “quasi‐autistic patterns”, 35 these attachment disorders are differentiable from ASD. 36 In Ian's case, there was no evidence of abuse or neglect; quite the contrary, Ian is being raised in a warm, loving environment, as documented by hours of video recorded in the home of Ian interacting with his parents and grandparents, who are highly engaged in his care, vigilant to his needs, and quick to seek help for his developmental delays.

Conducting evaluations for ASD via telehealth is a relatively new practice, increasingly used in response to the COVID‐19 pandemic. 21 It is unlikely that the changes in Ian's development and behavior across evaluations were due to the assessment method (i.e., tele‐assessment). First, all of Ian's evaluations were conducted via telehealth, so differences in behavior were not associated with differences in methods of evaluation. Second, Ian's parents confirmed at each tele‐visit that the behavior seen was representative of his current behavior. Third, while the family was trying to access services for Ian after receiving the ASD diagnosis, an independent evaluator in the state EI system observed via telehealth platform that he did not meet criteria for a diagnosis just a few months later (spurring the reevaluation through our study). Though this was not a traditional in‐person evaluation due to the pandemic, use of the TAP has shown high diagnostic agreement (86%) with clinical outcomes from a full diagnostic evaluation, including ADOS‐2. 37

This case report has several implications for clinicians involved in ASD diagnosis in young children. At the time a diagnosis is made, it may be beneficial to gather detailed information about the child's home and daily environment. This would allow for clinicians to assess whether, in addition to intensive EI services, recommendations such as limiting or eliminating screen time might also be beneficial. Such changes could be implemented by families immediately, even during the often‐long gap between when a diagnosis is made and when treatment services begin. This case also highlights the importance for clinicians to be aware that resolution of ASD symptoms in young children within a short time frame can happen, if rare. Even after a diagnosis is made, ongoing monitoring of symptoms and solicitation of caregiver experiences regarding behavioral changes is crucial to understanding the child's current and ongoing presentation and treatment needs.

AUTHOR CONTRIBUTIONS

Devon N Gangi: Conceptualization; data curation; formal analysis; writing – original draft; writing – review and editing. Ramkumar Aishworiya: Conceptualization; writing – original draft. Monique Moore Hill: Data curation; writing – original draft. Dan Thu Nguyen: Data curation; writing – original draft. Rachel Ni: Data curation; writing – original draft. Chandni Parikh: Data curation; writing – original draft. Erika Solis: Data curation; writing – review and editing. Sally Ozonoff: Conceptualization; funding acquisition; supervision; writing – review and editing.

FUNDING INFORMATION

NIMH R01 MH121344 & R01 MH127228.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.

Written patient consent has been signed and collected in accordance with the journal's patient consent policy.

ACKNOWLEDGMENTS

This study was supported by National Institutes of Health awards R01 MH121344 and R01 MH127228. We thank Ian and his family for their participation in our studies, for generously sharing their time and experience with us and with the field, and for reviewing and commenting upon this manuscript.

Gangi DN, Aishworiya R, Hill MM, et al. Case report: Transient symptoms of autism spectrum disorder in a 2‐year‐old boy. Clin Case Rep. 2023;11:e07345. doi: 10.1002/ccr3.7345

Pseudonyms are used and identifying characteristics disguised to maintain confidentiality.

DATA AVAILABILITY STATEMENT

Data for this study is available upon request from the corresponding author.

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