The first five minutes: Initial impressions during autism spectrum disorder diagnostic evaluations in young children

Abstract

Diagnosticians report that autism spectrum disorder (ASD) is immediately apparent in some, but not all, children ultimately diagnosed. Clinicians' initial diagnostic impressions have implications for ASD early detection, yet the literature raises questions about their accuracy. This study explores diagnostic impressions of ASD specialists made within the first 5 minutes of meeting a young child and investigates factors associated with the match between initial impressions and final diagnoses. Participants were children (n = 294, aged 12–53 months) referred for an ASD evaluation as part of multi‐site ASD screening studies. After 5 minutes observing each child, clinicians with expertise diagnosing ASD recorded if they thought the child would meet criteria for ASD following a complete evaluation, and recorded their confidence in this impression. Clinicians' initial impressions matched the final diagnosis in 81% of cases. Ninety‐two percent of cases initially thought to have ASD met criteria following a full evaluation; however, 24% of cases initially thought not to have ASD also met criteria, suggesting a high miss rate. Clinicians were generally confident in their initial impressions, reporting highest confidence for children initially thought correctly not to have ASD. ASD behavioral presentation, but not demographic characteristics or developmental level, were associated with matching initial impression and final diagnosis, and confidence. Brief observations indicating ASD should trigger referral to intervention services, but are likely to under‐detect positive cases and should not be used to rule out ASD, highlighting the need to incorporate information beyond initial clinical impression. Lay Summary When children come in for an autism evaluation, clinicians often form early impressions—before doing any formal testing—about whether the child has autism. We studied how often these early impressions match the final diagnosis, and found that clinicians could not easily rule out autism (many children who initially appeared not to have autism were ultimately diagnosed), but were generally accurate ruling in autism (when a child appeared to have autism within 5 minutes, they were almost always so diagnosed).

Initial diagnostic impressions of trainees during autism evaluations: High specificity but low sensitivity

“…Overall accuracy of initial impression was 0.75. Sensitivity of detecting autism within the first 5 minutes was low (0.56) and specificity was high (0.92); this is highly consistent with senior clinicians' impressions (Wieckowski, de Marchena, et al, 2021; Wieckowski, Hamner, et al, 2021). The positive predictive value of the initial impression was 0.86, and the negative predictive value was 0.71.…”

“…In our previous work, we looked at the match between expert clinicians' initial diagnostic impressions (i.e., after spending five minutes observing or interacting with a young child who had been referred for an autism evaluation) and final diagnosis made after a comprehensive evaluation (Wieckowski, de Marchena, et al, 2021). After this brief observation, when expert clinicians initially believed a child had autism, they were ultimately diagnosed 92% of the time, suggesting that a brief observation by an expert can detect autism in the vast majority of cases.…”

Utility of Diagnostic Classification for Children 0–5 to Assess Features of Autism: Comparing In-person and COVID-19 Telehealth Evaluations

“…Experimental studies could be designed to determine which information allows clinicians to make confident and accurate diagnostic decisions. One example of a novel study was used clinician impression from the first few minutes of a diagnostic in person encounter to determine whether first impressions held up to full evaluation results in the diagnosis of ASD (Wieckowski et al, 2021). These findings suggest that initial impressions may play an important role in diagnosis and may influence clinician confidence.…”

Clinical correlates of diagnostic certainty in children with autism

“…Another possible explanation for a modest association between certainty and symptom severity is that other factors not directly represented in the ADOS may also contribute to the clinician's certainty. However, previous studies do not show consistent patterns of association between certainty ratings and factors such as the level of intellectual developmental, age, or sex (7)(8)(9). We wanted to further explore the association of such factors as well as some additional phenotypes such as language level and head circumference (HC).…”