A Warning about “Screenings”

A mom on the west coast recently told me her 2.5 year old son was “informally” assessed for ASD (Autism Spectrum Disorder) at a prestigious medical center. The boy was asked to do a puzzle, and showed good joint attention towards his parents, and toward the Intern who was observing, but not towards the neuropsychologist conducting the assessment. The boy then said he wanted to go home. The examiner told the parents that their son has social delays because he is supposed to show joint attention and interaction towards her, not only toward parents. When the examiner next tried to have the boy build a tower of five blocks, he refused, and tried to steal her tower.

Seems to me his joint attention was fine. He just didn’t like this stranger.

The good news is that this 2.5 year old doesn’t have any glaring cognitive or language delays. Still, the examiner told the parents that she couldn’t rule out ASD, and that he might have a mild case – saying her gut feeling was that the worst outcome would be that he’s an “engineer” in Silicon Valley.

That’s a lot to pick up (and predict) from a puzzle or block tower in a few minutes.

Not being there, I can’t speak for the quality of this informal clinical evaluation, but my general impression about “informal evaluations” is that they aren’t very accurate or highly predictive. I assume informal means “screening”…   and to my way of thinking, quick screenings (whether for anxiety, depression, ADHD, ASD, etc), have little value other than trying to educate folks about potential mental health risks. Think of cholesterol screening or blood pressure screenings… you don’t have heart disease based on one time elevated findings. And these are objective, real medical tests measuring real body changes. We have nothing like that in psychiatry. Most screenings are subjective and are generally designed to cast a very large net. That generates lots of false positives. They generate lots of parental anxiety too.

I told this mom to take this informal screening with a grain of diagnostic salt. I told her that what’s more important is not building a tower of blocks with a stranger one time, but how he relates to other kids in his real life day in and day out – over weeks and months – on the playground – in the sandbox – at day care, etc. Early behavior of boys is often not very “social” or too “hyper”, but with more and more experience playing and interacting with other kids, they start to build their social toolbox.

I also told this mom – as I tell all parents – don’t coach your son too much when he struggles socializing. Let him make mistakes and learn from the real-life consequences. The presence of well-intentioned adults often delays development, instead of facilitating it.

She’s going to investigate things further for her son, but wants to meet a professional who won’t rush to a label in ten minutes. She’ll keep an eye on his social development, and will follow through with lots of play time and opportunities to be social.

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