Autism in children may be overdiagnosed, potentially causing harm to both the children themselves and those with the greatest needs, experts have claimed.
Researchers say that behaviours such as difficulty maintaining eye contact or ‘toe–walking’ – often thought of as tell-tale symptoms of autism in youngsters – do not always indicate that a child has the developmental disorder.
They also question the possibility of the concept of ‘camouflaging’, also known as ‘masking’, in which individuals with autism claim to adjust their traits to fit into social situations.
Their intervention comes against the backdrop of figures showing there are more than 166,000 autistic pupils in schools in England, an increase of eight per cent since 2020.
The NHS says signs of autism in young children can include avoiding eye contact, not responding to their name, repetitive movements and reduced engagement in play.
In older children, this may extend to strict routines, having intense interests and difficulties with social communication.
Published in JAMA Pediatrics, the experts have questioned current methods of diagnosing the disorder, claiming that nearly half of the children diagnosed do not meet the criteria for autism when reassessed by specialists.
The researchers – Lester Liao, a pediatrician at Montreal Children’s Hospital and assistant professor at McGill University, and Eric Fombonne, director of autism research at Oregon Health & Science University in Portland – say overdiagnosis can have ‘harmful implications’.
Researchers say that behaviours such as difficulty maintaining eye contact does not always indicate that a child has autism
They wrote: ‘Overdiagnosis leads to resource dilution. There are only so many public sites and professionals for evaluation of autism and therapeutic intervention.
‘Overdiagnosis diverts resources from children with the most significant challenges. Importantly, it is often those who are better resourced, whether in terms of cultural capital or functional capabilities (eg, the capacity to speak and self–advocate), who can navigate the medical system to ensure milder diagnoses receive supports.
‘This leaves the most vulnerable – those who cannot self–advocate and exhausted families caring for their children full–time – without the support they need.’
The researchers also argued that the ‘expansion of the term autism’ and increased diagnoses leaves those with more severe challenges caused by the condition overlooked.
It is claimed in their report that the autism diagnostic observation schedule – a 40–60 minute play or conversation session used by clinicians to assess autism in children – may be ‘interpreted incorrectly’.
They add: ‘For example, poor eye contact may be due to inattention or social anxiety rather than to limited social reciprocity.’
The researchers also say that emotional and behavioural problems can inflate scores on autism tests, even when a child does not have the condition.
Citing a separate study, they added: ‘Close to half of children who received autism diagnoses in the community did not meet autism criteria when reevaluated by an autism research team.
‘This group notably had higher rates of psychiatric disorders, suggesting psychiatric complexity contributes to misdiagnosis.’
Liao and Fombonne said behaviours such as toe walking or sensory aversion to clothing may be wrongly interpreted as signs of autism.
They also highlighted that autism has changed from being a narrowly defined condition to making up part of a broader spectrum, which allows for other conditions like ADHD.
As a result, they claim diagnosed cases tend to be less severe, with milder symptoms.
They argue that ‘camouflaging highlights this trend’, adding: ‘Camouflaging presupposes a person understands acceptable behavior and then adjusts their more natural behavioral pattern accordingly, even if it is uncomfortable.
‘Children with profound autism may not understand the norms in the first place, let alone adjust. Camouflaging involves a much milder form of autism, ie, an expansion of the autism concept.’
Overall, the researchers warned that overdiagnosis could create a ‘self–fulfilling prophecy’, where children labelled as autistic may have fewer opportunities to develop social and behavioural skills.
They say: ‘A child who is socially withdrawn is permitted to isolate, minimizing habituation to social circumstances and decreasing social opportunities, thereby reducing social practice.
‘The same applies to behavioral rigidities or sensory aversions. There is a risk of attributing all the child’s troubles to autism, as opposed to, say, a circumstance, thereby reinforcing one’s concept of the child.
‘This does not allow a child to develop their full capacity. There’s a significant difference between a child who has difficulty doing something and a child who utterly cannot. A spectrum does not negate this.’