Guidelines for preventive activities in general practice

Development and behaviour

Developmental Delay and Autism

      1. Developmental Delay and Autism

Development and behaviour | Developmental Delay and Autism

Case finding age bar

09* 1014 1519 2024 2529 3034 3539 4044 4549 5054 5559 6064 6569 7074 7579 ≥80

*Case finding from 0 – 5 years.

Child development occurs rapidly across all domains early in life, with most milestones met in the first three years of life.1

Developmental domains that should be assessed are social, emotional, communication, cognition/fine motor/self-care and gross motor. More than one in five children are developmentally vulnerable in at least one domain,2 with boys more vulnerable to delay in all domains. Parental health, including mental health, can have a significant impact on children’s health and lives in general, with an Australian survey showing that 12% of parents living with children rated their health as fair or poor, with a rate of 21% among  Aboriginal and Torres Strait Islander people.3

Current estimates are that 7.4% of children aged 0–14 years have some level of disability, with the most prevalent disabilities being intellectual (4.3%) and sensory and speech (3.2%).4 At five years of age, one in five children is described as developmentally vulnerable in Australia.5 Missed or delayed reporting of developmental delay may be associated with parental factors.6

Based on international data, the prevalence of autism spectrum disorder is thought to be 1–2%,7 with a higher prevalence in males. The male to female ratio was previously thought to be 3–4 : 1, but more recent data suggest this ratio is closer due to the ‘masking’ of symptoms by girls and a diagnostic bias towards boys.7–9

Autism is a neurodevelopmental condition that affects child development in the first few years of life and remains present for life. Autism is characterised by differences or delays in social communication and social interaction, which include problems with social or emotional reciprocity (a back-and-forward sharing of emotions) and joint attention between carer and child, as well as restricted, repetitive behaviour and interests and sensory issues. The latter can be a hypo- or hypersensitivity to any of the five senses.9

Early detection allows remediation, support for families and planned proactive developmental monitoring. Developmental delay is diagnosed when milestones are not met in one or more domains: social, emotional, communication, cognition, fine or gross motor. Developmental disability occurs when there are functional impacts for a child’s physical, cognitive, language or behaviour. ‘Developmental vulnerability’ is a term for children who are at risk of developmental delay because of child factors or environmental factors.

In addition to general practice opportunities to detect and manage developmental delay, there are children’s health services organised at state and territory levels. Parents are encouraged through handheld personal health records to use Parents’ Evaluation of Developmental Status (PEDS) assessments at intervals from birth to five years. Refer to the Preventive activities in childhood chapter for more information.

Screening

Recommendation Grade How often References
General population screening with standardised tools for developmental delay is not recommended in children aged <5 years. Generally not recommended N/A 6
Screening for speech and language delay is not recommended in the general population of children aged <5 years. Not recommended (Strong) N/A 10
General population screening for autism spectrum disorder in young children aged 1.5–5 years is generally not recommended in those for whom no concerns of autism spectrum disorder have been raised (because of insufficient evidence). Generally not recommended N/A 11
 

Case finding

Recommendation Grade How often References
In children at risk of developmental delay (see Box 1), assess achievement of milestones in social, emotional, communication, cognition, fine and gross motor domains. Practice Point Opportunistically 6, 12
In children aged <5 years:
  • be alert for risk factors, including low birthweight, premature birth, family history of developmental delay, prenatal exposure to alcohol and other drugs
  • elicit parent/carer concerns about developmental delay
  • observe but do not formally assess development.  
Practice Point Opportunistically 6, 12

When assessing child development, an understanding of the context in which child development occurs will assist with both the assessment process and advising parents and carers about how their child is going and how they can assist development. Particularly in the first year, the development by the child of secure attachment to their primary carer and the development of warm, responsive relationships will accelerate their neurological development,13,14 enhancing their social, emotional and interpersonal skills.

As child development progresses beyond age 12 months, two aspects are of great importance to childhood development, namely play and the emergence of language skills. Play, particularly with another person, provides opportunities to develop skills such as communicating, thinking, solving problems, moving and being with other people, including other children. In a similar way, language skills, which are a part of the broader communication developmental domain, provide opportunities for the enhancement of development across all the domains. Making parents and carers aware of the importance of providing opportunities for play, language and shared attention and interaction will enhance development, which is particularly important for the child for whom there may be developmental concerns.

When developmental concerns are flagged, a thorough assessment of the child’s development is essential. This may involve assessment by allied health or non-GP specialists. If developmental delays are confirmed, outcomes for children have been shown to be improved by early intervention using evidence-based programs, which are funded by the National Disability Insurance Scheme (NDIS) early childhood approach. Children who do not fully meet the definition of developmental delay but still have developmental concerns will also be supported through this program.

Pragmatic approaches in the GP context can include making the family’s journey to the doctor as easy as possible. Be aware of the stress that attending appointments can cause young people with autism and consider flexible approaches to consultations and offer support for families or carers. In recent years there has been a drift away from using the terms ‘high functioning’ and ‘low functioning’ because often the degree of functional impairment may not be determined by the level of autism, but more by co-diagnoses that often accompany an autism diagnosis.13 Common co-occurring conditions include intellectual disability,7 specific learning disorders,7 speech and language disorders, epilepsy and seizure disorders,14 attention deficit hyperactivity disorder (ADHD),14 anxiety15 and depression (more common in older children and adolescents).15,16

Box 1. Factors indicating children at risk of developmental delay6,12
  • Prematurity
  • Low birthweight
  • Birth complications
  • Poor maternal health during pregnancy
  • Prenatal exposure to alcohol or drugs
  • Infections
  • Genetic characteristics
  • Trauma
  • Maltreatment
  • Exposure to toxins
  • Lead poisoning
  • Low socioeconomic status

For specific recommendations for Aboriginal and Torres Strait Islander people, please refer to the Child health chapter in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.

The 'red flag' early intervention referral guide for children aged 0–5 years | Central Queensland Hospital and Health Services

 
 
  1. Children’s Health Queensland. Red flags early identification guide (birth to 5 years) brochure. Queensland Government, 2022 [Accessed 21 May 2023].
  2. Australian Government. Snapshot of early childhood development in Australia 2012 – AEDI national report. Australian Government, 2013.
  3. Australian Institute of Health and Welfare. A picture of Australia’s children 2012. Australian Government, 2012 [Accessed 22 February 2024].
  4. Australian Institute of Health and Welfare. Australia’s children. Australian Government, 2022 [Accessed 22 February 2024].
  5. Australian Early Development Census. Australian Early Development Census (AEDC) national report 2015. A snapshot of early childhood development in Australia. Commonwealth of Australia Department of Education and Training, 2015.
  6. Canadian Task Force on Preventive Health Care. Developmental delay (2016). Canadian Task Force on Preventive Health Care, 2016 [Accessed 22 February 2024].
  7. Lord C, Charman T, Havdahl A, et al. The Lancet Commission on the future of care and clinical research in autism. Lancet 2022;399(10321):271–334. doi: 10.1016/s0140-6736(21)01541-5.
  8. Halladay AK, Bishop S, Constantino JN, et al. Sex and gender differences in autism spectrum disorder: Summarizing evidence gaps and identifying emerging areas of priority. Mol Autism 2015;6:36. doi: 10.1186/s13229-015-0019-y.
  9. Whitehouse AJO, Evans K, Eapen V, Wray J. A national guideline for the assessment and diagnosis of autism spectrum disorders in Australia. Cooperative Research Centre for Living with Autism, 2018 [Accessed 22 February 2024].
  10. U.S. Preventive Task Force (USPSTF). Speech and language delay and disorders in children: Screening. USPSTF, 2024 [Accessed 22 February 2024].
  11. U.S. Preventive Task Force (USPSTF). Autism spectrum disorder in young children: Screening. USPSTF, 2016 - :~:text=The USPSTF concludes that there,of ASD have been raised.&text=The USPSTF has made a,children 5 yea [Accessed 22 February 2024].
  12. Wallace IF. Universal screening of young children for developmental disorders: Unpacking the controversies. RTI Press, 2018 [Accessed 22 February 2024].
  13. Ministries of Health and Education. New Zealand autism spectrum disorder guideline. 2nd edn. Ministry of Health, 2016 [Accessed 22 February 2024].
  14. Hyman SL, Levy SE, Myers SM. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics 2020;145 (1): e20193447. doi: 10.1542/peds.2019-3447.
  15. Ip A, Zwaigenbaum L, Brian JA. Post-diagnostic management and follow-up care for autism spectrum disorder. Paediatr Child Health 2019;24(7):461–77. doi: 10.1093/pch/pxz121.
  16. The Royal Children’s Hospital Melbourne (RCH). Parents' evaluation of developmental status (PEDS). Parkville, Vic: The Royal Children’s Hospital Melbourne [Accessed 22 February 2024].
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