What is the best course of action for a 33-month-old child with self-injurious behavior and suspected Autism Spectrum Disorder (ASD)?

Referral Pathway for 33-Month-Old with Self-Injurious Behavior and Suspected Autism

Refer immediately to a developmental-behavioral pediatrician or child psychiatrist for comprehensive autism evaluation, with concurrent referrals to speech-language therapy and occupational therapy to address the self-injurious behaviors while diagnostic assessment proceeds. 1

Primary Referral Targets

Core Diagnostic Team

• Developmental-behavioral pediatrician should be the first-line specialist for comprehensive autism evaluation in this age group, as they specialize in neurodevelopmental disorders and can coordinate the diagnostic process 1
• Child psychiatrist serves as an alternative primary referral if developmental-behavioral pediatrics is unavailable, particularly given the presence of self-injurious behavior requiring urgent behavioral management 1
• Child psychologist can conduct standardized diagnostic assessments and behavioral functional analysis of the self-injurious behaviors 1, 2

Immediate Therapeutic Interventions (Do Not Wait for Diagnosis)

• Speech-language therapist should be engaged immediately, as communication impairments are core features of autism and early intervention improves outcomes even before formal diagnosis 1
• Occupational therapist can address sensory processing issues and implement strategies to reduce self-injurious behaviors through environmental modifications and sensory integration techniques 1
• Applied Behavior Analysis (ABA) provider or behavioral therapist should assess the function of self-injurious behaviors and implement evidence-based behavioral interventions, as functional behavioral assessment is the critical first step in treating self-injury 2

Rationale for Urgent Multi-Disciplinary Approach

Why Not Delay Intervention

• The American Academy of Pediatrics emphasizes that therapeutic interventions should start as soon as autism is suspected rather than waiting for definitive diagnosis, as the second year of life represents a critical period of neural plasticity 1
• Early intensive intervention in children under 3 years produces better long-term outcomes in adaptive functioning, communication, and reduction of maladaptive behaviors 1
• Self-injurious behaviors require immediate behavioral assessment and intervention due to injury risk, regardless of final diagnostic outcome 1, 2

Evidence Supporting This Age Group

• Children aged 12-36 months with autism benefit most from developmentally appropriate early intervention programs that differ from approaches used in older children 1
• Comprehensive evaluation at this age typically requires 1-6 hours of assessment by multiple specialists to establish diagnosis and rule out differential diagnoses 1, 3

Critical Pitfalls to Avoid

Common Referral Errors

• Do not refer only to general pediatric neurology unless specific neurologic concerns (seizures, regression) are present, as autism evaluation requires specialized developmental expertise 1, 3
• Do not wait for a single specialist to complete full evaluation before initiating therapy services, as this delays critical early intervention during the optimal treatment window 1, 4
• Do not refer to psychiatry solely for medication management at this age without concurrent behavioral and developmental interventions, as behavioral approaches are first-line treatment for self-injury in autism 1, 2

Self-Injurious Behavior Considerations

• Functional behavioral assessment must determine whether self-injury serves to gain attention, escape demands, obtain sensory stimulation, or communicate needs before implementing treatment 2
• Environmental modifications (lighting, noise reduction, visual schedules) should be implemented immediately while awaiting comprehensive evaluation 1
• Pharmacotherapy (such as risperidone, FDA-approved for irritability in autism ages 5+) is not appropriate at 33 months and should only be considered after behavioral interventions have been thoroughly implemented 5

Coordination Strategy

Immediate Actions (Within 1-2 Weeks)

• Place referrals to developmental-behavioral pediatrician or child psychiatrist for diagnostic evaluation 1, 3
• Simultaneously refer to speech-language therapy and occupational therapy to begin intervention 1
• Request behavioral consultation for functional assessment of self-injurious behaviors 2

Supporting the Family During Evaluation

• Provide parents with visual communication systems and transition planning strategies to use at home while awaiting appointments 1
• Educate parents that breaks in routines, sensory sensitivities, and communication frustration commonly trigger self-injury in young children with autism 1, 2
• Connect family to early intervention services (Part C services for children under 3) which can begin immediately without requiring formal autism diagnosis 1, 4

Assessment for Co-occurring Conditions

• Ensure hearing evaluation has been completed to rule out hearing impairment as contributor to communication delays 4, 6
• Screen for sleep disturbances and gastrointestinal problems, which are common in autism and can exacerbate behavioral symptoms 6
• Assess for metabolic or genetic conditions if developmental regression, seizures, or dysmorphic features are present 4