Immediate Referral for Injurious Behavior in a 32-Month-Old with ASD
Yes, a 32-month-old child with autism spectrum disorder and speech delay exhibiting injurious behavior should be referred immediately to a multidisciplinary diagnostic team that includes access to psychiatric consultation, as self-injurious behaviors require urgent behavioral assessment and intervention, and approximately 75% of children with ASD have comorbid psychiatric conditions that may require pharmacotherapy. 1, 2, 3
Why Immediate Multidisciplinary Referral is Critical
The American Academy of Child and Adolescent Psychiatry recommends that ASD diagnosis and treatment planning requires multidisciplinary input, and single-provider evaluation is insufficient. 2, 3 For a child this young with injurious behavior, the team should include:
- A psychologist to conduct cognitive assessment, behavioral functional analysis of the self-injurious behavior, and measures of attention and processing 2, 4
- A developmental pediatrician or child neurologist to conduct medical assessment, rule out other conditions, and coordinate pharmacotherapy if needed 2, 3
- A speech/language pathologist to evaluate receptive and expressive language deficits, as communication impairments often drive behavioral problems 2, 4
- A psychiatrist or access to psychiatric consultation specifically for assessment and management of the injurious behavior and screening for comorbid psychiatric conditions 1, 3
Understanding Self-Injurious Behavior in Young Children with ASD
Self-injurious behaviors in autism include aggression toward others, deliberate self-injuriousness, temper tantrums, and quickly changing moods. 5 A thorough behavioral assessment aimed at determining the function of these behaviors is the first step to developing a treatment plan. 6 At 32 months, these behaviors frequently become the primary treatment target because of the potential for injury. 6
Common behavioral markers at this age that accompany injurious behavior include:
- Lower positive affect and higher negative affect 4
- Difficulty controlling behavior 4
- Temperament dysregulation 1
- Communication frustration due to speech delay 1, 4
Immediate Interventions While Awaiting Full Evaluation
The American Academy of Pediatrics recommends referring immediately to early intervention services without waiting for formal diagnosis completion, as wait times for team-based evaluations can exceed one year. 2 Concurrent actions should include:
- Immediate referral to early intensive behavioral interventions (20-30 hours per week) focusing on communication skills and functional behavioral assessment of the self-injurious behavior 1, 4, 6
- Applied Behavior Analysis (ABA) techniques with parent training in behavior management strategies 4, 7
- Speech/language therapy to address the communication deficits that may be driving behavioral frustration 4
When Pharmacotherapy May Be Indicated
Risperidone is FDA-approved for the treatment of irritability associated with autistic disorder in children ages 5 to 17 years, including symptoms of aggression toward others, deliberate self-injuriousness, temper tantrums, and quickly changing moods. 5 However, at 32 months (approximately 2.7 years), this child is below the FDA-approved age range. 5
If behavioral interventions are insufficient and the injurious behavior poses significant risk, psychiatric consultation is essential to weigh the risks and benefits of off-label pharmacotherapy in this age group. 1, 3 Risperidone demonstrated efficacy with a standardized mean difference of 1.1 (large effect size) for irritability and aggression compared with placebo, but is associated with adverse effects including changes in appetite, weight, and sleep. 5, 7
Screening for Psychiatric Comorbidities
Approximately 75% of children with ASD have comorbid psychiatric conditions, and screening should be conducted for ADHD, anxiety disorders, depression, and mood disorders. 3, 7 At 32 months, early signs of these conditions may include:
- Emotional dysregulation beyond typical toddler tantrums 1
- Sleep disturbances 1, 7
- Extreme difficulty with transitions or changes 1
Common Pitfalls to Avoid
- Do not delay referral for psychiatric consultation when injurious behavior is present - waiting for "behavioral interventions to fail first" puts the child at continued risk of injury 6, 8
- Do not assume speech delay alone explains the injurious behavior - functional behavioral assessment is required to determine whether the behavior serves a communication function, sensory function, escape function, or attention-seeking function 6
- Do not overlook the need for augmentative/alternative communication evaluation - a small but significant minority of children with ASD are nonverbal or minimally verbal and require alternative communication systems, which may reduce frustration-driven injurious behavior 4
- Do not fail to coordinate care through a medical home with multidisciplinary team involvement and regular follow-up to monitor treatment response 3
Specific Diagnostic Workup Required
The comprehensive evaluation should include:
- Autism Diagnostic Observation Schedule (ADOS) as the gold standard observational measure 2, 3, 4
- Autism Diagnostic Interview-Revised (ADI-R) for detailed developmental history 2, 3
- Autism Observation Scale for Infants (AOSI) given the young age 1, 4
- Communication Development Inventory-Words and Gestures (CDI-WG) to assess gestural and early language development 1, 4
- Functional behavioral assessment of the self-injurious behavior to guide intervention 4, 6
- Medical workup including physical examination, formal audiogram, Wood's lamp examination for tuberous sclerosis, and genetic testing (chromosomal microarray and fragile X DNA testing) 3, 9