The first five minutes: Initial impressions during autism spectrum disorder diagnostic evaluations in young children

Andrea Trubanova Wieckowski, Ashley de Marchena, Yasemin Algur, Lashae Nichols, Sherira Fernandes, Rebecca P. Thomas, Leslie A. McClure, Sarah Dufek, Deborah Fein, Lauren B. Adamson, Aubyn Stahmer, Diana L. Robins

Research output: Contribution to journalArticlepeer-review


Diagnosticians report that autism spectrum disorder (ASD) is immediately apparent in some, but not all, children ultimately diagnosed. Clinicians' initial diagnostic impressions have implications for ASD early detection, yet the literature raises questions about their accuracy. This study explores diagnostic impressions of ASD specialists made within the first 5 minutes of meeting a young child and investigates factors associated with the match between initial impressions and final diagnoses. Participants were children (n = 294, aged 12–53 months) referred for an ASD evaluation as part of multi-site ASD screening studies. After 5 minutes observing each child, clinicians with expertise diagnosing ASD recorded if they thought the child would meet criteria for ASD following a complete evaluation, and recorded their confidence in this impression. Clinicians' initial impressions matched the final diagnosis in 81% of cases. Ninety-two percent of cases initially thought to have ASD met criteria following a full evaluation; however, 24% of cases initially thought not to have ASD also met criteria, suggesting a high miss rate. Clinicians were generally confident in their initial impressions, reporting highest confidence for children initially thought correctly not to have ASD. ASD behavioral presentation, but not demographic characteristics or developmental level, were associated with matching initial impression and final diagnosis, and confidence. Brief observations indicating ASD should trigger referral to intervention services, but are likely to under-detect positive cases and should not be used to rule out ASD, highlighting the need to incorporate information beyond initial clinical impression. Lay Summary: When children come in for an autism evaluation, clinicians often form early impressions—before doing any formal testing—about whether the child has autism. We studied how often these early impressions match the final diagnosis, and found that clinicians could not easily rule out autism (many children who initially appeared not to have autism were ultimately diagnosed), but were generally accurate ruling in autism (when a child appeared to have autism within 5 minutes, they were almost always so diagnosed).

Original languageEnglish (US)
JournalAutism Research
StateAccepted/In press - 2021
Externally publishedYes


  • autism spectrum disorder
  • clinician confidence in diagnosis
  • diagnosis
  • early detection
  • initial impression
  • toddlers

ASJC Scopus subject areas

  • Neuroscience(all)
  • Clinical Neurology
  • Genetics(clinical)


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