Is my child at risk for ASD?

About 1 in 59 people has been identified with Autism Spectrum Disorder (ASD), the latest figure according to the Centres for Disease Control and Prevention (CDC). Signs of ASD usually begin during early childhood and typically last throughout a person’s life. We are honoured to have the opportunity to interview Dr. Angel Au to learn more about the signs and symptoms of ASD and her professional advice for parents who are in doubts.

Q1: What are the ‘red flags’ i.e. early signs, indicating a child who could be at risk of ASD?

The following boxes include some “red flags” that suggest a child could be at risk of ASD:
Possible signs of autism in babies and toddlers:
By 12 months
  1. Not responding to their name calls
  2. No imitation
  3. Little interest in others e.g. minimal desire to show caregivers things or to interact
  4. Rarely respond when others are pointing objects out for them
  5. Rarely point out objects at a distance to their caregivers spontaneously for the purpose of sharing their interest with their caregivers e.g. not pointing out an airplane or birds flying over
  6. Limited range of facial expressions
By 18 months
  1. No words
  2. Little interest in peers e.g. rarely watch or follow what they are doing
  3. Little curiosity in learning about things happening around them e.g. parents may find it hard to seek their attention or to engage their interest when demonstrating to them how to play a new toy
  4. Display of repetitive behaviours e.g. lining up objects
  5. Little interest in playing or rarely engage in “pretend” games e.g. not pretend to “feed” others, not use remote control or other daily objects to pretend talking on a telephone
By 24 months
  1. Delay in language development or untypical speech development e.g. pronoun reversal, not stringing up words to make simple sentences
  2. Immediate or delayed echolalia, i.e. immediately echoing words or phrases said to them; or repeating phrases said to them after a duration of delay
  3. Little interest in games common for toddlers
  4. Demonstrate unusual or repetitive / stereotypical behaviours
  5. Display unusual reactions to the way things smell, taste, look, feel, or sound

Parents should keep in mind that there are differences between ASD and other disorders with certain overlapping symptoms. For example, Speech Delay: children with speech delay usually show good attempts to communicate their wide variety of intents and will interact with others socially using a variety of non-verbal language: e.g. various flexible gestures (e.g. nodding their heads to indicate “yes”, tapping the person to seek their attention, holding their hand with the palm up to ask for an object); whilst pre-verbal children with ASD usually show fewer “social” desires and adopt only a few basic gestures to communicate their needs (e.g. pulling other’s hands, reaching for the item directly or holding their hands out to be carried). Another example is children that are socially anxious. Whilst social anxiety is not uncommon in children with ASD, children who are only socially anxious present clear social connectedness and communicate their thoughts and feelings adequately in more familiar settings with people they feel comfortable with. As such, a formal evaluation is crucial.

Q2: Why do some parents delay the diagnosis and the opportunity for early intervention?

a. Inadequate understanding about early childhood development
  1. There is a wide variation to normal development, particularly in the early years. New parents usually are not aware of the normal developmental milestones for Communication and Social development. They might have very little experience with typically developing children (e.g. knowing how frequent a child pointing out things to show others to be considered “normal”) as there is no comparison.
  2. In cities with high living standard, like Hong Kong, we have a lot of families with both parents working full time. As a result, parents have fewer opportunities to compare the development of their children with others’. They could only rely on reports from their domestic helpers or grandparents. Sometimes, it is not easy to know how accurate these reports are, since worries to offend their employers and overprotection from grandparents are not uncommon.
b. Misconception
It is not easy for parents to know about the symptoms for children with very mild ASD presentation. Their motor and speech developmental milestones were usually achieved within the typical ranges. Their overlapping symptoms with other developmental diagnoses, such as Speech Delay, could confuse some parents. In addition, the misconception about “delayed speech development is not uncommon in boys” is firmly grounded in most parents. In fact, some parents themselves were also late speakers, who obviously lead a successful life, which could be another reason that parents did not seek an early assessment.

c. Special interests and strengths
Some parents may see their narrow interests (e.g. early interest and advanced skills in reading and learning about numbers) as strengths which overshadow other areas of deficiencies.


Q3. What are the risk factors for a child to develop ASD?

The cause of ASD remains unknown. However, there are certain factors that may increase their risk:
a. Genes & heredity
If there is a close family member who has the diagnosis, such as a sibling, twin, or parent, the chance of another child having the same diagnosis is much higher.

b. Genetic disorders linked to ASD
There is a list of genetic disorders that linked to ASD, including Fragile X Syndrome and Tuberous Sclerosis.

c. Age of parents
Children born to older parents are at greater risk of developing ASD.

Q4: Please share some advice with our parents.

Parents should familiarize themselves more with early childhood development, including not only motor and language development but also the milestones of play and social development. I highly recommend the website of Centres for Disease Control and Prevention ( provides comprehensive information including checklists, videos, and a lot of other useful resources to professionals and parents about early developmental milestones and symptoms of ASD in young children.
If you suspect your child could have ASD or other developmental problems, contact a General Practitioner for referral to a specialist who is trained to perform in-depth diagnostic assessment for childhood disorders as soon as possible. The Hong Kong Department of Health also provides developmental surveillance for young children.

Interview conducted by Beverly Chong (AP Lead Behavioral Therapist) and Kelvin Ho (AP Senior Behavioral Therapist)
Information provided by: Dr. Angel Au, Psy. D., Clinical Psychologist
Angel Au
Dr. Angel Au is a Registered Clinical Psychologist of Hong Kong Psychological Society and has undergone doctoral training in Clinical Psychology. She has received extensive training and on-going supervision from Dr. B. J. Freeman, a world-renowned diagnostician in Autism Spectrum Disorder. After completing the Clinical Training of Autism Diagnostic and Observation Schedule (ADOS) in 2003, which is a well-regarded as gold standard in diagnosing ASD, Dr. Au has also completed the ADOS Advanced Research training, from the University of Michigan Autism and Communication Disorders Centre in 2011. Her doctoral thesis was on early identification of the more able children with ASD in mainstream preschool settings. She specializes in assessing individuals on the milder end of the spectrum and has more than 14 years of experience in diagnosing individuals from toddlerhood to middle-age adults. Other than ASD, Dr. Au also assesses a wide array of individuals with different diagnosis, including Attention Deficit / Hyperactive Disorders, Global Developmental Delay and individuals with various behavioral challenges.

Under the direct supervision and training of Dr. Ronald Leaf and Dr. Mitch Taubman, Dr. Au started providing Applied Behavior Analysis therapy for individuals with ASD since 1996. Other than seeing cases locally, she has also provided overseas consultations in China, India, Japan, Malaysia and Singapore. Applying her many years of experience in helping children with ASD, Dr. Au also specializes in providing psychotherapy and social skills training for adolescents and adults with ASD and other behaviorally challenged conditions.

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