Study Shows Age 6 May Be a Turning Point for Most Autistic Children, Requiring Extra Support

New research shows that age six is a time when parents, educators, and other helpers must put in extra time and effort with children on the autism spectrum to ensure that they continue to make progress in a time when progress naturally stalls, around the time that students typically begin elementary school.

A new long-term study has shown that autism severity tends to decrease from ages three to six in most children on the spectrum, but that progress will stall for about three-quarters of them once they reach age six. Age six, according to researchers, is a key turning point, during which extra support is needed from families, clinics, schools, and communities.

“We can think about making sure these turning points turn out positively instead of negatively for kids,” says lead investigator Stelios Georgiades, associate professor of psychiatry and behavioral neurosciences at McMaster University in Hamilton, Canada.

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In 2020, a study showed that autism traits are not stable in young children with autism. The long-standing idea has been that these struggles do not ease with time, but the latest research shows this isn’t the case.

“Most children with autism do show some improvement, in contrast with a lot of the literature,” says David Amaral, professor of medical psychiatry at the University of California, Davis, who led the 2020 study but was not involved in the new study. “Change in the severity of symptoms over time is more likely than ever thought before.”

Georgiades and his colleagues analyzed data from 187 children with autism who were enrolled in the Pathways in ASD study, a long-term development project. They measured autism trait severity at the time of diagnosis (average age three years and five months) and then later at ages four, six, and 10.

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The children studied were placed into two groups based on the changes in their autism traits. About 73 percent saw a slight decrease in their symptoms up until age six but then no change after that point. The other 27 percent showed a more drastic decline in symptoms up until age six, followed by a slower rate of decrease in symptoms after age six.

The children who continued to improve over time tended to start out with slightly less severe traits than those children who stagnated at age six. They also performed marginally better on cognition tests, language tests, and daily-living skills tests.

“They didn’t start off all that different from children in the other group, but the discrepancies between the groups increased over time,” Georgiades says. “What that tells me is that at diagnosis, we may have a window of opportunity to ensure that all children develop in a positive way, and that family, clinical, and community services should help make sure that improvement doesn’t stop or plateau or regress.”

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The researchers say that the reasons for the turning point at this specific age are uncertain but posit that the start of school may play a role.

“We know that the social environment of school can be a challenge for many young children with autism,” says Tony Charman, professor of clinical child psychology at King’s College London in the United Kingdom. “But from the work presented, which has no school-based data about the cohort, it is hard to draw any definitive conclusions about whether school entry itself — and if so, what factors — are contributing to the change in trajectory.”

Researchers think brain development may also play a role in the turning point at age six. According to a 2020 brain imaging study by Amaral and his colleagues, brain development differs between those children whose autism traits continue to diminish over time and those who reach a plateau.

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“I think their idea of turning points is really important — as someone who tries to do trajectory analysis myself, I look forward to trying to figure out how to find them with our own studies,” says Cathy Lord, professor of psychiatry at the University of California, Los Angeles.

It’s unclear whether the turning point also applies to girls with autism, as 85 percent of the study participants were male. Amaral’s previous work, however, suggests that girls’ autism trait severity decreases more over time than boys’ does.

“There is the question of whether or not this decrease in the severity of symptoms we see in girls is real, or whether they are better able to mask or hide their symptoms,” says Einat Waizbard-Bartov‬, a graduate student in Amaral’s lab who was not involved in the new work. “There are many different types of mental-health costs from such camouflaging or compensation, such as anxiety, depression, and burnout, so that is something we want to be mindful of.”

The study results were published in March 2021 in the Journal of Autism and Developmental Disorders. Georgiades and his colleagues are now launching the Pediatric Autism Research Cohort project to analyze how clinical services and other support might change the trajectories of children’s autism traits. Georgiades hopes his research will have real-life implications for schools and communities in the very near future.

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