Structured interactive play for autism spectrum disorder screening in toddlers: a primary care-based cohort study

Early identification of autism spectrum disorder (ASD) is crucial for improving outcomes, yet diagnosis is often delayed. Primary care faces challenges, including the limited accuracy of existing tools and scarce access to specialist assessments. This prospective cohort study evaluated the feasibility of a novel, structured examiner-child interactive play protocol as an early behavioral screening tool for ASD.

We recruited 260 toddlers aged 18-36 months. At baseline, all children participated in a structured interactive play session. Their behaviors (e.g., eye contact, turn-taking, social smiling, symbolic play) were coded from video recordings to quantify nine core indicators. After a 6-month follow-up, 217 children completed comprehensive clinical assessments. Core symptoms were evaluated using the Childhood Autism Rating Scale (CARS), and developmental level was assessed using the Bayley Scales of Infant and Toddler Development-Fourth Edition (Bayley-4). Based on clinical assessment results, participants were classified into an ASD group (n = 45) and a typically developing (TD) group (n = 165) for primary analysis. Spearman correlation analysis was used to examine the relationships between behavioral indicators, developmental levels, and symptom severity. Receiver operating characteristic (ROC) curve analysis assessed each indicator's discriminative validity for ASD.

During the structured interactive play, the ASD group performed significantly worse on all behavioral indicators than the TD group. Correlation analysis revealed that several behavioral indicators, including eye contact, turn-taking, and symbolic play, showed positive correlations with cognitive (rs = 0.30-0.51) and language ability (rs = 0.34-0.43) and negative correlations with symptom severity (rs=-0.53--0.36). ROC analysis identified that eye-contact metrics were the strongest discriminators. Specifically, eye contact frequency yielded an AUC of 0.915 (sensitivity 96.36%, specificity 73.33%), and total eye contact duration achieved an AUC of 0.899 (sensitivity 86.67%, specificity 84.44%).

Behavioral observation through examiner-child structured interactive play, particularly metrics related to eye contact, effectively differentiates toddlers with iASD. This objective, low-cost method shows potential as a primary screening tool for enhancing early ASD detection in primary care settings.

Not applicable.