ISSN 2317-1782 (Online version)

Early symptoms of autism spectrum

Original Article
disorders and association with Brazilian
children’s development and behavior
Rafaela Silva Moreira1 
Marina Aguiar Pires Guimarães2 
Lívia de Castro Magalhães3 
Janaina Matos Moreira4 
Claudia Regina Lindgren Alves4 

Keywords ABSTRACT
Autism Spectrum Disorder Purpose: to examine the association between the early autism spectrum disorder (ASD) signs and developmental
and behavioral performance of Brazilian children aged 18 to 34 months. Methods: A cross-sectional study with
Infants
221 children recruited at public healthcare and early education services. Early symptoms of ASD were screened
Child Development using the Parental Observations of Social Interaction (POSI). Children’s development and behavior were examined
Behavior using the Ages and Stages Questionnaires (ASQ-3) and Survey of Well-being of Young Children (SWYC-BR).
Screening The results of children at risk for ASD were compared to the no-risk ones using Chi-square and t-test. Results:
The overall frequency of children at risk for ASD (POSI-positive screening) was 33% and did not differ across
children’s age range and gender. Children at risk for ASD showed worse socio-emotional behaviors (p=0.004)
and lower scores for overall development (p=0.0001), communication (p=0.0007), fine motor (p=0.04), and
personal-social domains (p=0.01). Differences between groups varied according to children’s age and across
developmental/behavioral domains and were more evident in older children. Children aged 30 to 34 months
presented significant differences in overall development (p=0.001), behavior (p=0.004), and the personal-social
domains (p=0.03). Conclusions: The frequency of children at risk for ASD was higher than described in the
literature. Also, the development and behavior of children at risk for ASD were significantly different from
their peers and compatible with the presentation of ASD in young children. Our findings reinforce the need for
systematic and holistic surveillance of child development during well-being visits to improve ASD early detection.

Correspondence address: Study conducted at Universidade Federal de Minas Gerais – UFMG - Belo Horizonte (MG), Brasil.
Claudia Regina Lindgren Alves 1
Departamento de Ciências da Saúde, Universidade Federal de Santa Catarina, Araranguá (SC), Brasil.
Departamento de Pediatria, Faculdade de 2
Baby Gym, Vitória da Conquista (BA), Brasil.
Medicina, Universidade Federal de Minas 3
Departamento de Terapia Ocupacional, Escola de Educação Física, Fisioterapia e Terapia Ocupacional,
Gerais – UFMG
Universidade Federal de Minas Gerais – UFMG - Belo Horizonte (MG), Brasil.
Av. Alfredo Balena, 190/247, Belo
Horizonte (MG), Brasil, CEP: 30130-100.
4
Departamento de Pediatria, Faculdade de Medicina, Universidade Federal de Minas Gerais – UFMG - Belo
E-mail: lindgren@[Link] Horizonte (MG), Brasil.
Financial support: Grand Challenges Canada-Saving Brains (Grant 0582-3), CNPQ Productivity Grant, Santa
Received: September 26, 2024 Catarina State Research and Innovation Foundation - FAPESC (Grant 2015TR328), Dean of Research at Federal
University of Minas Gerais - UFMG (scientific initiation and extension scholarship), CAPES (Doctorate Social
Accepted: March 12, 2025
Demand scholarship).
Conflict of interests: nothing to declare.
Editor: Larissa Cristina Berti.
Data Availability: Research data is not available.

This is an Open Access article distributed under the terms of the Creative Commons Attribution license (https://
[Link]/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Moreira et al. CoDAS 2025;37(4):e20240306 DOI: 10.1590/2317-1782/e20240306en 1/8

INTRODUCTION M-CHAT have demonstrated sensitivity above 75% in evaluating
risk for autism(10).
Autism spectrum disorder (ASD) is a neurodevelopmental The M-CHAT is the most widely used instrument for ASD
disorder that is more common in males, manifests in early screening(9,25). M-CHAT has 23 items, is available in several
childhood, and persists throughout life(1,2). It is characterized languages, including Brazilian Portuguese, and has been recently
by persistent deficits in communication and social interaction, validated in Brazil(26).
repetitive and restricted behavior and interest patterns, which POSI is a brief seven-question questionnaire that compounds the
may cause significant impairment in overall development, Survey of Well-being of Young Children (SWYC), a developmental-
limitations in daily activities, and restrictions in social behavioral screening instrument cross-culturally adapted to the
participation(1,3). Brazilian context(24,27). It assesses social interaction, communication,
Recent studies have registered an increase in the prevalence and repetitive behaviors in children aged 18 to 34 months and takes
and incidence of ASD worldwide despite data heterogeneity less than five minutes to be answered and interpreted(22). POSI has
regarding diagnostic criteria, children’s age, ethnicity, and already been adapted to Brazilian Portuguese(27), although cutoff
gender(2,4,5). In 2014, it was estimated that 17 out of 1,000 points have yet to be established, and accuracy studies with Brazilian
North American four-year-old children had ASD. In 2020, the children have not yet been conducted.
overall prevalence among children aged 4 was 21.5 per 1,000; Nevertheless, POSI is part of the Survey of Well-being of
for those aged 8, it was 27.6 per 1,000. ASD was 3.8 times as Young Children (SWYC), a comprehensive instrument designed
prevalent among boys as girls(4). In low- and middle-income to assess both child development and behavioral domains. SWYC
countries, including Brazil, data on the prevalence of ASD also screens risk factors in the family context, helping to compose
are scarce, especially among young children(3). Population the puzzle of ASD diagnosis. Sheldrick et al. highlight the
studies in Turkey(6) and Vietnam(7) estimated a prevalence importance of reconciling the screening test results, the parents’
of 0.8% in young children. In Brazil, the most well-known and professionals’ concerns, and the clinical observations when
populational study identified 6.4% of children between 7 and deciding when to refer or not a child suspected of having ASD(28).
14 years old as suspected of having ASD, whereas only 0.3% Thus, POSI might also be a promising instrument to be used on
were confirmed(8). a large scale in primary healthcare settings as part of an integral
Although specific ASD symptoms can be recognized developmental evaluation, mainly in early ages.
around 18 months and ASD diagnosis confirmed by age 2, Considering the challenges of suspecting and diagnosing ASD
most children are still diagnosed at school age(9-11). This long in early childhood and recognizing the need to evaluate tools that
gap causes incredible stress to families(8,12) and directly affects can enhance ASD screening in public healthcare settings, the
the child’s prognosis(13,14), as early suspicion and interventions present study aimed to examine the association between early ASD
are essential for better outcomes. signs and developmental and behavioral performance of Brazilian
Earlier in life, ASD symptoms may be subtle, varied, and children aged 18 to 34 months.
nonspecific(3,9,12,15). The American Academy of Pediatrics
recommends child developmental surveillance in all routine METHODS
medical visits and universal screening for ASD, using specific
instruments, at 18 and 24 months(9,16). In the Brazilian National Study design
Health System (SUS), development and growth surveillance
This study is an observational cross-sectional study that was
should be offered to all children at the primary health care part of a larger cohort study that investigated the evidence of
level. The screening and diagnosis of ASD can be made the validity of the SWYC Brazilian version questionnaires(27). It
by teams of the Family Health Strategy, but usually at risk was approved by the Research Ethics Committee of the Federal
children are referred to other levels of the System, where University of Minas Gerais (CAAE 0456.0.203.000-11).
specialized professionals proceed with the investigation and
early stimulation(17-20). Incorporating universal ASD screening Sample
into clinical practice is challenging(19,21).
Some tests are costly, require extra materials and It was a convenience sample composed of 221 children
training, and necessitate additional time for application and aged 18 to 34 months, recruited from Basic Healthcare Units/
interpretation. These practical aspects frequently prevent the Family Health Strategy (BHU/FHS) and at Early Childhood
use of ASD screening tools by pediatricians and other health Education Centers (ECEC) in two Brazilian urban cities, as part
care professionals in their daily routine(3,16,22). Furthermore, of the sample of the larger study. Following the protocols of
there is still a lack of tools specific for ASD screening in young the larger study, parents were invited to participate when they
children adapted to the Brazilian context and with evidence visited the BHU/FHS for any reason or when they went to pick
of validity(12,17,19,20). up their children at the ECEC. All children in the age range
The Modified Checklist for Autism in Toddlers (M-CHAT) whose parents/caregivers answered both the POSI questionnaire
(23)
and the Parents’ Observations on Social Interaction (POSI) and the other developmental and behavioral assessments during
(22,24)
are both simple and accessible questionnaires based on the recruitment period of the larger study were included in the
parents’ reports(9,16) and are compatible with universal ASD present study. Children with a prior diagnosis of neuromotor,
screening(25). In North American children, both POSI and sensory, or cognitive disorders were excluded.

Moreira et al. CoDAS 2025;37(4):e20240306 DOI: 10.1590/2317-1782/e20240306en 2/8

Instruments room by the research team in the BHU/FHS or ECEC between
June 2014 and December 2018. The questionnaires were
The researchers developed a structured questionnaire to assess answered in the following sequence: sample characterization,
the mothers’ socio-demographic characteristics, such as education Developmental Milestones, PPSC, POSI, and ASQ-3. Interviews
level and age at childbirth. The families’ purchasing power was
lasted about 25 minutes.
assessed using the Economic Classification Criterion of the
Brazilian Market Studies Association (CECB), which classifies
Analysis plan
socioeconomic levels, ranging from the highest (Level A) to the
lowest (Levels D-E)(29). Categorical variables were described using frequency
Developmental assessments were performed using the distributions. The frequency of children presenting symptoms
Brazilian versions of the Survey of Well-being of Young Children
related to ASD was calculated according to the children’s age
(SWYC-BR)(24,27) and the Ages and Stages Questionnaire
and gender. Children’s characteristics and their mean scores in
(ASQ-3)(30,31), both based on parents’ reports. Beyond assessing
SWYC-BR and ASQ-3 questionnaires were compared to POSI
classic developmental domains, such as motor, language, and
cognitive milestones, the SWYC-BR also has specific screening results (negative and positive screening) using the Chi-square
questionnaires for socioemotional behavioral problems (PPSC) test and T-test, respectively. The significance level was set at 5%.
and difficulties in social interactions (POSI), providing a holistic The analyses were performed in the Epi Info [Link] software.
approach to child development.
The SWYC-BR is a multidimensional instrument for screening RESULTS
children’s developmental delays and behavioral problems from 2 to
65 months(24). The Developmental Milestones questionnaire was Table 1 presents the sample’s characteristics. Mothers were
used to assess the child’s overall development. It has 10 questions the main respondents (81.4%). They were predominantly adults
per age range to assess motor, cognitive, and language skills. The (85.4%) and had completed nine years of education or more
maximum score is 20 points, with higher scores indicating better (80.4%). The families had low or very low socioeconomic
performance(24). The Preschool Pediatric Symptom Checklist status (74.2%). Most children were boys (51.1%) and were
(PPSC) comprises 18 items related to the child’s socio-emotional born full-term (90.3%).
behaviors (externalizing and internalizing behaviors, attention
problems, and parenting challenges). The maximum score is
36 points. The higher the child’s scores, the higher the chances Table 1. Characteristics of the sample
of behavioral problems and the need for further evaluation(32). Total (n=221)
The Parental Observation of Social Interaction (POSI) Characteristics of mothers and families
N %
questionnaire, which is also part of the SWYC-BR, is based on the Mother’s education (years)*
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ≤8 43 19.6
and DSM-V) and the M-CHAT(22,24). It includes items related to 9-11 99 45.2
the child’s social behavior, such as “Does your child look if you >11 77 35.2
point to something across the room?” and “How does your child Mother’s age at child’s birth (years)*
usually show you something he or she wants?”. Parents answer ≤ 19 32 14.6
how often the child exhibits such behaviors and which toys are >19 187 85.4
preferred. The interpretation is based on the graphic design of Socioeconomic classification (CECB)*
the questionnaire; the maximum score is seven points (Figure A+B1+B2 54 25.8
S1 - Supplementary Material). Scores greater than or equal to C1+C2 133 63.7
three indicate that the child should be referred for specialized D/E 22 10.53
evaluation due to symptoms related to ASD(24). In our sample, First child*
children with a positive screening were referred for diagnostic Yes 108 49.1
evaluation in the public healthcare system. No 112 50.9
The Ages and Stages Questionnaire (ASQ-3) was used to assess Characteristics of the children
the communication, problem-solving, personal-social, and fine Gender
and gross motor domains(30). The ASQ-3 has been translated and Male 113 51.1
validated into several languages, including Brazilian Portuguese(31). Female 108 48.9
The forms are age-specific and contain six items by domain. Each Prematurity (weeks)
ASQ-3 item is scored on a three-point scale, and the maximum <37 21 9.7
score per domain is 60 points. The higher the scores, the better ≥37 196 90.3
the performance in that domain(30). Age (months)
18-23 46 20.8
Procedures 24-29 88 39.8
30-34 87 39.4
All parents who consented to participate in the study signed CECB - Criteria for Economic Classification of the Brazilian Association of
an informed consent form. Parents were interviewed in a private Market Research (ABEP)(30). data missing

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 Table 2 reports the frequency of children with positive with negative screening, children with positive screening
screening in POSI by age group and gender. The overall frequency for ASD showed lower scores in Developmental Milestones
of children who should be referred to specialized evaluation (p=0.0001), higher scores in PPSC (p=0.004), lower scores in
for ASD was 33%. The frequency of positive POSI screening communication (p=0.0007), fine motor (p=0.04), and personal-
results did not differ across age groups and children’s genders. social (p=0.01) domains of the ASQ-3.
Table 3 presents children’s developmental and behavioral Table 4 shows the analysis of the association between the
performance according to POSI results. Compared to children POSI results and mean scores on the SWYC-BR and ASQ-3

Table 2. Comparison of POSI results, according to children’s age and gender

Total sample Male Female
(N=221) (N=113) (N=108)
POSI
Negative Positive Negative Positive Negative Positive
screening screening screening screening screening screening
p *
p*
p*
Age in
n % n % n % n % n % n %
months
18–23 32 69.6 14 30.4 0.93 14 60.8 9 39.1 0.80 18 78.2 5 21.7 0.58
24–29 57 64.8 31 35.2 27 62.7 16 37.2 30 66.6 15 33.3
30–34 59 67.8 28 32.2 32 68.0 15 31.9 27 67.5 13 32.5
Total 148 67.0 73 33.0 - 73 64.6 40 35.4 - 75 69.4 33 30.5 0.53**
*Chi-square; **males vs. females

Table 3. Comparison of POSI results and mean scores on the SWYC-BR and ASQ-3 questionnaires
POSI (N= 221)
Negative screening Positive screening
p-value*
(n=148) (n=73)
SWYC-BR questionnaires (Mean±SD)
Developmental Milestones 15.6±3.5 13.4±4.3 0.0001
Preschool Pediatric Symptom 8.9±5.0 11.1±6.4 0.004
Checklist (PPSC)
ASQ-3 domains (Mean±SD)
Communication 51.3±10.6 45.4±14.1 0.0007
Fine motor 42.4±12.7 38.7±12.4 0.04
Gross motor 52.9±8.7 51.0±9.6 0.14
Personal-social 47.7±10.6 43.8±12.4 0.01
Problem solving 46.4±10.8 45.8±10.5 0.66
* T-test

Table 4. Comparison of POSI results and mean scores on the SWYC-BR and ASQ-3 domains, according to children’s age range
18–23 months (n=46) 24–29 months (n=88) 30–34 months (n=87)
Instrument Negative Positive Negative Positive Negative Positive
screening screening p-value* screening screening p-value* screening screening p-value*
(n=32) (n=14) (n=57) (n=31) (n=59) (n=28)
SWYC-BR (Mean±SD)
Developmental 15.7±3.3 14±3.8 0.13 15.7±3.7 13.8±5.2 0.04 15.3±3.7 12.6±3.4 0.001
Milestones
Preschool Pediatric 8.5±4.5 10.8±5.6 0.14 8.8±5.4 9.7±6.2 0.48 9.1±5.1 12.9±6.9 0.004
Symptom Checklist
(PPSC)
ASQ-3 domains (Mean±SD)
Communication 50.2±12.5 38.9±16.2 0.01 51.1±10.8 45.8±15.2 0.06 52.0±9.5 48.2±10.8 0.09
Fine motor 45.3±8.7 41.8±12.2 0.27 43.9±13.6 40.2±12.5 0.21 39.5±13.2 35.5±12.0 0.18
Gross motor 53.4±9.1 54.6±6.9 0.66 53.0±9.6 50.0±11.0 0.19 52.6±7.7 50.4±9.1 0.23
Personal-social 47.3±9.2 42.5±11.2 0.13 45.8±11.3 44.2±12.0 0.53 49.8±10.5 43.9±13.6 0.03
Problem solving 46.9±9.2 46.0±5.9 0.77 44.7±11.7 46.1±11.5 0.59 47.8±10.8 45.2±11.3 0.30
*T-test

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domains by age range. For the younger children (18-23 months), will enable a quick response to children’s needs, which will not
in general, those with a positive screening in the POSI scored necessarily be an ASD diagnosis. Therefore, the POSI results
lower considering developmental milestones and ASQ-3 domains, observed in the present study should be understood as just one
although differences were significant only for the communication necessary piece of information to help professionals decide
domain (p=0.01). This pattern was also observed in the other whether to proceed with the investigation for ASD.
age groups, with significant differences in overall development In the present study, we observed an association between the
(SWYC-BR) for children aged 24 months or older. Children outcomes of children at risk for ASD and their global development,
aged 30-34 months with POSI-positive screening also scored using both the SWYC-BR and the ASQ-3. We found that the
significantly higher in PPSC (p=0.004) and significantly lower mean scores in the communication and social-personal domains
in the personal-social domain (p=0.03). Of note, the differences of the ASQ-3 were lower in children at risk of ASD. Similar
between children with positive and negative screening tended to results were observed in a study that examined the ability of
be significant for those older than 24 months in the communication the ASQ-3 to predict the risk of ASD in 2848 North American
domain (p<0.10). children aged 16 to 30 months(35). About 70% of the children
with a positive ASD screening (M-CHAT) scored lower than
DISCUSSION expected in at least one of the ASQ-3 domains. Among the 21
children with a confirmed diagnosis of ASD, 95% presented
The present study analyzed the association between POSI impairment in communication, 71% in social-personal, and
results and child development and socio-emotional behavior. 66% in fine motor skills. The authors reinforce the importance
Early symptoms of risk for ASD were associated with children’s of longitudinal monitoring of overall development to detect
performance in the developmental and behavioral questionnaires. children at risk of ASD(35).
We found that approximately one-third of the children were Considering the results according to age groups, we found
considered at-risk for ASD and would need a specialized that communication delays were the first and most affected
reassessment. In general, the children identified as at-risk for domain. They were present in the youngest children at risk for
ASD had lower scores on developmental scales and higher scores ASD and tend to be present in the oldest children, too. Similarly,
on behavioral assessment than those with a negative screening. Li et al.(37) found that autistic traits at age 3 were predicted by
In the present study, the frequency of risk symptoms for ASD expressive language at 14 months and receptive language at 24
in children aged 18 to 34 months was higher than reported in months. In children older than 24 months, differences in overall
other studies conducted in Brazil(33,34). Considering only studies development were more evident, reflecting a global delay in
with children under three years old that applied M-CHAT, the cognitive, language, and motor skills. Probably, the youngest
suspicion of ASD ranged from 10.8%(7,35) to 15.3%(36), and the children do not yet show signs of developmental delays that
diagnostic confirmation rate ranged from 0.08%(36) to 0.8%(6,7). indicate a risk of ASD, the signs becoming more visible to
Important methodological differences, such as sample size, the parents from age 2. Sacrey et al.(38), in a prospective study of
nature of the tests, settings, children’s age, and clinical profile, children aged 6 to 36 months at risk of ASD, found that parental
may explain the divergences across the studies. Moreover, reports of concerns about sensory, motor, and play aspects in
the POSI is a pre-screening test, so a high number of false- the first year of life and communication and social skills after
positive cases can be expected. The sensitivity of POSI in the second year of life were predictive of ASD.
North American children was very high, but its specificity was Children between 30 and 34 months at risk of ASD
low(10,22). In the original POSI validation study, the prevalence showed fewer personal and social skills, more internalizing
of positive screening was 12%, and the diagnosis of ASD was and externalizing symptoms, and attention difficulties than
confirmed in 2.5% of at-risk children. However, around half of their peers. These findings indicate that behavioral challenges
the children who screened positive on the POSI but ASD was were better observed from the age of 30 months and, despite
not confirmed had developmental delays and other diagnoses, not being part of the ASD diagnostic criteria, can be predictors
indicating that they could benefit from early intervention(22). of other neurodevelopmental disorders. Behavioral problems
It highlights the importance of considering other signs and are one of the biggest concerns of parents of children at risk
symptoms that may raise suspicions of ASD to increase the of ASD because they directly affect families’ social lives and
specificity of the POSI results. children’s adaptation to a variety of environments(1,9). These
Aligned with the literature(9,11), our results showed that findings corroborate the need for a holistic approach to child
the developmental and behavioral performance of children development, looking at socioemotional behaviors and parents’
considered at risk for ASD differed from those not at risk. The concerns as well as the classic developmental milestones. The
most significant differences were noted in domains compatible early diagnosis of autism is a difficult but extremely important
with early ASD manifestations, such as socioemotional behavior, task. Therefore, it is necessary to gather all the symptoms and
communication, and social-personal skills(1,9,35), meaning that relevant information in order to help children access early
other developmental delays and behavioral problems frequently intervention, even if they have not yet been diagnosed.
accompanied the suspicious of ASD. ASD diagnosis is challenging This study has strengths but also some limitations. The sample
in young children as signs and symptoms can be unspecific and was relatively large compared to previous Brazilian studies.
subtle, so parents and professionals should value each other’s Participants were recruited from two cities with different contexts
concerns about the child’s development and behaviors(3,9,12,15). It and included children who presented no previous known risks

Moreira et al. CoDAS 2025;37(4):e20240306 DOI: 10.1590/2317-1782/e20240306en 5/8

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SUPPLEMENTARY MATERIAL

Supplementary material accompanies this paper.

Figure S1. POSI questionnaire
This material is available as part of the online article from [Link]

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