University of Gothenburg
Protocol for ESSENCE-observation in preschool

Observation is a tool in the examination process

When examining ESSENCE* (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) (2) it is crucial to gather information about different functions from as wide a perspective as possible. Observation is an important tool, particularly when examining younger children. The aim is to find out how they fare in everyday situations, and when they are unable to describe their own strengths and difficulties, we have to find another way of obtaining this information. The majority of children in Sweden under the age of 6 spend many of their waking hours at preschool before eventually moving on to primary school. Preschool groups vary in size, but they usually consist of about 20-25 children (or more). Preschools mostly employ preschool teachers, but also educators with other training.


Gunilla Westman Andersson

*) This text primarily uses the umbrella term ESSENCE to refer to neuropsychiatric or neurodevelopmental disorders

Why is observation so important in preschool settings specifically?

By observing how a child gets on in their preschool setting, we gain crucial, comprehensive information about potential symptoms, because children with ESSENCE problems like autism often have major limitations in exactly the kinds of areas that are crucial in preschool. Preschool teachers and other educators who work with the child have very valuable knowledge which, when combined with information provided by parents, serves to provide a more complete picture of the situation. Observation isn’t enough – talking to teachers and educators is also necessary in order to properly gauge the child’s ability to handle different everyday situations.

Preschools expect children to develop certain skills

The Swedish preschool curriculum (1) places great emphasis on children learning through communication, interaction and play. Among other things, children are expected to:

  • interact and communicate with both peers and adults
  • develop in play
  • develop in everyday skills
  • adapt to different routines
  • adapt to changes
  • build a foundation for continued learning in a life perspective

Compare this with the fundamental difficulties in children with autism spectrum disorders, according to the diagnostic manual DSM-5:

  • Limitations in social communication and social interaction
  • Limited and repetitive behaviours, interests and activities

This means that many situations in preschool (and later in school) present major challenges for children with autism and similar disorders. Difficulties often become more pronounced in these settings than at home, although sometimes the opposite is true.

Is observation only useful for diagnostic purposes?

In preschool settings, observation is a common and effective way of mapping out a child’s specific needs. The aim then is to create optimal circumstances for positive development, as the main purpose of preschool education is to provide the child with a good foundation based on the goals of the preschool curriculum. Whether the child meets criteria for a diagnosis or not, mapping out the child’s specific strengths and weaknesses enables us to adjust the learning environment and direct our intervention measures so as to allow for optimal development. In other words, it is just as valuable to identify areas where the child is in need of support regardless of whether the ESSENCE assessment leads to any diagnosis or not.

Focus on both the individual and the circumstances of their surroundings

When observing, one must focus on both the individual and their surroundings. Personal circumstances are influenced by environmental circumstances, and this is something that must be kept in mind when assessing someone. Therefore, the observer should preferably be familiar with the preschool’s routines and way of operating, as well as any educational challenges the preschool might be facing. Potential difficulties in the specific setting can then be identified by examining the relationship between the individual’s skillset and environmental factors.

Isn’t it too early to examine children in their preschool years?

There is now extensive research showing not only the possibility of early detection of ESSENCE-related difficulties, but also the importance of implementing early intervention measures. ESSENCE (2) emphasises how critical it is to identify individual areas of development and take early signs of problems seriously. The earlier we can identify a child’s difficulties, the better we’re able to help their development and tailor our education efforts to suit the individual’s specific needs.

Which areas should one focus on?

Here are examples of some areas to focus on, but one must of course adjust and zero in more on specific areas according to both the individual in question and their environment:

When focusing on the individual:

  • How does the child interact?
  • Does the child show reciprocity?
  • How does the child communicate?
  • What is the child’s language like (generally speaking)?
  • How does the child play?
  • How does the child behave? What are their interests?
  • How does the child react to different sensory impressions?
  • How does the child generally adjust to daily routines?
  • How would you describe the child’s level of activity and impulsivity?
  • How well is the child able to concentrate/focus?
  • How would you describe the child’s motor skills?
  • How does the child handle eating, getting dressed, going to the toilet, et cetera?
  • What is your impression of the child’s general developmental level compared to children of the same age?

When focusing on the child’s environment:

  • What is the group composition like?
  • What kind of support is the child getting with regard to communication, interaction and play?
  • Is there a tendency to clarify and explain things?
  • What is the child’s environment like in terms of sensory impressions?
  • What adjustments, if any, have been made to accommodate the child?
  • Have staff members been provided with any guidance?
  • Any other pertinent aspects

Observation in conjunction with examination is a part of the team effort and requires good knowledge of ESSENCE

The scientific recommendations for diagnosing these conditions point to the importance of viewing the individual from many different perspectives, and this in turn highlights the need for multidisciplinary investigation teams. Many studies also emphasise the importance of good clinical experience. i.e. having both a theoretical understanding and extensive practical experience of children with difficulties in the autism spectrum and other ESSENCE areas (2, 3).

This means that general knowledge about child development isn’t enough – one must also have knowledge and experience relating to the specific difficulties being examined. Observations (like any other assessment tool) cannot be considered separately; they must be viewed in relation to any other information that emerges during the examination process. Moreover, the observer must try to see “the big picture”, as individuals with ESSENCE usually exhibit difficulties related to more than one area or diagnosis (2).

Is this scientifically grounded?

Two studies carried out at the GNC have shown the value of including preschool observation in the examination process. The first study showed that structured observation in the preschool setting (with the other children and adults present and with access to the preschool’s own material) produced virtually the same results as ADOS (Autism Diagnostic Observation Schedule) assessments (4). ADOS assessments are performed in a clinical setting with the child and 1-2 adults present; they are frequently used all over the world to examine suspected cases of autism.

The second study not only included observation but also added information gathered from preschool staff, which proved to contribute greatly in terms of concordance with the ultimate diagnosis (5), even more so than ADOS at the clinic provided. Both of these studies are relatively small, but they still suggest that observation and knowledge of the child’s everyday environment provide very valuable information and should be included when investigating ESSENCE related difficulties.

Download protocol

There is an observation instrument based on practical/clinical experience and the studies outlined above, and it is available in Swedish and English. It is intended for use by professionals with extensive experience investigating ESSENCE conditions. Anyone using this observation instrument should have good knowledge of ESSENCE as well as the preschool’s routines and everyday operations (preferably special educators in neuropsychiatric investigation teams).

In assessment and analysis of the observation, one needs to consider, in addition to the conditions provided in the learning environment, the expected development in relation to the child's age.

  • Digitalisation of this protocol is not permitted.
  • If you download this protocol for use (clinical or research), please inform


1. Skolverket. (2018). Läroplan för förskolan. Lpfö 18. Norstedts Juridik AB.

2. Gillberg, C. (2010). The ESSENCE in child psychiatry: early symptomatic syndromes eliciting neurodevelopmental clinical examinations. Research in developmental disabilities, 31(6), 1543-1551.

3. Charman, T., & Baird, G. (2002). Practitioner review: Diagnosis of autism spectrum disorder in 2‐and 3‐year‐old children. Journal of Child Psychology and Psychiatry, 43(3), 289-305.

4. Westman Andersson G., Miniscalco C., Johansson U., & Gillberg, C. (2013). Autism in toddlers: Can observation in preschool yield the same information as autism assessment in a specialised clinic? The Scientific World Journal, vol. 2013: Article ID 384745.

5. Westman Andersson G., Miniscalco C., & Gillberg, C. (2013). Autism in preschoolers: Does individual clinician’s first visit diagnosis agree with final comprehensive diagnosis? The Scientific World Journal, vol. 2013: Article ID 716267.