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Identification of Autism in Early Childhood - Stephan M. Silverman, Ph.D.
 
There is significant developmental variety in presentation of symptoms in children with autism. Parents sometimes find that their child seems different from birth and, in some cases; there are a few individual or combined unusual symptoms that emerge developmentally in the first months or years of life. For some forms of higher functioning autism, parents are not initially aware of a meaningful problem.

A significant subgroup of autistic children (20-49%) experiences regression. Some children seem to develop normally and, then, at around 18 months of age, regress dramatically, losing previously established skills. A child who may have been affectionate and vocal may suddenly withdraw, reduce communication, and might become seemingly indifferent to others or even self-abusive.

The point of first contact may be the general practitioner, psychiatrist, pediatrician, a school system “child find” clinic, a local children’s hospital, or a preschool. Only 30% of children with ASD are identified in primary care settings.

Early Markers

General practitioners and pediatricians have an important role in early identification of children with autism. It is well recognized that the presence of a child with autism results in increased levels of parental stress and challenges to family and marital functioning.

At the present time research does not always reliably afford us clear markers in the first year of life. But there are some interesting precursors not yet fully confirmed in the literature. An analysis of home videos taken by parents at around the first birthday of 11 children, who were later diagnosed to be autistic, has shown that these children already failed to point, did not show objects to parents, did not make good eye contact or orient to being called by name.

There is also some structural evidence that there is an abnormal acceleration of growth in head size between 6 and 14 months, which may serve as an early warning sign.
The following is a list of markers provided for family physicians by Dr. Sunil Karande from the Indian Journal of Medical Science (2006).

Children Aged Two to Three years - Social impairments

1. Does not imitate actions (e.g., clapping)
2. Does not show toys to other people
3. Lacks interest in other children (e.g., does not smile at or touch face of another child)
4. Is indifferent to other people’s happiness or distress (e.g., not distressed when mother cries)
5. Prefers to be alone (does not want cuddling or act cuddly)
6. Has little or no eye contact
7. Prefers solitary play activities
8. Has odd relationships with adults (too friendly or ignores)
9. Develops loss of any social skills

Communication impairments

1. Does not babble, point by 12 months
2. Does not speak single words by 18 months
3. Does not speak two word spontaneous (non-echoed) phrases by 24 months
4. Has poor response to name
5. Has delayed language development, especially comprehension
6. Has unusual use of language (e.g., repeats words or phrases in place of normal responsive language)
7. Has deficient non-verbal communication (e.g. no gestures with hands while talking)
8. Does not participate in shared imaginary games (e.g. cannot play ring-a-ring roses or other nursery games)
9. Develops loss of any language skills

Repetitive and stereotyped behavior patterns

1. Resists changes in routine (e.g., rigid and limited food preferences)  
2. Inappropriate attachment to objects (e.g., interacts continuously with one toy)
3. Unable to cope with change, especially in unstructured settings
4. Has repeated motor movements (e.g., hand flapping, rocking)
5. Plays repetitively with toys in a manner for which the toy was not designed (i.e. spinning a stuffed bear).
6. Plays repetitively with household objects such as light switches.
7. Is hypersensitive to sound or resistant to touch 
8. Is aggressive to adults and peers (e.g. biting)
9.  Displays inappropriate emotional responses such as laughter or anger without known cause.

The Early School Aged Child - Social impairments

1. Does not initiate or maintain play with peers.  
2. Makes inappropriate disruptive attempts at joint play
3. Has difficulty understanding customary norms for behavior in a standard setting like a classroom.
4. Does not develop age-appropriate interests
5. Gets easily overwhelmed by social stimulation in a classroom
6. Fails to develop attachments with adults beyond primary signs of affection.

Communication impairments

1. Speaks in a monotone, or with abnormal modulation of volume or prosody of voice.
2. Displays persistent echolalia and may repeat media jingles and advertisements.
3. Does not employ pronouns appropriately
4. Has highly developed specialized interests or vocabulary.
5.  Lacks language or has immature, poorly developed, poorly articulated or formulated language.

Other behaviors

1. Shows extreme reactions and temper tantrums to invasion of personal space 
2. Shows extreme resistance to being “hurried”
3. Is unable to cope with change or in unstructured situations 
4. Has unusual responses to sensory visual / olfactory stimuli (e.g. starts crying in sunlight)

When looking for the above markers, consider normal milestones as re-iterated by Ozonoff  (2002):

Milestones: 4-6 months

• Attend to human voice
• Show interest in faces
• Reciprocal social smile
• Coo or babble

Milestones: 9-12 months

• Exchange back-and-forth sounds, looks
• Respond to pointing/showing gestures
• Play peek-a-boo and other social games
• Orient to name
• Babble in consonant-vowel combinations

Milestones: 12-15 months

• Use gestures and sounds to get needs met
• Show objects and share interests with others
• Use a few words
• Show interest in other children

Milestones, 24 months

• Use lots of gestures
• Use at least 50 words
– 2-word combinations
• Perform simple pretend acts
• Imitate others
• Enjoy being with other children

Much new research is focused on early identification. It is hoped that one day we will clearly recognize markers of autism before the child is born, in utero or at the hospital at birth. We know that in many realms of medicine science fiction becomes reality. Studies have clearly demonstrated that early intervention is critical in taking charge of these disorders. Being active in providing appropriate interventions requires accurate diagnostic procedures as early as possible.  For the more severe forms of  “classic” autism, the consequences of late diagnosis and delayed intervention can be devastating difficult to reverse, modify or contain, and expensive. As science progress we can become proactive in addressing the challenges of autism.

Stephan M. Silverman, Ph.D., is the Director of Assessment, The Weinfeld Education Group and lead author of “School Success for Kids with Asperger’s Syndrome”

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