First Signs of Autism

Girl on climbing structure Definition
Causes and risk factors
Symptoms of Autism
Signs and Tests
Questions to clear up autistic tendencies
Warning Signals
Suggestive symptoms of Autism in early childhood
Referral
Assessment





Autism is a complex developmental disorder with a wide spectrum that appears in the first 3 years of life, although it is sometimes diagnosed much later. It affects the brain's normal development of social and communication skills. Common features of autism include impaired social interactions, impaired verbal and nonverbal communication, problems processing information from the senses, and restricted and repetitive patterns of behavior. The symptoms may vary from moderate to severe.


Causes and risk factors

Autism is a physical condition linked to abnormal biology and chemistry in the brain. The exact causes of these abnormalities remain unknown, but this is a very active area of research. There is probably a combination of factors that lead to autism.

Genetic factors seem to be important for autism. For example, identical twins are much more likely than fraternal twins or siblings to both have autism. Similarly, language abnormalities are more common in relatives of autistic children. Chromosomal abnormalities and other neurological problems are also more common in families with autism.

A number of other possible causes for autism have been suspected, but not proven. They involve digestive tract changes, diet, mercury poisoning, vaccine sensitivity, and the body's inefficient use of vitamins and minerals.

The exact number of children with autism is not known. A report released by the U.S. Centers for Disease Control and Prevention (CDC) suggests that autism and related disorders are more common than previously thought, although it is unclear if this is due to an increasing rate of the illness or an increased ability to diagnose the illness. (In the US the autism rate is at 1:140 children, 2007)

Autism affects boys 4 times more often than girls. Family income, education, lifestyle, race, and religion do not seem to affect the risk of autism.

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Symptoms of Autism

Most parents of autistic children suspect that something is wrong by the time the child is 18 months old and seek help by the time the child is 2. Children with autism typically have difficulties in verbal and nonverbal communication, social interactions, and pretend play. In some, aggression - toward others or self - may be present.

Some children with autism appear normal before age 1 or 2 and then suddenly "regress" and lose language or social skills they had previously gained. This is called the regressive type of autism.

People with autism may perform repeated body movements, show unusual attachments to objects or have unusual distress when routines are changed. Individuals with autism may also experience sensitivities in the senses of sight, hearing, touch, smell, or taste. Such children, for example, will refuse to wear "itchy" clothes and become unduly distressed if forced because of the sensitivity of their skin.

Some combination of the following areas may be affected in varying degrees in people with autism.

Communication:

  • Lack of pointing to direct others' attention to objects (occurs in the first 14 months of life)
  • Does not adjust gaze to look at objects that others are looking at
  • Cannot start or sustain a social conversation
  • Develops language slowly or not at all
  • Repeats words or memorized passages, such as commercials
  • Does not refer to self correctly (for example, says "you want water" when the child means "I want water")
  • Uses nonsense rhyming
  • Communicates with gestures instead of words

Social interaction:

  • Shows a lack of empathy
  • Does not make friends
  • Is withdrawn
  • Prefers to spend time alone, rather than with others
  • May not respond to eye contact or smiles
  • May actually avoid eye contact
  • May treat others as if they are objects
  • Does not play interactive games

Response to sensory information:

  • Has heightened or low senses of sight, hearing, touch, smell, or taste
  • Seems to have a heightened or low response to pain
  • May withdraw from physical contact because it is over stimulating or overwhelming
  • Does not startle at loud noises
  • May find normal noises painful and hold hands over ears
  • Rubs surfaces, mouths or licks objects
  • Shows little pretend or imaginative play
  • Doesn't imitate the actions of others
  • Prefers solitary or ritualistic play

Behavior:
  • Has a short attention span
  • Uses repetitive body movements
  • Shows a strong need for sameness
  • "Acts up" with intense tantrums
  • Has very narrow interests
  • Demonstrates perseveration (gets stuck on a single topic or task)
  • Shows aggression to others or self
  • Is overactive or very passive
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Signs and tests

All children should have routine developmental exams by their pediatrician. Further testing may be needed if there is concern on the part of the clinician or the parents. This is particularly true whenever a child fails to meet any of the following language milestones:

  • Babbling by 12 months
  • Gesturing (pointing, waving bye-bye) by 12 months
  • Single words by 16 months
  • Two-word spontaneous phrases by 24 months (not just echoing)
  • Loss of any language or social skills at any age.


These children might receive a hearing evaluation, a blood lead test, and a screening test for autism (such as the Checklist for Autism in Toddlers (CHAT) or the Autism Screening Questionnaire).

A health care provider experienced in the diagnosis and treatment of autism is usually necessary for the actual diagnosis. Because there is no biological test for autism, the diagnosis will often be based on very specific criteria laid out in a book called the Diagnostic and Statistical Manual IV. Autism encompasses a broad spectrum of symptoms. Therefore, a single, brief evaluation cannot predict a child's true abilities. Ideally, a team of different specialists will evaluate the child. They might evaluate speech, language, communication, thinking abilities, motor skills, success at school, and other factors.

Sometimes people are reluctant to have a child diagnosed with autism because of concerns about labeling the child. However, failure to make a diagnosis can lead to failure to get the treatment and services the child needs.

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Questions to clear up autistic tendencies

1) Does the baby respond to his or her name when called by the caregiver?
Within the first few months of life, babies respond to their own name by orienting toward the person who called them. Typical babies are very responsive to the voices of familiar people, and often respond with smiles and looks.

In contrast, infants later diagnosed with autism often fail to respond to their own name. That is, when called by name, they tend to turn and look at the person only about 20% of the time as found- in the videotaped one year-old birthday parties of children with autism. They also are often selectively responsive to sounds. They may ignore some sounds and respond to others that are of the same loudness. Thus, they may fail to respond to their parent calling their name, but immediately respond to the television being turned on. It is not unusual for parents to suspect their child has a hearing loss.

2) Does the young child engage in "joint attention"?
Near the end of the first year of life, most infants begin to join with their caregivers in looking at the same object or event. To aid in this process of "joint attention", typical infants begin to shift their gaze from toys to people, follow other's points, monitor the gaze of others, point to objects or events to share interest, and show toys to others. These behaviors have a distinct sharing quality to them. For example, the young infant may point to an airplane flying over head, and look to the parent, as if to say, "do you see that!"

In contrast, young children with autism have particular difficulties in jointly attending with others. They rarely follow another's points, do not often shift their gaze back and forth from objects to people, and do not seem to share "being with" the caregiver as they watch and talk about objects, people, or events. They also tend not to "show" a toy to the parent.

3) Does the child imitate others?
Typical infants are mimics. Very young infants can imitate facial movements (e.g., sticking out their tongue). As early as 8-10 months, mothers and infants say the same sounds one after another, or clap or make other movements. Indeed, imitation is a major part of such common infant games as pat-a-cake and So Big ("How big is baby? Soooo big!" as infant raises hands to sky).

Young children with autism, however, less often imitate others. They show less imitation of body and facial movements (waving, making faces, playing infant games), and less imitation with objects.

4) Does the child respond emotionally to others?
Typical infants are socially responsive to others. They smile when others smile at them, and they initiate smiles and laughs when playing with toys and others. When typical infants observe another child crying, they may cry themselves, or looked concerned. Somewhat older infants may crawl near the person, pat, or in other ways offer comfort. These latter behaviors are suggestive of empathy and are commonly observed among children in the second year of life.

In contrast, children with autism may seem unaware of the emotions of others. They may not take notice of the social smiles of others, and thus may not look and smile in response to other's smiles. They also may ignore the distress of others. Several researchers have now shown that when an adult feigns pain and distress after hitting herself with a toy, or banging her knee, young children with autism are less likely to look at the adult, or show facial concern.

5) Does the baby engage in pretend play?
Someone once noted that "play is the work of children." Young children love to pretend-to be a mother, father, or baby, to be a firefighter or police officer. Although children start to play with toys around six months or so, play does not take on a pretend quality until the end of the first year. Their first actions may involve pretending to feed themselves, their mother or a doll, brush the doll's hair, or wipe the doll's nose. Nearer their second birthday, children engage in truly imaginative play as dolls may take on human qualities of talking or engaging in household routines. Children may pretend that a sponge is a piece of food, a block is a hat, or a plastic bowl is a swimming pool that contains water.

In contrast, the play of children with autism may be lacking in several ways. The young child may not be interested in objects at all, paying more attention to the movement of his hands, or a piece of string. If interested in toys, only certain ones may catch his interest, and these may be used in a repetitive way that is not consistent with how most children would play with the toy. They may be more interested in turning a toy car upside down and spinning the wheels than pushing the car back and forth. Overall, pretend qualities are nearly absent in the play of children with autism under 2 years of age.

It is important to note that in each of the 5 areas we have flagged, we are most concerned with behaviors that are absent or occur at very low rates. The absence of certain behaviors may be more difficult to pinpoint than the presence of atypical behaviors. But concerns in any of the above areas should prompt a parent to investigate screening their child for autism. Several screening measures are now available, and information from the screener will help to determine if the parent should pursue further evaluations. If the parent is convinced their child has autism, then they should seek an evaluation with an expert in autism. Most likely, this evaluation will involve an interview with the parents to obtain a complete developmental history of the child, and direct observations of the child in different situations.

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Warning Signals


The following warning signals of autism may indicate a child is at risk for atypical development, and is in need of an immediate evaluation.

Warning signals in Social Interaction/Communication:


  • No big smiles or other warm, joyful expressions by six months or thereafter
  • No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter
  • No babbling by 12 months
  • No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months
  • No words by 16 months
  • No two-word meaningful phrases (without imitating or repeating) by 24 months
  • Any loss of speech or babbling or social skills at any age
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Suggestive symptoms of Autism in early childhood

According to a study by Gillberg, it is possible to recognize autism in infancy. The symptoms most commonly reported were peculiarities of gaze, hearing and play.

Gaze

Avoidance of eye contact is often thought to be a characteristic of children with autism. This feature is less important than the unusual quality of the gaze. Many infants do not appear to see people and so may not look people in the eye, but in the baby with autism the gaze tends to be brief and out of the corner of the eye.

Hearing

Peculiarities of hearing seem to be especially significant. Many children with autism have been suspected of being deaf at an early stage in their lives. Very few actually have a hearing loss, though they may not respond to their name and appear to be unaffected by audible changes in the environment. Children with autism may seem to ignore even very loud noises that would be expected to startle most ordinary children. This may be to do with a generalised lack of interest in their surroundings. It may be due to abnormalities in perception, since children with autism can appear to be especially sensitive to certain sounds. For example, a child with autism may develop a fascination for particular sounds such as that made by a friction-driven toy, or respond to the sound of a sweet being unwrapped from a considerable distance. Other sounds may appear to cause extreme distress, such as a police siren or a barking dog.

Social development and play

In young babies play and social activity are closely connected and it is in this sphere of development that parents may note that their child is odd. Babies with autism may show a lack of interest in the types of play that most infants enjoy, such as those which involve social interaction with the parent.

The lack of sharing activity appears to be significant. Frith and Soares's study of responses from parents of children with autism indicate the lack of joint interest and activity displayed by their children in the first year. Babies with autism do not point out things of interest, do not take an active part in playing baby games and do not want to share in activities. These signs of autism were not mentioned by the control group of parents of normally-developing children.

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Referral

Early parental concerns about the developmental progress of their baby should always be heeded. If a mother expresses anxiety about her baby's social and emotional responses and perceptual abilities, the professional must be alert to the possibility of autism. Appropriate referral to specialists in normal and abnormal child development may mean that a diagnosis is reached sooner than has been typical in the past. A child development unit has the resources to assess a child in all aspects of development. While babies may display "autistic features", only a comprehensive diagnostic assessment can reveal whether they have autism or are merely displaying behaviour attributable to other difficulties.


Assessment

This is best done at a child development unit because the expertise of a variety of disciplines is required and a team approach has been found to result in more accurate diagnosis. Assessment of suspected autism entails the parents providing a review of the family history, the pregnancy and the child's behavior and developmental progress. A physical examination is required to determine any underlying medical conditions contributing to deviations and/or delays in expected developmental progress.

Developmental assessment includes fine and gross motor skills, language, (reception, expression and verbalization), sensory perception, social and emotional development and play. The quality of development is an important feature of the assessment, hence the way skills are used are as important as their presence. For example, a child with autism may have acquired the ability to reproduce words, but not have developed an understanding of their meaning. Or a young child with autism may point to an object but in a non-social fashion rather than to direct another person's attention to it.

Ideally, children should also be observed in their usual environment, at home or nursery / preschool.

The diagnosis of autism is unlikely to be made on the basis of one examination, especially if the child is very young.

Close monitoring of progress and regular assessment are essential to enable a full picture to be built up. Regardless of whether a definite diagnosis of autism is reached, children and their parents can be offered help. Babies suspected of having a developmental disorder (autism, autistic spectrum) can receive services for their particular needs and have their progress monitored. Parents can be supported and taught ways to assist their child that are specific for each sphere of the baby's development.

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