One Baby's Story
Melanie is a healthy one-year-old, but her parents are worried because she’s not doing many things that her older brother did at her age, like playing peek-a-boo and mimicking expressions and gestures. Melanie’s mom and dad try to engage her with toys, songs, and games, but nothing they do gets her interest, let alone a laugh or a smile. In fact, she rarely makes eye contact. And although her hearing has been checked and is normal, she doesn’t babble, make other baby noises, or respond when her parents call her name. Melanie needs to be checked out by a child development specialist right away.
Autism is a spectrum of closely related disorders with a shared core of symptoms. Autism spectrum disorders appear in infancy and early childhood, causing delays in many basic areas of development such as learning to talk, play, and interact with others.
The signs and symptoms of autism vary widely, as do its effects. Some autistic children have only mild impairments, while others have more obstacles to overcome. However, every child on the autism spectrum has problems, at least to some degree, in the following three areas:
- Communicating verbally and non-verbally
- Relating to others and the world around them
- Thinking and behaving flexibly
There are different opinions among doctors, parents, and experts about what causes autism and how best to treat it, and much that we still don’t know. But on one fact, everyone agrees: early and intensive intervention helps. For children at risk and children who show early signs, it can make all the difference.
As a parent, you’re in the best position to spot the earliest warning signs of autism. You know your child better than anyone and observe behaviors and quirks that a pediatrician, in a quick fifteen-minute visit, might not have the chance to see. Your child’s pediatrician can be a valuable partner, but don’t discount the importance of your own observations and experience. The key is to educate yourself so you know what’s normal and what’s not.
- Monitor your child’s development. Autism involves a variety of developmental delays, so keeping a close eye on when—or if—your child is hitting the key social, emotional, and cognitive milestones is an effective way to spot the problem early on. While developmental delays don’t automatically point to autism, they may indicate a heightened risk.
- Take action if you’re concerned. Every child develops at a different pace—so you don’t need to panic if your child is a little late to talk or walk. When it comes to healthy development, there’s a wide range of “normal.” But if your child is not meeting the milestones for his or her age, or you suspect a problem, share your concerns with your child’s doctor immediately. Don’t wait.
- Don’t accept a wait-and-see approach. Many concerned parents are told, “Don’t worry” or “Wait and see.” But waiting is the worst thing you can do. You risk losing valuable time at an age where your child has the best chance for improvement. Furthermore, whether the delay is caused by autism or some other factor, developmentally delayed kids are unlikely to simply “grow out” of their problems. In order to develop skills in an area of delay, your child needs extra help and targeted treatment.
- Trust your instincts. Ideally, your child’s doctor will take your concerns seriously and perform a thorough evaluation for autism or other developmental delays. But sometimes, even well-meaning doctors miss red flags or underestimate problems. Listen to your gut if it’s telling you something is wrong and be persistent. Schedule a follow-up appointment with the doctor, seek a second opinion, or ask for a referral to a child development specialist.
Regression of any kind is a serious autism warning sign
Some children with autism spectrum disorders start to develop communication skills and then regress, usually between 12 and 24 months. For example, a child who was communicating with words such as “mommy” or “up” may stop using language entirely, or a child may stop playing social games he or she used to enjoy such as peek-a-boo, patty cake, or waving “bye-bye.” Any loss of speech, babbling, gestures, or social skills should be taken very seriously, as regression is a major red flag for autism.
If autism is caught in infancy, treatment can take full advantage of the young brain’s remarkable plasticity. Although autism is hard to diagnose before 24 months, symptoms often surface between 12 and 18 months. If signs are detected by 18 months of age, intensive treatment may help to rewire the brain and reverse the symptoms.
The earliest signs of autism involve the absence of normal behaviors—not the presence of abnormal ones—so they can be tough to spot. In some cases, the earliest symptoms of autism are even misinterpreted as signs of a “good baby,” since the infant may seem quiet, independent, and undemanding. However, you can catch warning signs early if you know what to look for.
Some autistic infants don't respond to cuddling, reach out to be picked up, or look at their mothers when being fed.
Early signs of autism in babies and toddlers
- Doesn’t make eye contact (e.g. look at you when being fed).
- Doesn't smile when smiled at.
- Doesn't respond to his or her name or to the sound of a familiar voice.
- Doesn’t follow objects visually.
- Doesn't point or wave goodbye or use other gestures to communicate.
- Doesn’t follow the gesture when you point things out.
- Doesn’t make noises to get your attention.
- Doesn’t initiate or respond to cuddling.
- Doesn’t imitate your movements and facial expressions.
- Doesn’t reach out to be picked up.
- Doesn’t play with other people or share interest and enjoyment.
- Doesn’t ask for help or make other basic requests.
The following delays warrant an immediate evaluation by your child’s pediatrician.
- By 6 months: No big smiles or other warm, joyful expressions.
- By 9 months: No back-and-forth sharing of sounds, smiles, or other facial expressions.
- By 12 months: Lack of response to name.
- By 12 months: No babbling or “baby talk.”
- By 12 months: No back-and-forth gestures, such as pointing, showing, reaching, or waving.
- By 16 months: No spoken words.
- By 24 months: No meaningful two-word phrases that don’t involve imitating or repeating.
As children get older, the red flags for autism become more diverse. There are many warning signs and symptoms, but they typically revolve around impaired social skills, speech and language difficulties, non-verbal communication difficulties, and inflexible behavior.
Signs and symptoms of social difficulties in autism
Basic social interaction can be difficult for children with autism spectrum disorders. Many kids on the autism spectrum seem to prefer to live in their own world, aloof and detached from others.
- Appears disinterested or unaware of other people or what’s going on around them.
- Doesn’t know how to connect with others, play, or make friends.
- Prefers not to be touched, held, or cuddled.
- Doesn’t play "pretend" games, engage in group games, imitate others, or use toys in creative ways.
- Has trouble understanding or talking about feelings.
- Doesn’t seem to hear when others talk to him or her.
- Doesn't share interests or achievements with others (drawings, toys).
Signs and symptoms of speech and language difficulties in autism
Children with autism spectrum disorders have difficulty with speech and language. Often, they start talking late.
- Speaks in an abnormal tone of voice, or with an odd rhythm or pitch (e.g. ends every sentence as if asking a question).
- Repeats the same words or phrases over and over.
- Responds to a question by repeating it, rather than answering it.
- Refers to themselves in the third person.
- Uses language incorrectly (grammatical errors, wrong words).
- Has difficulty communicating needs or desires.
- Doesn’t understand simple directions, statements, or questions.
- Takes what is said too literally (misses undertones of humor, irony, and sarcasm).
Signs and symptoms of nonverbal communication difficulties in autism
Children with autism spectrum disorders have trouble picking up on subtle nonverbal cues and using body language. This makes the "give-and-take" of social interaction very difficult.
- Avoids eye contact.
- Uses facial expressions that don't match what he or she is saying.
- Doesn’t pick up on other people’s facial expressions, tone of voice, and gestures.
- Makes very few gestures (such as pointing). May come across as cold or “robot-like.”
- Reacts unusually to sights, smells, textures, and sounds. May be especially sensitive to loud noises.
- Abnormal posture, clumsiness, or eccentric ways of moving (e.g. walking exclusively on tiptoe).
Signs and symptoms of inflexibility in autism
Children with autism spectrum disorders are often restricted, inflexible, and even obsessive in their behaviors, activities, and interests.
- Follows a rigid routine (e.g. insists on taking a specific route to school).
- Has difficulty adapting to any changes in schedule or environment (e.g. throws a tantrum if the furniture is rearranged or bedtime is at a different time than usual).
- Unusual attachments to toys or strange objects such as keys, light switches, or rubber bands.
- Obsessively lines things up or arranges them in a certain order.
- Preoccupation with a narrow topic of interest, often involving numbers or symbols (e.g. memorizing and reciting facts about maps, train schedules, or sports statistics).
- Spends long periods of time arranging toys in specific ways, watching moving objects such as a ceiling fan, or focusing on one specific part of an object such as the wheels of a toy car.
- Repeats the same actions or movements over and over again, such as flapping hands, rocking, or twirling (known as self-stimulatory behavior, or “stimming”). Some researchers and clinicians believe that these behaviors may soothe children with autism more than stimulate them.
Common self-stimulatory behaviors:
Until recently, most scientists believed that autism is caused mostly by genetic factors. But groundbreaking new research indicates that environmental factors may be just as important in the development of autism—if not more so—than genes.
It appears that certain babies are born with a genetic vulnerability to autism that is then triggered by something in the external environment, either while he or she is still in the womb or sometime after birth.
It’s important to note that the environment, in this context, means anything outside the body. It’s not limited to things like pollution or toxins in the atmosphere. In fact, one of the most important environments appears to be the prenatal environment.
Prenatal factors that may contribute to autism
- Taking antidepressants during pregnancy, especially in the first 3 months
- Nutritional deficiencies early in pregnancy, particularly not getting enough folic acid
- The age of the mother (children born to older fathers also have a higher risk of autism)
- Complications at or shortly after birth, including very low birth weight and neonatal anemia
- Maternal infections during pregnancy
- Exposure to chemical pollutants, such as metals and pesticides, while pregnant
While more research on these prenatal risk factors is needed, if you’re pregnant or trying to conceive, it can’t hurt to take steps now to reduce your baby’s risk of autism.
Reducing the risk of autism: Tips for expectant mothers
- Take a multivitamin. Taking 400 micrograms of folic acid daily helps prevent birth defects such as spina bifida. It’s not clear whether this will also help reduce risk of autism, but taking the vitamins can’t hurt.
- Ask about SSRIs. Women who are taking an SSRI (or who develop depression during pregnancy) should talk with a clinician about all the risks and benefits of these drugs. Untreated depression in a mother can also affect her child’s well-being later on, so this is not a simple decision to make.
- Practice prenatal care. Eating nutritious food, trying to avoid infections, and seeing a clinician for regular check-ups can increase the chances of giving birth to a healthy child.
Source: Harvard Health Publications
Autism and vaccines
While you can’t control the genes your child inherits or shield him or her from every environmental danger, there is one very important thing you can do to protect the health of your child: make sure he or she is vaccinated on schedule.
Despite a lot of controversy on the topic, scientific research does not support the theory that vaccines or their ingredients cause autism. Five major epidemiologic studies conducted in the U.S., the UK, Sweden, and Denmark found that children who received vaccines did not have higher rates of autism. Additionally, a major safety review by the Institute of Medicine failed to find any evidence supporting the connection. Other organizations that have concluded that vaccines are not associated with autism include the Centers for Disease Control and Prevention (CDC), the U.S. Food and Drug Administration (FDA), the American Academy of Pediatrics, and the World Health Organization.
Myths and facts about childhood vaccinations
Myth: Vaccines aren't necessary.
Fact: Vaccines protect your child from many serious and potentially deadly diseases, including measles, meningitis, polio, tetanus, diphtheria, and whooping cough. These diseases are uncommon today because vaccines are doing their job. But the bacteria and viruses that cause these diseases still exist and can be passed on to children who aren’t immunized.
Myth: Vaccines cause autism.
Fact: Despite extensive research and safety studies, scientists and doctors have not found a link between childhood vaccinations and autism or other developmental problems. Children who are not vaccinated do not have lower rates of autism spectrum disorders.
Myth: Vaccines are given too early.
Fact: Early vaccination protects your child from serious diseases that are most likely to occur—and most dangerous—in babies. Waiting to immunize your baby puts him or her at risk. The recommended vaccination schedule is designed to work best with children’s immune systems at specific ages. A different schedule may not offer the same protection.
Myth: Too many vaccines are given at once.
Fact: You may have heard theories that the recommended vaccine schedule overloads young children’s immune systems and may even cause autism. But research shows that spacing out vaccinations doesn’t improve children’s health or lower their risk of autism, and as noted above, actually puts them at risk for potentially fatal diseases.
If your child is developmentally delayed, or if you’ve observed other red flags for autism, schedule an appointment with your pediatrician right away. In fact, it’s a good idea to have your child screened by a doctor even if he or she is hitting the developmental milestones on schedule. The American Academy of Pediatrics recommends that all children receive routine developmental screenings, as well as specific screenings for autism at 9, 18, and 30 months of age.
- Schedule an autism screening. A number of specialized screening tools have been developed to identify children at risk for autism. Most of these screening tools are quick and straightforward, consisting of yes-or-no questions or a checklist of symptoms. Your pediatrician should also get your feedback regarding your child’s behavior.
- See a developmental specialist. If your pediatrician detects possible signs of autism during the screening, your child should be referred to a specialist for a comprehensive diagnostic evaluation. Screening tools can’t be used to make a diagnosis, which is why further assessment is needed. A specialist can conduct a number of tests to determine whether or not your child has autism. Although many clinicians will not diagnose a child with autism before 30 months of age, they will be able to use screening techniques to determine when a cluster of symptoms associated with autism is present.
- Seek early intervention services. The diagnostic process for autism is tricky, and can sometimes take awhile. But you can take advantage of treatment as soon as you suspect your child has developmental delays. Ask your doctor to refer you to early intervention services. Early intervention is a federally funded program for infants and toddlers with disabilities. Children who demonstrate several early warning signs may have developmental delays. They will benefit from early intervention whether or not they meet the full criteria for an autism spectrum disorder.
You don’t have to wait for a diagnosis to start helping your child
While autism isn’t normally diagnosed and treated before the second year of life, there are things parents can do if your child's social and emotional development doesn't seem to be on course. You don’t have to wait for an official diagnosis to start targeting developmental delays and working to enhance the bond you share. This is something you can do even when your child’s just an infant.
The attachment bond is the unique relationship between your baby and yourself as his or her primary caretaker. This instinctual bonding relationship draws the two of you together insuring that the needs of your helpless and vulnerable infant will be met. In the 90’s, an explosion of learning uncovered the fact that this unique relationship, the attachment bond, is a key factor in your infant’s social, emotional, intellectual and physical development.
The quality of the attachment bond varies. A secure bond provides your baby with an optimal foundation for life: eagerness to learn, healthy self-awareness, trust and consideration for others. An insecure attachment relationship, one that fails to meet an infant’s need for safety and understanding, leads to confusion about oneself and difficulties in learning and relating to others.
Resources & References
General information about autism
Autism Spectrum Disorders (Pervasive Developmental Disorders) – Learn the signs and symptoms of autism and other pervasive developmental disorders. Includes information about causes and treatment. (National Institute of Mental Health)
Early warning signs and symptoms of autism
First Signs – Non-profit organization dedicated to educating parents and pediatric professionals about the early warning signs of autism and other developmental disorders. Helpful articles include Hallmark Developmental Milestones and Early Intervention. (First Signs)
Learn the Signs. Act Early – Government resource on child development, including important developmental milestones and warnings signs and symptoms of developmental delays. (Centers for Disease Control)
Early Features of Autism – Fact sheet from the Australian Child to Adult Development Study covers the early warning signs and symptoms of autism. (ACT-NOW)
Autism: Recognizing the Signs in Young Children – Covers early red flags for autism and the reasons why early diagnosis is so important. (The National Autistic Society)
Sharing Concerns: Parent to Physician – Features tips on how to effectively communicate with the doctor regarding your concerns about your child. (First Signs)
Screening: Making Observations – Overview of developmental screening and how they can identify autism and other problems early. (First Signs)
Making Early Developmental Screenings Routine – Article on early developmental screenings for autism and how you can be an advocate for your child. (Spark Action)