ACTNOW Fact Sheet 3

EARLY FEATURES OF AUTISM

by Dr Avril Brereton

Parents of children with autism often report difficulties or delays in their child’s early development prior to two years of age, yet diagnosis is often not made until a child is about four years of age or older. Placement in early intervention programmes before four years of age is thought to improve outcome for children with autism. Those children who receive a diagnosis of autism after four years of age may be missing the opportunity for early intervention.

In recent years a number of studies have sought to describe the early features of autism in infants and preschool children. Some studies have interviewed parents to establish what problems initially cause them the most concern, others have observed children in controlled play and assessment situations.

The early features of autism identified in these studies are listed below (Gray & Tonge, 2001).

1. Social interaction

Poor social interaction
Lack of interest in other children
Lack of seeking to share own enjoyment
Failure to develop peer relations
Failure to join in activities of others
Failure to direct adult’s attention to own activity
Does not direct the attention of others
Does not hold up arms to be lifted up
Does not show affection
Does not seek or offer comfort
Dislikes social touch and being held
Lack of social responsiveness 
Ignores people
Lack of social play
Being in own world
Prefers being alone
Indifferent to others
Does not differentiate between people
Lack of attention to voices
No social smile
Lack of eye contact
Lack of gesture
Lack of facial expression
No greeting behaviours

2. Communication

Lack of verbal communication
No social chat
Lack/limited range of facial expression
No/abnormal eye contact
No or “empty” smiling
Loss of previously acquired words
Problems with language comprehension 
Does not express emotion
Poor imitation
Use of other’s body as a tool
Lack of infant babble
Echolalia
No gaze monitoring
No pointing to express interest
No use or understanding of gestures

The features listed under the categories of Stereotyped and repetitive routines, behaviours and interests (3), Play and Sensory (4) and Other behaviours (5) are not necessarily present in very young children. This may be because there is a developmental process in the emergence of these autism symptoms.

3.Stereotyped and repetitive routines, behaviours  and interests

Verbal rituals
Hand and finger mannerisms
Whole body mannerisms 
Unusual/repetitive preoccupations
Unusual/repetitive attachment to objects

4. Play and sensory

Lack of spontaneous play
Lack of imitative play
No pretend play
Sensitivity to noise
Insensitivity to pain/cold 
Unusual sensory interests
Deafness suspected
Mouthing of objects
Unusual looking at objects/patterns/movements

5. Other behaviours

Distractibility
Behavioural variability
Sleep problems
Self-injury
Food fads
Unusual fears
Lack of curiosity 
Lack of response to name
Running away
Overly quiet
Indifferent to animals
Having an intelligent looking face
Overexcited when tickled

Some of the features listed above are also present in young children with developmental delay. Therefore, studies that have compared the behaviour of young children with autism with those who have developmental delay without autism provide the best information on the features and symptoms of autism in infants and preschool children.

The absence of stereotyped and repetitive behaviour in very young children does not exclude the possibility of autism. The presence of obsessional behaviour may be dependent upon more advanced language and cognitive skills and emerge later as the child makes developmental gains. Deficits in basic communication and social skills are apparent in the first two years of life in young children with autism (Gray & Tonge, 2001; Zwaigenbaum, 2001).

Differentiating between speech delay, developmental delay and autism in young children.

Parents of young children with autism often report delayed speech as their first concern, but speech delay is not specific to autism. Delayed speech is also present in young children with global developmental delay caused by intellectual disability and those with severe to profound hearing loss. Children with speech delays or hearing loss are usually able to compensate for their limited or lack of  speech by the use of non verbal communication skills such as using gestures (e.g. pointing), eye contact and facial expression to get their message across. These children also respond to praise, can empathise, imitate and engage in make believe play. Children with developmental delay will also usually attain these skills when their developmental level passes about 12 months of age. However, the child with autism continues to have ongoing problems with delayed and disordered language, social communication skills, empathy and  pretend play skills regardless of developmental level (Charman & Baird, 2002). These findings have implications for early screening and diagnosis in very young children.

• The diagnostic features of insistence on sameness, distress over change in routines, adherence to rituals and routines, abnormal comfort seeking and unusual attachment to objects that are typically present in older children are often not present in preschool children.
  
  
• The range of communication problems present in older children, such as impaired conversational skills and problems with speech production are not typically present in younger children who are yet to acquire speech.
  
  
• Assessment of very young children needs to take the absence of some autism symptoms into account. Some researchers have suggested that standard diagnostic criteria should be modified for children under two to take into account the presentation of autism in infants and preschoolers.

Early identification of autism is clearly important but is not an end in itself. How we respond to very young children with autism and their families is critical. Early identification is only useful if followed up by access to early intervention programmes, parent education and support and a range of health, education and welfare services for the child and his/her family.

What to look for in the first year of life:

Lack of social smile
Lack of appropriate facial expression
Poor attention
Aversion to being touched
Not responsive to name
Unusual looking at objects/patterns/movements

What additional things to look for in the two year old:

Ignoring people
Preference for aloneness
Lack of or impaired eye contact
Lack of gestures (e.g. pointing to objects)
Lack of emotional expression
Lack of age appropriate play with toys

References

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

Gray, K & Tonge, B. (2001). Review article. Are there early features of autism in infants and preschool children? J. Paediatr. Child Health, 37, 221-226.

Zwaigenbaum, L. (2001). Autistic spectrum disorders in preschool children. Canadian Family Physician, 47, 2037-2042.

These articles can be found through the Further Reading menu on the ACT NOW home page.