What are the signs of Autism Spectrum Disorder?

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Do you worry constantly about your child’s behavior? Is your baby behind on speech? Do you think something is wrong with your child’s development but can’t quite pinpoint the problem? Is your child the pickiest eater you have ever seen?…If you answered yes to any of the above questions, keep on reading.

What is Autism Spectrum Disorder?

Autism Spectrum Disorder (ASD) is a developmental disability that typically affects behavior, communication, and social skills. It can present with a broad range of symptoms and severity. ASD now includes several disorders that were previously diagnosed separately like autistic disorder, pervasive developmental disorder and Asperger Syndrome.

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How common is Autism Spectrum Disorder (ASD)?

According to the Centers for Disease Control and Prevention (CDC), 1 in 59 children are affected with Autism Spectrum Disorder; and according to the American Academy of Pediatrics (AAP), ASD can affect any child, regardless of his/her racial, ethnic, or socioeconomic background.

Is my child going to be screened for ASD?

Yes! Every child should be screened at the ages of 18 and 24 months during their well checkup visit. Your pediatrician will most likely provide a questionnaire for you to fill out and ask specific questions regarding all aspects of your child’s development. This questionnaire is a standardized screening that will help your pediatrician understand your child’s development and pick up any potential delays. It is imperative that you bring up any and all concerns you might have about your child’s speech, social interactions, or behavior. Once a problem has been identified with the screening, your pediatrician will refer your child for a comprehensive diagnostic evaluation by a developmental  behavioral specialist, child neurologist, child psychiatrist, or child psychologist depending on the resources available where you live. A hearing test, lead level, and referrals for interventions like speech therapy and occupational therapy are probably going to be ordered as well. Other referrals might be necessary depending on the family history and the specific symptoms your child is exhibiting.

Before you child’s next well-visit please check out the CDC’S Developmental Milestones  by age and print out the age appropriate check list . This is a great resource for parents to have prior to discussing any concerns they might have with the pediatrician.

Remember, you know your child better than anyone else, so bring up your concerns and request a screening if it hasn’t been done. Early diagnosis and intervention are extremely important to improve the outcome.

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Tell me again…how does ASD affect children?

The key components of Autism Spectrum Disorder are:

  1. Impaired Effective Communication
  2. Impaired social interactions
  3. Presence of stereotypical patterns of behaviors and interests

Ok…Let’s go over these components in more detail.

Impaired Effective Communication

For someone to communicate effectively, it is necessary to be able to use and interpret verbal (spoken) and nonverbal (non-spoken) language. Verbal communication refers to the use of spoken language (words, sentences, stories) in the correct context and timing to communicate with others. Nonverbal communication refers to the understanding and use of gestures, facial expressions, body posture, and head/body orientation to convey a message.

A child with ASD typically has delays acquiring language, has difficulty with the use of language in the appropriate context and timing, and/or has challenges understanding nonverbal cues related to language and communication.  Some children with ASD may completely lack the intent or desire to communicate.

Impaired social interactions

Social skills refer to the ability a person has to interact and communicate with others. In order to have appropriate social interactions, one must have the motivation, attention, and behaviors necessary to be successful. For example, making eye contact, smiling, or using the proper word or gesture to start a conversation. Another important aspect of social interactions is to have the ability to share interests or emotions. For example, when a toddler brings and shows a toy to his parent or caregiver, or points to an object that is interesting to him/her.

In order to develop and sustain friendships a child must master more than just good social skills. It requires processing, interpreting, remembering, integrating, and internalizing social interactions with others which they can mimic later in similar social situations. It requires lots of attention and interpretation of both verbal and nonverbal language.

In children with ASD, social interactions are generally infrequent or atypical. They generally do not demand attention from parents or siblings, except when they must fulfill a need. For the most part they are not interested in peers and prefer to play by themselves. They usually have a hard time interpreting social situations.

Presence of stereotypical patterns of behaviors and interests

Children with ASD often exhibit a stereotypical pattern of repetitive behaviors, restricted activities or interests, resistance to change, and hyper- or hyposensitivity to sensory stimulation. These symptoms could be present during early childhood and are especially obvious when they persist into school age.

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When should I worry about my child’s communication skills?

Concerning signs for younger children:   

  • Absence of babbling or cooing by 9-12  months
  • Doesn’t mimic/imitate sounds by 9 months
  • Absence of single words by 16 months
  • Regression or slowing down of new language development by 15 to 24 months (or at any age). About 1/3 of patients with ASD present with this problem.
  • Failure to acquire language by age 2. This is the most common parental concern, and roughly 2/3 of patients with ASD present with this problem.
  • Absence of meaningful two-word phrases by 24 months
  • Does not use language as a means for communication (simply repeats word)

Concerning signs for older children:

  • Has a hard time initiating or continuing a conversation with family or peers
  • Has trouble expressing needs with the right word or phrases
  • Repeats words or phrases (known as parroting or echoing), but doesn’t understand how to use them correctly or in context
  • Often speak in a monotone voice that seems to lack expression or emotion (robot-like voice)
  • Often has a hard time taking turns to talk and dialogue is over-focus on personal interests.
  • Difficulty understanding the context of what is said (for example; gives unrelated answers to questions)
  • Has trouble understanding sarcasm, jokes, and teasing
  • Often very literal, unable to understand metaphors
  • Unable to understand nonverbal signs (for example; doesn’t get that the listener is rolling his eyes or looking at his watch because it’s annoyed by the conversation)

When should I worry about my child’s social skills?

Concerning signs for younger children:

  • Doesn’t mimic/imitate parent’s facial expressions by 9 months
  • Child does not respond or alert to name by 12 months
  • Child does not point to objects to show interest by 12-15 months
  • Regression of social skills by 15 to 24 months, or at any age
  • Child does not pretend play by 18 months
  • Child doesn’t bring objects of personal interest to show a parent or caregiver by 24 months
  • Does not appear interested at what a parent is pointing to or looking at
  • Child resists cuddling and holding
  • Does not appear to be easily comforted by parent

Concerning signs for older children:

  • Child appears not to hear you most of the time
  • Lack of empathy or concern
  • No interest in peers/family
  • Doesn’t make eye contact or has a hard time keeping eye contact
  • Has a hard time understanding others facial expressions
  • Often lacks facial expression, and has difficulty expressing emotions or feelings
  • Has a hard time making friends or does not care about making friends
  • Prefers to be alone
  • Often has difficulty understanding other people’s feelings
  • Inappropriately respond to social interaction with indifference or aversion
  • Plays alone and often performs scripted activities like repeating word by word a dialogue that has been seen on television or a movie previously
  • Avoids hugs and physical contact
  • Often does not understand others personal space and tends to get too close to family and peers not noticing that this makes them uncomfortable

When should I worry about my child’s behavior?

Concerning signs for younger children:

  • Often exhibits repetitive motor mannerisms like hand or finger flapping, head-banging, face or body slapping, self-biting, spinning, rocking, swaying, walks on toes most of the time
  • Has unusual sleeping habits or appears to not need sleep
  • Often lines up the same number of objects in the exact same manner, but does not understand what the toy or object represents
  • Difficulty transitioning from one activity to another or exhibits intolerance to change
  • Has frequent tantrums, is always fussy
  • Extremely picky eater, only eats a particular food or very few food items. Often only eats one brand of a certain food, and refuses to eat the same food if it is a different brand because can tell the difference (for example if likes Juicy Juice Apple juice, would refuse any other brands of apple juice)
  • Excessive preoccupation with unusual objects like ceiling fans, vacuum cleaners, or toilets

Concerning signs for older children:

  • Restricted interests despite appropriate motivation and exposure
  • Becomes obsessed over a certain topic and is always talking about it, or repetitive questioning about a certain topic
  • Likes specific routines, and does not do well with change
  • Often obsesses with a few or unusual activities, doing them multiple times during the day
  • Plays with parts of toys instead of the whole toy (for example, spinning the blades of a helicopter toy), but doesn’t understand the overall purpose or function of the toy
  • Often appears to not feel pain or temperature
  • Often appears to be extremely sensitive or not sensitive at all to smells, sounds, lights, textures, and touch
  • Gets overwhelmed easily
  • Appears to be uncoordinated and clumsy, falls frequently
  • Appears to be bothered by foods with particular tastes and textures, or obsesses over eating only certain foods.

Is autism spectrum disorder caused by vaccines?

No!  This theory was disproved a long time ago, but many people still insist that vaccines, especially the MMR, can cause autism. There is no reliable study out there that links vaccines to Autism Spectrum Disorder. In fact, a study  published at Annals.org on  March 2019 has confirmed that the chances of developing autism were the same in children who received the MMR vaccine and those who did not. Interestingly, the study also revealed the results held true for vaccinated children who had a sibling with autism. Among girls, the risk of autism was lower in those who were vaccinated. According to the study,  the largest risk factors for autism were having an older mother or father, low birthweight, poor Apgar scores, preterm birth, large head, assisted birth and smoking in pregnancy.

Are boys and girls affected equally with ASD?

It is believed that boys are four times more likely to be diagnosed with Autism Spectrum Disorder than girls, but also the time of diagnosis in girls could be delayed because ASD presents with linguistic differences among both genders. A new study  done by researchers at Children’s Hospital of Philadelphia that was recently published in the journal Molecular Autism, found that school-aged girls with ASD use considerably more cognitive process words (for example; think, know, or feel) than boys allowing them to communicate more like a neurotypical  child.  In general, cognitive process words, also known as internal state words, help convey a thought, a feeling, or emotion and its proper use allows the listener to perceive that the speaker can understand the thoughts and feelings of others.

At what age is Autism Spectrum Disorder typically diagnosed?

The current recommendation is for children to be screened for ASD during their routine well checkup appointments at 18 and 24 months, so many children get diagnosed successfully by around age 2; however there are still a big number of children being diagnosed after age of 3 or 4.  A  new study published in April 2019 in the medical journal Jama Pediatrics, proposed that children can be responsibly diagnosed with autism at an earlier age if formal screening starts earlier than what is currently recommended. The toddlers involved in the study were screened around 12 to 14 months of age and 84% of the kids who were diagnosed retained their ASD diagnosis when a follow up was done at age 3.   Earlier diagnosis would be ideal as it would allow children with the disease to initiate therapies and interventions at a younger age.

Among all children, minority groups are usually diagnosed later and less often, probably due to less exposure to proper medical care and/or less parental awareness that there might be a delay.


Tools/Resources for parents

This book– Autism Spectrum Disorder: What Every Parent Needs To Know  is a vital resource for parents. It can help the parent learn more about the ASD diagnosis and current modalities of treatment.

CDC’s Milestone Tracker App -With this app you can track your child’s milestones from age 2 months to 5 years.

Before your child’s next well visit, check out the CDC’s developmental Milestones page , and print and fill out the CDC developmental milestone checklist

Not sure how to talk to your pediatrician about your concerns? Check out these tips from the CDC.

Resources (click on the links to read more)

Uptodate : autism spectrum disorder clinical features

Uptodate: autism-spectrum-disorder-surveillance-and-screening-in-primary-care

https://www.healthychildren.org: Autism

https://www.healthychildren.org: Autism Early-Signs-of-Autism-Spectrum

https://www.mayoclinic.org: autism-spectrum-disorder

https://www.cdc.gov: autism signs

https://www.aappublications.org

https://annals.org: mmr-vaccine and autism

https://www.philly.com: delayed diagnosis of autism in girls

https://molecularautism.biomedcentral.com : linguistic markers of autism in girls

Disclaimer: The content in this blog is not to be considered medical advice and it is not intended to replace the relationship you have with your primary care provider. If you have specific questions, please contact your physician.