Be educated, be aware, and be accepting!
I want to talk about some of the characteristics some families are confused about, and really explain what this is.
Caregivers in my office, as well as followers on my social media are always asking about milestone and development and if certain characteristics are signs of autism.
April 2nd is World Autism Awareness Day as designated by the World Health Organization, however, many in the autistic community don’t look fondly on this day/month. I encourage you to take a look at this reading that provides history of this month and this day, and what it means to the autistic community.
My goal during the month of April is to spread education and acceptance for our neurodiverse community.
When is Autism screening done at well-visits?
In the United States, at 18 month and 24 month visit, your child should receive a questionnaire or screen form, to screen for autism.
I am not a huge fan of these screenings because it is placing a child in one of two boxes, yes or no. Really, many times in autism, it’s not so cut and dry. I think it’s important to recognize this and bring awareness to this.
These visit are important in the toddler years to asses your child’s development. However, in many kids, an autism diagnosis can happen much later. This can be above two, three or even four years old (in many cases even into adulthood as well).
Therefore, it is important to know the different characteristics and to know if it is something you need to bring to your child’ clinician’s attention.
So why screen at 18 & 24 month mark if diagnosis can sometimes be made much later?
The reason for this is it’s important to know at this time frame, if there’s any characteristics we are concerned about, in order to get services and an evaluation early. I want to reiterate that we should really be pro-intervention. Anyone that’s involved in a child’s life, whether it’s a teacher, a parent, a caregiver, a loved one, a pediatrician, a clinician – it’s really important that we’re pro-intervention.
Watch this PedsDocTalk YouTube video for more information on pro-intervention.
Characteristics Vary
It’s important to remember this. This is why the boxes of a questionnaire don’t always work so well. You can’t fit a child’s development into one box. Big picture is important and conversation with the clinician is important.
To make an autism diagnosis, we are looking at various characteristics affecting various domains:
You may not have every single characteristic, but it’s important to know that if your child is having characteristics in the social, communication or repetitive behavior category, especially combined, that you speak to your child’s clinician.
We do also see these characteristics impact other aspects of development such as: behavior, feeding, sleep, etc.
The DSM V Criteria for Autism
- Social Interaction and Communication (At least one characteristic in all three areas)
- social and emotional reciprocity (eg. failure to produce mutually enjoyable and agreeable conversations or interactions because of a lack of mutual sharing of interests, lack of awareness or understanding of the thoughts or feelings of other)
- nonverbal communication (eg. difficulty coordinating verbal communication with its nonverbal aspects – eye contact, facial expressions, gestures, body language, and/or prosody/tone of voice)
- creating and maintaining relationships (eg. difficulty adjusting behavior to social setting, lack of ability to show expected social behaviors, lack of interest in socializing, difficulty making friends even when interested in having friendships)
- Repetitive Behaviors and Activities (at least 2 of 4 characteristics)
- a stereotyped speech and behavior (eg. stereotypes such as rocking, flapping, or spinning); echolalia (repeating parts of speech; repeating scripts from movies or prior conversations).
- insistence on sameness, unwavering adherence to routines, or ritualized patterns of verbal and nonverbal behavior (eg. ordering toys into a line)
- fixated interests (eg. preoccupation with certain objects [trains, vacuums cleaners, or parts of trains or vacuum cleaners]); perseverative interests (eg. excessive focus on a topic such as dinosaurs or natural disasters)
- hypersensitivity or hyposensitivity to sensory input (eg. adverse response to particular sounds; apparent indifference to temperature; excessive touching/smelling of objects)
- Presentation in early childhood
- Impacts everyday activities
Characteristics parents often ask about
These characteristics can be present in a neurotypical child, but when it’s more consistent and pervasive, we want to ensure we are doing an evaluation for autism or any other developmental concern.
Social Interaction and Communication Domain: Eye Contact
We would expect eye contact in a baby by the 9 month of age. Note though that this doesn’t mean consistent eye content. I want you to remember that if your child is past the 9 month of age, and the eye contact is not becoming more prominent or if its regressing – AND you feel your child is not making eye contact. This is a reason I want you to speak to your child’s clinician.
Social Interaction and Communication Domain: Responding to their name
We would expect this milestone by the one year mark. You say their name, they look up, they make a sound – it’s an important milestone. If your chid is not responding to their name by the 15 month mark, it is important to talk to clients clinician. It’s similar to what I mentioned about eye contact, as months go by I want to see them being more responsive to their name, making more eye contact. You should feel that you can get your child’s attention by 15 to 18 months.
Social Interaction and Communication Domain: Joint attention
This can be initiated one of two ways – child initiated or caregiver initiated. Child initiated would be for example, a child pointing to an item – a plane in sky, they may point and look back at you to see if you’re looking. They could also be utilizing word approximations or words, the point is they’re trying to get your attention. This shows the child is recognizing something in their environment and trying to engage with caregiver with that item. Caregiver initiated would be for example, look at the ball – and your child looks at the ball and responds perhaps saying “ba, ba”. This article is a great resource about joint attention – it is important to know how you can engage with your child in this milestone, and if they’re not engaging in this joint attention, bring it up to your child’s clinician.
Social Interaction and Communication Domain: Pretend Play
We would expect pretend play by 18 months. An example would be – your child takes a car and they roll it around, they put a phone to their ear or feed a baby.
Repetitive Domain: Stimming
These are actions that are helpful for autistic children and adults to help manage emotions in stressful situations. Examples of this would be swaying, spinning, rocking, twirling their fingers, hand gestures near the eyes. These are behaviors that if your toddler is doing, especially in toddler years in conjunction with other characteristics – your clinician would want to know.
Repetitive Domain: Echolalia
It sounds like what it is. It’s echoing a sound or word. A child will do this when they are learning a word. But by the time a child is 2 to 2.5 years old, this should diminish. So, if your child is doing this past the 2 to 2.5 year mark, bring it up to your child’s clinician. This may be a sign to have them evaluated.
Repetitive Domain: Playing with parts of a toy
What this looks like is for example your toddler has a car and they continuously spin the wheels, just the wheels. They don’t play with the actual car or engage in pretend play.
Repetitive Domain: Ritualistic Behavior
What this looks like is for example your toddler lines items up, needing to touch things in a certain order. This would be an important characteristic I would also want you to monitor.
Repetitive Domain: Hypersensitivity
This would be sensitivity to sounds, textures, different foods. This is an important one. Children can be very sensitive to sounds, lights, textures and foods. But if you’re starting to notice that many things are becoming an issue, consistently, I would want you to bring this up to your clinician.
And remember when we make the diagnosis of autism, we are seeing characteristics in each of the 3 domains. However, it is still important that if you are concerned of just one of the characteristics that you bring it up.
It is our job to look at the big picture. We may want to monitor that characteristic every couple of months, we may want you to get an evaluation or you may want an evaluation.
Remember that no child – neurotypical or neuro-atypical – is going to fit into a box or mold. It is important to understand that and it’s also why it’s important to know the different characteristics and know how we look at different domains. I always ask my families to look at how this may be affecting other activities of daily living. Look at the big picture of a child.
- “They’re really not taking to eating”
- “It’s really hard to console them for sleep”
- “They’re having more tantrums than developmentally appropriate”
Takeaways
- Diagnosis of autism is not as always as straightforward as you may think. It is a spectrum and a variety of different characteristics that we are looking for.
- From the time that you see characteristics in your child to the time of diagnosis can seem like a very long time. This can happen because of the process of getting services, monitoring different things, giving the child speech or OT or PT. Then seeing maybe things are not improving, and what else do need to do. Remember though, itt is still important to bring up any concerns to your clinician because early intervention is best.
- Always bring up your concerns. We want to be pro-intervention – so if we have a concern about a child’s development that we get them evaluated to get them the services they need. If we can get them into early intervention services, the better outcomes that child can have – meaning before the age of five.
Resources
Early Intervention Resources
- Zero to Three – Early Intervention
- CDC – Learn the Signs. Act Early.
- Understood – Requesting an Early Intervention Evaluation
Other resources
I encourage you to watch the PedsDocTalk Youtube Video: Autism Traits and Characteristics!
