Two worried mothers
Within 2 weeks, our clinic’s phone has received messages from two troubled mothers.
“My child is almost 9 months old and is showing symptoms of autism. I’m really worried and hope to schedule an appointment soon. I’m so anxious that I can’t sleep.”
“Hi, my 8-month-old baby doesn’t respond when called by name and has poor eye contact. We have close relative with autism, and I’m really worried.”
Case #1:
The mother who sent the first message began to worry when her infant , Brian was about 6 months old.
She has noticed that Brian lacks eye contact, sometimes do not respond to being called by name, and rarely cries.
Brian also seems to lack pain sensation. There was an incident while she was trimming Brian’s nails, she accidentally cut the skin adjacent to the nail, and Brian did not show any distress.
She has also noticed that Brian shows unusual excitement when looking at a rotating fan.
Brian has a history of excessive screen time from birth to 8 months.
About three weeks before the clinic consultation, parents have significantly reduced his screen time exposure . Initially, Brian engaged in what seemed like a “protest” in the form of “food strike” for a week, drinking very little milk and refusing to eat porridge, resulting in some weight loss. Fortunately, a week later, Brian returned to his normal food intake level.
Brian has two relatives who have been diagnosed to have Autism Spectrum Disorder, namely his cousin and maternal grandmother’s sister ‘s son.
During clinical observation, Brian has inconsistent response to name calling ,non- sustained eye contact and there were no babbling.
Case #2
Mother who sent the second message has noticed that her infant, Mark has poor eye contact, does not respond when called by name, and rarely smiles.
Mark also seems unbothered when his mother leaves him . He is unusually quiet, and has not started babbling.
Mark has a maternal cousin who has been diagnosed with Autism Spectrum Disorder.
During clinical observation, he was very quiet, did not have babbling, had poor eye contact, and showed inconsistent responses to name calling.
To be honest, I am deeply impressed by the astute observational abilities of these two mothers .
Both infants displayed red flags symptoms for Autism Spectrum Disorder. It is vital to closely monitor their developmental milestones, initiate home-based interventions and to arrange hearing assessments to rule out hearing impairments.
I would like to share with you simple ways to capture 9 early signs of autism in young infants and toddlers, in order to initiate early intervention and diagnosis process as early as possible.
At what age can children with autism be diagnosed?
Currently, there are no laboratory tests available for diagnosing autism, so a careful examination of a child’s developmental and behavioural history, as well as direct observation of symptoms, is necessary.
The age at which autism is diagnosed varies from person to person.
Nowadays, autism can typically be diagnosed by experienced clinicians at around 18-24 months of age. However, some children may not be diagnosed with autism until they are older or even into adulthood.
According to research, early signs of autism usually begin to manifest between 6 and 18 months of age (or even earlier). However, these early signs are sometimes overlooked because parents may not have fully grasped the milestones of typical infant and toddler development.
If a child may not be diagnosed with autism before 18 months of age, why is it still important to detect early signs of autism?
Studies have shown that effective early intervention can greatly improve outcomes of infants and toddlers , even BEFORE a formal autism diagnosis .
Early interventions significantly improve at risk children developmental potential, reduce negative behaviours, and enhances adaptive skills.
The Early Start Denver Model (ESDM), developed by Professor Sally Rogers of the University of California, Davis MIND Institute, and Geraldine Dawson, Chief Science Officer of Autism Speaks, is a great example of evidence based and effective early intervention for young children 12 to 48 months old.
Who can diagnose autism besides Developmental Paediatricians?
The American Academy of Pediatrics (AAP) latest clinical guidelines for autism spectrum disorder (ASD): Identification, Evaluation, and Management of Children With Autism Spectrum Disorder (Published on 1st January 2020) states:
“Although most children will need to see a specialist, such as a developmental-behavioral or neurodevelopmental pediatrician, psychologist, neurologist, or psychiatrist, for a diagnostic evaluation, general pediatricians and child psychologists comfortable with application of the DSM-5 criteria can make an initial clinical diagnosis. Having a clinical diagnosis may facilitate initiation of services. ”
If the waiting time for an evaluation by Developmental Paediatrician exceeds 6 months – one year or more, is it necessary to wait for a definitive diagnosis before starting intervention?
Long waiting time to see a developmental paediatricians remains a challenge faced by Autism Community globally , including first-world countries like Canada, UK, and Australia. Our country, Malaysia, is of no exception.
Generally speaking , at the time of writing , the waiting times for to see a Developmental Paediatricians in both public and private healthcare systems in Malaysia have exceeded 1-2 years, and in some cases, more than 3 years.
The lengthy waiting period may translate to at risk children missing out on crucial early interventions for conditions such as developmental delays or autism spectrum disorder.
The American Academy of Pediatrics (AAP) latest clinical guidelines for autism spectrum disorder (ASD): Identification, Evaluation, and Management of Children With Autism Spectrum Disorder (Published on 1st January 2020) emphasizes:
“ A definitive diagnosis is not necessary to institute services for documented delays that would be served through early intervention or school services.”
The “9 Nots S²P²IRA²L ” Simple Screening Method
For ease of remembering the 9 the red flags for autism in children under 18 months, I have simplified them into the mnemonic: “9 Nots S²P²IRA²L”
“9 Nots S²P²IRA²L”
1) Not Smiling (or smiling less),
2) Not Speaking ( or speaking less),
3) Not Pointing (or pointing less),
4) Not Progressing (but regressing),
5) Not Imitating (or imitating less),
6) Not Responding (or responding less),
7) Not Appropriate
8) Not Afraid (of strangers),
9) Not Looking (or looking less),
1) Not smiling (or smiling less) and not sharing emotions:
Normally developing babies typically exhibit responsive smiles at around 1.5 to 2 months and spontaneous smiles around 4 months old.
By 6 months old , if your child lacks spontaneous smiles or does not use sounds, smiles, or facial expressions to interact with you , this could be deficits of of social interaction development , which is a signs of autism.
2) Not speaking (or speaking less):
Children typically start babbling around 6 months, repeating syllable combinations with consonants and vowels, like “bababa” or “mamama,” with changes in tone and volume.
Around 10-12 months, children start saying their first meaningful word, like “ma” for mother.
By 12-15 months, they usually have about three meaningful words.
Red flags of significant delays in language and communication development in children include not babbling or or lack of babbling at 10 months old, and not having meaningful single words by 16 months old. These children may appear unusually quiet and very easy to be taken care of.
3)Not pointing (or pointing less):
Typically, children begin to point at people or objects to get your attention to something that they are interested in around 10-11 months of age.
If your child is 14 months old and still has not or rarely uses this gesture, it could be a early sign of autism.
4) Not progressing (but regressing):
Autism regression is a phenomenon where in some children with autism, after a period of typical development, lose some of their communication and social skills.
Research suggests that this affects about 20% to 30% of children with autism and can occur at different ages. The causes and outcomes of autism regression are still not fully understood and are currently under investigation.
Earlier studies indicates that this condition typically occurred between 12 and 30 months, with an average onset at around 19 months.
However, recent research shows that some children may start losing progress between 6 months and 1 year of age.
Parents may notice that their child seems to “regress,” losing previously acquired language abilities. Examples include transitioning from babbling or saying a few meaningful words to becoming quiet, or producing unintelligible sounds or babbling in a nonsensical manner. Some children lose previously acquired social skills, such as sustaining eye contact and interest in others.
5) Not imitating (or imitating less):
Around 13 months, children start observing others and imitating their actions, such as clapping hands and waving goodbye.
They gradually learn to pretend in play. For example, a child might pretend to drink from a cup or offer you an empty cup to drink from, or they may try to feed you with an empty spoon.
If your child is 18 months old, but rarely or does not imitate others’ actions, lacks imagination in play, does not engage in role-playing or creative play, this could be an early sign of autism.
6) Not responding (or responding less):
Around 6-8 months of age, children will begin to respond when you call their name by looking in your direction.
If your baby is already 10 months old, and rarely or never responds when their names are called, this could be an early symptom of autism or hearing impairment.
Any children with speech /communication delay will need hearing assessments to rule out hearing impairments.
7)Not Appropriate
7(i) Inappropriate gestures – using your hand as a tool:
Between 9-16 months, children learn to use various hand gestures such as reaching, giving, raising their hand, waving, and pointing.
Gestures use in children with autism is limited, and they may develop unusual ways of communicating with you .
One common behaviour observed among children with autism is using your hand as a tool. For example, if they are not able to open a container with lid , they may grab your hand as a tool and use it to manipulate the object, without looking at your face or engaging in any social interaction or communication during the whole process.
7(ii) Inappropriate interests – more interested in objects than people:
Normally, infants prefer looking at people’s faces over other objects.
If your child avoids making eye contact when you interact, smile, talk, or play peek-a-boo with him/her, indifferent to your departure, or more interested in objects than looking at you or engaging with you, this could be an early sign of autism.
7(iii) Inappropriate interests – intensely focused on or attached to unusual objects:
Infants with autism may become intensely focused on or attached to objects that are unusual for their age, such as ropes , long pieces of fabric, empty cans, bottle caps, or specific parts of toys (eg. the wheels of toy cars).
I have young patients who are fixated on watching spinning ceiling fans and looking at the seams of clothing.
7 (iv) Inappropriate intensity of interest – excessively interested in specific objects or activities:
Young children with autism may show excessive interest in specific objects or activities.
Due to their intense interest, they may have difficulty shifting their attention from the object of interest to other things.
This intense interest can lead them to develop advanced skills in a particular area, such as building with blocks, learning shapes, letters, and numbers, however it can also hinder their learning opportunities in other areas.
7(v) Inappropriate body movements – unusual finger, hand, or body movements:
Children with autism may display unusual finger, hand, or body postures and movements, such as hand flapping, body rocking, self spinning and etc.
Some children always need to hold stick-like object in their hands. For example, I have seen a girl who would always want to grasp a straw in her hand no matter where she goes.
7(vi) Inappropriate object use – repetitive actions:
Children with autism may engage in unusual repetitive actions with objects, such as spinning, shaking, knocking over, and rolling.
Some of my patients like to repetitively arrange objects or toys, manipulate string-like objects , or spin the wheels of toy cars.
8) Inappropriate insistence on sameness – rigid rituals and discomfort with change:
Typically, infants and young children can adapt to changes in daily routines, such as earlier ending of an activity or addition of a new routine .
Children with autism may exhibit overly ritualized behaviours and may be unwilling to complete a series of actions or activities in a different way.
If your child insists that certain things must remain unchanged and becomes very anxious with sudden changes, this could be an early sign of autism.
Some children may also display obsessive-compulsive behaviours, such as arranging items neatly or adhering to specific daily habits and sequences.
One common traits that I have observed among my clinic patients , is that they become distressed when parents choose a different travelling route instead of the usual route.
9) Inappropriate sensory responsiveness:
Children with autism may show unusual sensitivity or dulled responses to certain sensory stimuli, such as touch, light, sound, taste, and smell.
In short, if a child is overly sensitive to certain stimuli, he/she may be fearful or exhibit avoidant behaviours when exposed to the stimuli. Conversely, if they are under-sensitive to certain stimuli, they may demonstrate sensory seeking behaviours or lack of response.
Examples of hyper-responsiveness include covering their ears towards certain sounds, squinting in response to specific lights, vomiting or exhibiting extreme picky eating behaviours when presented with certain food textures, or feeling uncomfortable when their skin is in contact clothing labels or sticky substances. I have also seen many children who are fearful of stepping their feet on grass or sand at the beach.
Here are some examples of sensory under-responsiveness. Some children seems to have high pain threshold, showing no distress after an injury or fall. Some children enjoy rubbing objects against their lips and cheeks as a way to seek sensory stimulation.
9) Not Afraid (of strangers) – lack of stranger anxiety:
Typically, infants begin to differentiate between familiar and unfamiliar people at around 6 months of age, and by 9 months, they usually exhibit noticeable stranger anxiety.
If your child shows no reaction or a lack of reaction when encountering a stranger, or , conversely, they display inappropriate intimacy with strangers, such as getting close to them or sitting on their laps, this can be a sign of atypical social interaction development .
Conclusion
If you have noticed any of the symptoms mentioned above, please trust your instincts.
Do not wait and see. Go for check and intervene.
References:
(1) Hyman, Susan L., Susan E. Levy, and Scott M.Myers.”Identification, Evaluation, and Management of Children With Autism Spectrum Disorder.” Pediatrics 145.1 (2020).
(2) Book, L. A. (2009). Early Red Flags for Autism Spectrum Disorders in Toddlers in the Home Environment. Retrieved from http://purl.flvc.org/fsu/fd/FSU_migr_etd-3545
(3) Autism Speaks. Perspective on New Findings on Regression in Autism. Autism Speaks. https://www.autismspeaks.org/expert-opinion/new-findings-regression-autism-researchers-perspective
(4) Feldman, H. M., Elias, E. R., Blum, N. J., Jimenez, M., & Stancin, T. (Eds.). (2022). Developmental-Behavioral Pediatrics (5th ed.). Elsevier.
(5)Voigt, R. G., Macias, M. M., Myers, S. M., & Tapia, C. D. (Eds.). ( 2018). AAP Developmental and Behavioral Pediatrics (2nd ed.)AAP.
(6) Sheridan, M. (2014). From Birth to Five Years: Children’s Developmental Progress. Routledge.