Red Flags for Autism in Toddlers

One of my passions as a pediatric speech-language therapist is helping parents understand the early signs and symptoms of autism.  Autism is a complex disorder that requires systematic and often intense treatment, but there is much hope for children who receive this diagnosis, especially if they are diagnosed a young age and receive treatment early.  Early diagnosis, though, depends on a keen understanding of the early signs and symptoms of autism in toddlers.

Parents are often told to talk to their pediatrician about autism if their child has not spoken a single word by 15 months, or is not using 50 words and short phrases by 24 months. This is good advice, because delays in verbal communication are part of the diagnosis of an autism spectrum disorder (except in the case of Asperger's Syndrome, but I'll chat about that in another post). However, (note the italics because this is a *really important* however), just because a child is a late talker, one can not assume that the child has autism. Not by a long shot. Many, many children have language delays without having a diagnosis of autism. A delay in language is one indicator of autism, but it is a very broad one.  Luckily, we do have other, much more specific signs and symptoms to look for in toddlers to help us differentiate children with "simple" language delays from children who we may suspect have autism. A significant loss of language, for example, is one red flag.  Here are the others.

Decreased Use of Gestures and Facial Expressions to Communicate

Even if they are not yet talking, typically developing toddlers constantly attempt to communicate their needs and interests to the adults in their world. They do so through gestures, facial expressions, and eye contact. Watch as Baby Girl manages to communicate suprise, joy, and love all without saying a word.

In this video, Baby Girl communicates mainly through facial expressions, and she's very effective in doing so.  By 12 months, children are also really starting to use gestures to communicate with their world.  They wave bye-bye, shake their head no, reach toward things and people they want, give objects to people to get help, show objects to people to share their interest in them, and point out things of interest to those around them. 

Importantly, typically developing toddlers use their gestures to both indicate what they want and to show others what they find interesting.  They point--not only to things they want to wrap their little hands around, but also to things that they simply want to show their parents. This pointing to get their parents to look at things (technically called proto-declarative pointing)  is an important skill that we really want to see children develop.  It tells us that toddlers want to share their world with the grown-ups in it, something we call joint attention. Joint attention simply means that two people are looking at and sharing an interest in the same thing at the same time. Imagine a child pointing out the window at a dog to get his mom to look at it. His mom looks at the dog and then smiles at the child to share his joy. This child has just used a proto-declarative point as a way of establishing joint attention with his mom (in other words, he used a gesture to get his mom to look at the same thing he was looking at).  Typically developing toddlers do this all the time-- they are constantly trying to get the attention of their parents for a wide variety of reasons.

Red Flag: Toddlers with autism are less likely to use gestures and facial expressions to communicate with others, less likely to try to get their parents' attention to show them something, and less likely to use a proto-declarative point to share their interest in their world with their loved ones. 

Decreased Eye Contact

We expect children to look at their parents often. They start doing this very early on, and continue to develop their use of eye contact as they grow. By 6-12 months, we want toddlers to use what we call gaze shifts. Gaze shifts occur when children look from an object to the face of an adult (often their parent or caregiver) and then back to the object.  Children use gaze shifts to share emotion with others-- for example, a child might be playing with a pop-up toy, find it delightful, look at his parent and smile broadly to share his joy, and go back to playing with that toy.  He's just completed a gaze shift.

Watch the video of Baby Girl again. This time, check out how she uses gaze shifts to share her joy (and surprise) with us. She alternates between looking up at the TV where the music is coming from, looking at me sitting next to her, and peeking around me to see her brother laughing at her. In doing so, she involves each of us in her joy.

Toddlers also look at their parents' faces for what is called social referencing. This occurs when young children are unsure of themselves and look to their parents' faces to figure out what to do. If a child was scared of a pop-up toy, for example, he might look to his mother to see her reaction. If she was smiling, he might go back to playing, but if she looked scared, he might crawl over to her for comfort. Amazingly, even very young children use their parents' faces to help them decide what to do.  A classic and fascinating study of social-referencing involved presenting babies with a "virtual cliff" and watching how the babies' reactions to the cliff depended on their mothers' facial expressions. You can check it out here:

Red Flag: Young toddlers with autism are less likely to look at their parents' faces to share emotions such as joy and less likely to check out their parents' faces to observe the parent's reaction in ambiguous or scary situations.

Infrequent Social Games and Bids for Attention

Typically developing young children love to play little social games such as "peek-a-boo" and "hide and seek."  They'll also often repeat their behaviors to get their parents to laugh.  Again, I'll use the video of Baby Girl as an example--she is clearly enjoying the attention she is receiving as she responds to her brother's laughter. As she dances some more, she peeks around to make sure he is still watching.  Although she is enjoying the  music, it is the reaction from her brother that is really making her smile. Her actions are, in part, attempts to get her brother to continue laughing at her.

Red flag: Children with autism are less likely to engage in  social people games such as peek-a-boo and are less likely to perform for attention and laughter.

Lack of Pretend Play

By 12-18 months old, typically developing children are using objects in functional ways. This means that a child this age will use the object for its intended purpose-- he might put a brush to his hair or a toothbrush to his teeth, or he might pretend to drink from a cup or feed his parent with fork. You'll see him start to imitate housework as he uses a washcloth to wipe the table or grabs the broom to sweep the floor. Then, by 18-24 months, children engage in  true pretend play. The toddler will now talk on the phone, fly airplanes, drive cars, give a drink to a baby, put the baby to sleep, and push that baby in a stroller. These pretend play episodes might be very short, but they are still important.  Around 12-18 months, toddlers will also start taking an interest in other young children. Although they won't always play with other young children, they will enjoy playing next to them. 

Red Flag: Children with autism are less likely to use objects in pretend play and often do not take as much of an interest in other young children. They are also more likely to use the same type of repetitive action with a object or toy over and over (for example, opening a door and shutting it repeatedly) and to get upset if someone interrupts their repetitive play.

Decreased Response to Adults 

Babies start to recognize and respond to their name as early as six months;  by 12 months, they respond to their name being called consistently. They also follow an adult's eye gaze when that adult points out something interesting across the room.  

Red flag: Toddlers with autism are less likely to respond to their names when called.  They're also less likely to be able to follow an adult's point at something across the room.

Each of the above categories lists a red flag for autism.  However, (here's another really big however), just because a young toddler has one or more of these risk factors, this does not mean he has autism. Autism is a complex diagnosis that can only be diagnosed through careful evaluation by trained professionals. What's more, many of the above categories are very subjective-- it can be really hard to know how often, for example, your child should be looking at your face to share joy. It can be easy to read into something that is really not there. It can be just as easy, though, to ignore the signs that are right in front of you.  If you have any concerns, it is really worth a conversation with your pediatrician. And if you see your child in a number of the above categories, don't hesitate to push for an evaluation by an early intervention professional.  As scary as it might be (and I can only begin to imagine how scary it might feel), you will never do your child wrong by seeking help early.

Looking for more information on the early signs of Autism?

 First Signs

M-CHAT

Wondering What To Do If You Are Worried About Autism?

Next Steps
The ABCs of ABA in the SLP World

Wondering what the early intervention process will be like? 

Early Intervention: The Beginning