Early identification of Autism Spectrum Disorder in Infancy

By: Satinder Kaur Walia

Autism Spectrum Disorder (ASD) is the most prevalent neurodevelopmental disorder in today’s world. Its prevalence in India is estimated to be 1 in 125 children between the ages of 3-6 years and 1 in 85 in children between the ages of 6-9 years as per the INCLEN study administered in 2018. ASD is a spectrum disorder and is mostly characterized by a broad range of symptoms. Each child with ASD manifests symptoms distinctively but the main hallmark symptoms are in the areas of social-emotional skills, behaviors, and communication. Children with ASD have difficulty forming age-appropriate social relationships and they tend to indulge in repetitive behaviors. They have delays in both verbal and nonverbal communication which can lead to frustration and more tantrum behaviors. They also appear to have more sensory issues that involve both hyper-sensitivity (over-responsiveness) and hypo-sensitivity (under-responsiveness) to a wide range of stimuli. Since every child is different therefore they demonstrate their own set of strengths and challenges. The children with ASD can range from highly skilled to severely challenged individuals. Individuals with moderate to severe symptoms may require significant support in their daily living whereas others who have minimal or mild symptoms may need less support and many can be entirely independent. 

As per the guidelines of both national and international bodies all children should be monitored for their growth (height and weight) and development during their well-baby or child check-ups by their pediatricians. Child development is measured using developmental milestones checklists. Milestones are set of functional skills that are age-specific however each child is unique and their development can vary from one to another. Developmental milestones are defined as skills or things most children can do at a certain age. Our brain is plastic during the first three years of life and that’s why these are very critical and crucial years from a child development perspective. Since children develop at their own pace therefore at times it is difficult to tell when a child has learned a particular skill or they are lagging in their milestones. Nevertheless, there are benchmarks for each milestone to be attained by a certain age limit. For example, a child usually starts sitting by 6 months and walking by 12 months. If a child is not sitting by 9 months and not walking maximum by 15 or 18 months then they are considered to have delayed motor milestones and should have a developmental assessment.

By following the milestone guidelines and benchmarks we can identify children who may be at risk for developmental delay. Child development is usually measured in five domains: 1. Physical that comprises of Gross (bigger muscles) and fine motor (hand and fingers) skills. 2. Adaptive which is self-care and daily living skills. 3. Social-emotional- your relationship with self and other individuals (adults and children). 4. Cognitive- thinking and problem-solving skills and 5. Communication- that comprises of receptive and expressive language and other nonverbal communication skills. The social-emotional and communication milestones are most prominently impacted in children with features of ASD.

Most autism screenings are administered at the age of 18 to 24 months (e.g, M-CHAT is a screening tool) and a formal diagnosis of ASD is not given usually before the age of 2 or 3 years. The Autism Observation Scale for Infants (AOSI) is a tool that can be used for early diagnosis of ASD but its accuracy is more reliable at 12 months of age. Many pieces of research have shown that children who are later diagnosed with a formal diagnosis of ASD start demonstrating features in infancy itself. Hence there is a need to screen children as early as possible. Monitoring child development and picking delays as soon as possible can lead to early interventions.  Early intervention should be the only intent of early screening as its results have shown significant positive outcomes in the lives of children with ASD and their families.

Even if the delays are mild, early intervention programs can be hugely beneficial and children can make the best possible progress. Studies have shown that children who received intensive evidence-based early intervention programs were able to get mainstreamed, had minimal challenges, and later lead more independent lives. There are now evidence-based interventions for babies as young as 9 months or 12 months old who are at risk for autism therefore early diagnosis is paramount. Early signs of autism can be detected in infants as young as 6 months of age. Most common milestones from a typical child development perspective to be attained between the age of 6-12 months in the areas of social-emotional and communication are:

Social-Emotional skills: Children usually between the ages of 6-12 months are:

• able to recognize family members
• like to play with them
• respond to their caregiver’s emotions
• often seem happy when primary caretakers are around
• start showing strangers anxiety,
• may cling to more familiar adults.
• start to imitate actions and sounds
• play simple games like “peek-a-boo” and “pat-a-cake”.

Communication skills: Children usually by the age of 6 to 9 months: 

• start responding to their name,
• make sounds to show joy and displeasure
• understand “no”,
• babbles 
• can use a finger to point at things.

By the age of 12 months children usually:

• respond to simple spoken requests
• use simple gestures like shaking head to say no or waving “bye-bye”.
• say few words meaningfully like “mama” and “dada” and
• try to copy what you say.

Both parents and pediatricians must be proactive regarding developmental concerns. Parents’ knowledge of milestones and tracking development can alert professionals in picking delays and children who are at risk for developmental disabilities i.e ASD. Recognizing warning signs as early as possible can lead to evidence-based interventions and build competency in the areas of need. Most evidence-based strategies are most effective when introduced early in life. Children who are at high risk for autism (i.e siblings of children with ASD and any family history of autism) should be monitored meticulously especially for delays in the areas of social-emotional and communication domains of development. If as a parent one has concerns about how their child plays, learns, speaks, acts, or moves one should talk to their pediatrician. Early signs and markers that usually show at the age of 6 months to the 1-year range should be viewed with caution. It is important to highlight that any of these traits on its own is not a diagnosis of ASD. Some of the early possible signs or red flags during infancy are: 

Social connection or response– Children usually by the age of 2-3 months have a social smile and they mostly start showing affection for caregivers by the age of 6 months. Lack of ability to connect and enjoy social relationships like back and forth play i.e peek-a-boo by the age of 9 months to one year can be a concern.

Eye contact and gaze: Most children are born with an innate interest in the human face particularly their parents, family, and caregivers. Children who have difficulty in establishing appropriate and sustained eye contact and who have difficulty in coordinating gaze with actions on objects by one year of age can be a concern.

Response to own name: Most children respond to their name by the age of 9 months. They usually will move their head or their eyes toward the person when their name is called. Lack of response to the name by 12 months can be a concern.

Visual Tracking: If a child is not able to visually follow a moving object i.e bright-colored toy laterally across the midline and tends to lose interest in it. If a child disengages easily or doesn’t look at where you point by the age of 12 months can be a concern.

Verbalizations: Children by the age of 6 months usually make vowel sounds like “eh” “oh” etc and laugh loudly and make squealing sounds; by nine months they usually babble (mama, baba, and dada) and by one year they usually say single words meaningfully. Children with ASD may lack verbal noises or they may be slow in verbalizing and at times they stop verbalizing after a point (regression in speech).

Socialization: Children usually in infancy indulge in social babbling meaning an ability to engage in back and forth (reciprocal) vocalizations. They also show social interests and share a positive effect on their caregivers.

Fixation on unusual objects: Children with ASD usually insist on specific objects/activities and they demonstrate some fixations on unusual objects like paper, shampoos, parts of toys, fans, or may show the presence of repetitive interests or behaviors. They may indulge in repetitive body movements i.e hand or arm flapping or lining up the toys or playing with only parts of toys like wheels of the car and not the whole toy.

Since each child develops differently and some differences may indicate a slight delay whereas others may be a cause of greater concern. The above mentioned red flags are important guidelines for tracking the development and to look for early signs of ASD. However by no means, they can be used in place of screening or as assessment tools. The presence of the above signs does not necessarily suggest an ASD or even pathology. However it suggests that the child may warrant an evaluation. These behaviors and observations can be used as discussion points between the parents and the professionals. Also most importantly if a child at any age has a loss of any skill that was attained previously should be discussed with their pediatrician on a priority basis. Finally, some of the strategies that can be used as part of stimulation and early intervention are as follows:

• Floortime- Play with your child on the floor every day
• Reciprocal play – smile when your child smiles or when he or she makes sounds and repeat your child’s sounds and say simple words with those sounds. Play peek a boo with your child and later hide and seek
• Copy your child’s sounds and words
• Read books to your child. It can start by showing colorful and bright pictures and naming the pictures. Later your child can point to the pictures and finally name the pictures.
• Talk to your child i.e describe what your baby is looking at or talk about what your baby wants when he or she points at something. Later on talking to them about what you’re doing for example mommy is washing your hands with soap and water or mommy is changing your clothes.
• Give your child a lot of hugs, kisses, and praise their good behavior.
• Play with blocks, shape sorters, and other toys that encourage the use of hands.
• Let your child draw or scribble freely with crayons on paper.
• Teach them simple gestures like “Namaste”, “bye-bye” etc and ask your child to label body parts
• Sing nursery rhymes to them and helps them do the actions along with it.

Lastly but most importantly it is highly recommended that the use of gadgets like television, phones, tablets, or computers (screens) should not be used before the age of 2 years. The screens do not interact with children and are mostly one way of stimulation. Social reciprocity and interactions are the two main catalysts children need to learn the language. Most children with ASD have difficulties in communication and have delayed language. Although there is no causation between screens and ASD however the excessive usage of gadgets can lead to delays in communication and social responsiveness. Computer and TV programs are interactive, but they aren’t responsive to a child’s ideas. Human interactions and playing with your children are the most important aspect of child development. Children who demonstrate any delays should consult with their primary health care professional, i.e., pediatrician. If required they will be recommended for additional screening or early intervention programs. Remember, the most important aspect is to act early to make a big difference in skill attainment which can make a significant impact on your child’s development.

Satinder Walia

Visiting Consultant to BLK Super Speciality Hospital
New Delhi and Max Hospital (Gurgaon)