The rates of autism are exploding around the country and the shortage of clinicians able to diagnose this condition is critical. Healthcare professionals and primary care providers may miss the early signs of this condition without specialized training, as every child with the condition presents with unique varying characteristics of the condition. Many members in our communities, both family members and healthcare providers alike, maintain a certain perception of what autism “looks like”. But autism does not have a “look”. It is a neurobiological condition that impacts an individual’s social and behavioral development and can be difficult to spot. Autism may also impact a child’s cognitive development, however some children with autism present with average or even above-average intelligence, further complicating the identification of this condition. We see children with autism who speak fluently but present with concerning or unusual behaviors, meltdowns, or other difficulties in social situations. Some have been kicked out of daycare for aggression or biting. Others present as very “shy” or “anxious”. Every child is different. If you have any concerns in any of these areas, have your child evaluated by a specialist as soon as possible. Autism does not have a particular look and we as healthcare professionals need to do a better job of identifying and treating it early.
A delay in language is often one of the early signs of autism spectrum disorder. We often hear parents state that “it’s just a speech and language delay”. Young children should have a bare minimum of 50 words by the age of 2, with many children speaking between 150 and 250 words by this age. When we look at communication, we look at many different strategies that the child may use to get their wants and needs met. Vocalizations such as babbling and speaking words are the most common markers parents use to assess communication. We also want to see a child using gestures and sustained eye gaze to supplement their language. By 16 months of age, a young child should have 16 different gestures they use to communicate, such as pointing, holding out their hand as if to say ‘stop’, shrugging their shoulders when asked a question to indicate “I don’t know”, or holding their hands out with palms up to say “where is it?” With a true speech and language delay only, children will use these other appropriate ways to communicate and it will look like a game of charades. They will stare at you, do all kinds of gestures, use eye gaze with vocalization to try and tell you something, etc. These children often understand what others say and can follow directions well but are unable to express themselves with words. They make up for their delays in language by using other appropriate means of communication, such as gestures. A lack of development of these gestures, not holding eye gaze on others who are speaking, or pulling others to what they want are all signs of possible autism.
We often hear “but he makes such good eye contact”. Many children with autism that we see today present with fairly good eye contact. We further assess eye contact in autism assessments to see if it is sustained, modulated, used to not only initiate an interaction with others, but sustain it for a back-and-forth social exchanges. Some children have eye contact that looks more like a ‘stare’, with little change in facial expression. Others give frequent glance of eye contact but do not hold it when others are speaking, as if to try and listen. Yet other children will only give eye contact during times of emotional extreme, when they are very excited about something or very frustrated and upset. Children with autism often have difficulties with social referencing. This is where a child will look at another individual and ‘read their face’ or other social cues in order to gain information before moving on with their own actions. They “check-in” to see what others think and feel about their actions, or to see if they are watching. Social referencing is an important part of development and is often reduced or delayed in children with autism.
Some children with autism are very active and busy with seemingly boundless energy. Younger ones will climb on furniture within the home and are good problem-solvers, often meeting their own needs by climbing or reaching for what they need without communicating to others. Parents often refer to them as very ‘independent’ and report that they do not request or drink or a snack, they just go and get it.
Playing with toys in a purposeful manner is an important part of a child’s early development and we like to see young children engaging in make-believe play tasks with a variety of different toys and objects. Children with autism will often show interest in the moving parts of toys, such as playing with the wheels of a car or spinning the propeller on an airplane. This sensory interest in the toy can then interfere with the child’s purposeful use of that toy in a representational manner, i.e. flying the airplane around in the air while making airplane noises or driving the toy car around on the floor. Children with autism will sometimes show an intense interest in taking toys apart or bending board books until the pages break. We often hear parents say “he’s really interested in how things work and how things go together” when this may not be the case. Other children on the spectrum will become easily overwhelmed and will throw toys, swipe them off the surface of a table, or gather them all into a pile and then move the pile to another location. Some children like to put toys into unusual spots, such as behind a tv stand or into a slot in another toy. This is not purposeful toy play and warrants a closer look at what is going on with development.
If my child does some of the things mentioned above, does that mean he has autism? The answer is that we do not know until a formal assessment is completed. Guessing or remarking on whether a child has autism or not, without a clinician performing standardized testing, is a dangerous narrative that we need to try and reduce within our community and amongst our healthcare professionals. A child lining up toys or putting toys into his mouth is not enough to make a diagnosis. A child who walks on his or her toes is not enough to make a diagnosis. The atypical patterns of development within autism, while often visible or concerning to parents, need to be formally measured and assessed to ensure that they meet criteria for the condition. The earlier these answers are provided, the better chance your child has to reach his or her full developmental potential. Never wait if you have a concern about your child’s behavior or development. Bringing a child in for assessment and finding out that they are just behind and do not have autism brings peace of mind. Finding out that it is autism is incredibly hard to hear but leads to the opening of many doors of support and early learning opportunities for your child, which has a direct and positive impact on their future.