By Jason Mosheim
The barriers to diagnosing autism before age 2 threaten to keep children from receiving early intervention. However, now that clinicians are beginning to understand what to look for-and when-those barriers may crumble sooner rather than later.
Until the last few years, professionals didn't know what to look for in children who were only 9, 12 or 15 months old. They are gaining ground in this area, but the typical age for diagnosis remains between 2 and 3 and sometimes 4.
Clinicians may hesitate to make an early diagnosis or mention red flags to parents because of the variability in early child development. Although children may appear to have early delays, some will improve and go on to develop normally while others may fail to make gains or even regress. "You might see a 12-month-old and think everything's going great, but then things begin to look worse over the next six to eight months," said Elizabeth Crais, PhD, CCC-SLP, a professor at University of North Carolina-Chapel Hill.
One way to see what children with autism look like prior to a diagnosis is through the use of retrospective video analysis. When children are diagnosed, Dr. Crais and colleagues Grace Baranek, PhD, OTR/L; Linda Watson, EdD, CCC-SLP; and Steve Reznick, PhD, director of the Program in Developmental Psychology, ask parents to provide home videos of their children made before the diagnosis in order to review early behaviors. Currently, they are looking at videos of children in two age groups: 9-12 months and 15-18 months.
"If we can get videotapes of the kids between 9 and 12 or 15 and 18 months, it allows us to see them potentially before anybody has a suspicion and look at their characteristics or behaviors," Dr. Crais said. "Some children begin to look worse as time goes on."
According to the literature, repetitive and stereotypical behaviors appear later in development, but they can appear early on in some children. These children may turn to repetitive behaviors as a way to engage themselves because of a significant deficit in their social skills.
"We are trying to identify children early so we can prevent some of the repetitive behaviors," Dr. Crais told ADVANCE. "Opening up their social world at an early age also allows them to take advantage of all the social and? play interactions that come afterwards."
Many children also engage in sensory-seeking behaviors, she said. "We look for things like pushing themselves against you or demonstrating atypical behaviors with their hands, bodies and eyes."
Her team also looks at broad communication skills like eye gaze and vocalizations.
Videos contribute to the study of gesture development, she noted. "We look at the early gestures that kids produce or ones they don't produce. There are patterns of gesture use even at these early ages. For example, categories such as joint attention have fewer gestures. A pattern of use begins to exemplify kids even in the 9- to 12-month range."
One interesting finding, she reported, is that "gestures, or lack of them, in the 9- to 12-month range are highly predictive of later language skills at ages 3 and 4. That's pretty powerful." As a result, researchers now are paying more attention to gestures, specifically joint attention behaviors of showing, giving and pointing. Dr. Crais has seen many 2-year-olds over the years who aren't talking but are gesturing, smiling, and using other ways to communicate. In many cases these children are late talkers who probably will catch up with their typically developing peers.
"If one 2-year-old gestures, communicates, vocalizes, looks at you, and understands much of what you say and another has limited or no gestures, few vocalizations and limited comprehension, the one that has all these means of communicating is probably going to be more successful. The other child likely will continue to have language problems," she said.
Gestures can be a powerful, discriminating set of behaviors that can help clinicians decide if they need to see children in intervention or can wait, monitor them, and let them mature.
In joint attention behaviors an individual attempts to direct a person's attention to something. For example, a parent points out an airplane to a child; a child shows an object to someone; or a child gives a rattle to an adult, wants it back, and repeats the interaction. "Many little children who have something in their hand want to show it to you and will look at you to make sure you're seeing it, too, and enjoying it with them," said Dr. Crais. "Little kids with autism are less likely to engage in some of these social behaviors that represent joint attention."
The most well-known gesture is pointing. Typical children point to things with the intent of sharing the experience with someone else. Children with autism often use behavior regulation acts to try to get a person to do or not do something. "Even very young children with autism focus on those kinds of behaviors. They grab your hand to get something or take your hand and guide you to the refrigerator to get you to open the door," said Dr. Crais. There are fewer joint attention acts and less variation in social interactions but not a total absence of either type, the researchers have found.
What makes it difficult to identify some children with autism earlier is that they may participate with others in games like peek-a-boo and communicate by smiling, laughing and looking when they are younger.
"If I raise the possibility of autism, some parents say, 'But he smiles, laughs, plays with us, and looks at us.' The notion that these children don't smile, laugh, or socially interact is incorrect," said Dr. Crais. "Some are very hard to reach, but even they have times where they can be reachable. The public has the idea that these children aren't social, and that's not the case in a number of situations."
At 12 months children should be demonstrating some behavior regulation, social interaction and joint attention acts. At 15 to 18 months, they should have a variety of behaviors in each area as they begin using words. "Words are coming in and begin to replace gestures," said Dr. Crais, "but there's a period of time where words and gestures are both used. The child will point and say 'airplane.' As words become more powerful and prominent to them, gestures begin to slide away."
Another important early behavior is play. The four common levels of play are exploratory, relational, functional and symbolic. Children with autism have an easier time with exploratory and relational play. They begin to falter when they encounter functional play, which is built on relational play. At this stage, for example, children put things together or line up blocks. In order to move on to functional play, they need to have a good sense of what other people are doing.
"Some activities require children to look around, see what everybody else is doing, and repeat the behaviors," she said. "Kids with autism traditionally are not that aware of peers around them and therefore don't learn ways to play functionally with toys."
Symbolic play also can be difficult for this population. "A child who blows on an empty cup and says 'hot!' is pretending to have a hot drink. Or they put scraps of paper on a plate and say, 'Do you want some chips?' They're symbolizing that something is there," explained Dr. Crais. "Those are very hard skills for children with autism. Many researchers feel the cause is a lack of social interaction."
Research has demonstrated that the development of play and language skills runs parallel at some point, she said. "We can look at both sets of behaviors and say, 'How is this child doing in both domains, and can we use that?' If their play is good but their language is poor, can we use play to enhance their language, or vice versa?"
Dr. Crais and her colleagues are conducting an intervention study using a parent report tool they developed.1If parents score their child high on the First Year Inventory (FYI), indicating many risk factors for a possible autism diagnosis, the researchers test the child. Those children who appear to have symptoms characteristic of autism are placed in a randomized control treatment trial, where they receive project-specific intervention or are referred for community services.
"Only a few children have finished the study, but already we're seeing really nice changes," Dr. Crais said.
A number of sources have identified effective components of intervention for children with autism.2Among the most important are enrolling them in intervention as early as possible and actively engaging them in intensive instructional programming for at least 25 hours. Also key is building spontaneous functional communication, as well as the amount of time spent in speech and language intervention.3-5"It's a pat on our backs to say that it's critical for children to get into speech-language therapy so they can begin to enhance their communication and social skills," she said. "It's affirming for us as speech-language pathologists to see that."
All children should receive a 12-month well baby check-up, which is a perfect time to begin looking at behavior, Dr. Crais said. The American Academy of Pediatrics recommends all children be screened for autism twice by age 2-at 18 and 24 months.6"We would like to see a tool like ours used even earlier, at 12 months, to see if there are any signs that might be a concern," she said. "Ultimately, we would like to get early identification down to 12, 15 or 18 months because these are critical periods for some children."
1. Baranek, G., Watson, L., Crais, E., et al. (2003). First-Year Inventory (FYI). Unpublished manuscript. University of North Carolina-Chapel Hill.
2. National Research Council. (2001). Educating Children with Autism. Washington, DC: National Academy Press.
3. Rogers, S. (1998). Empirically supported comprehensive treatments for young children with autism. Journal of Clinical Child Psychology, 27 (2): 168-79.
4. Rogers, S., Vismara, L. (2008). Evidence-based comprehensive treatments for early autism. Journal of Clinical Child & Adolescent Psychology, 37 (1): 8-38.
5. Turner, L., Stone, W., Podzol, S., et al. (2006). Follow-up of children with ?autism spectrum disorders from age 2 to age 9. Autism, 10 (3): 245-65.
6 Plauche Johnson, C., Myers, S.M., et al. (2007). Identification and evaluation of children with autism spectrum disorders. Pediatrics, 120 (5): 1183-1215.
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Jason Mosheim is a Senior Associate Editor at ADVANCE. He can be contacted at firstname.lastname@example.org.
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