Tuesday, February 9, 2010

Early Concerns to Autism Spectrum Diagnosis, The Toddler Years

As we moved beyond's J.'s first birthday, we were amazed at some of the skills that we saw developing. He rapidly added new words to his vocabulary, and his articulation was, for the most part, clear and distinct. However, subtle gaps in J.'s development began to slowly emerge. As new parents, some of these were quite difficult to recognize. It is important to note that developmental delays associated with some autistic spectrum diagnoses can be difficult to detect with commonly used developmental screening tools, such as the Denver Developmental Screening Test which our pediatrician uses.

Some early indicators of autism spectrum disorders include: problems with eye contact, orienting to one’s name, joint attention, pretend play, imitation, nonverbal communication, and language development. Most of these indicators were not assessed by out doctor's developmental checklists that we filled out at each visit. Because our son seemed to respond to his name and was actually advanced in language development, we thought there was no reason to be concerned.

During the second year of J.'s life, we took pride in his noteworthy accomplishments, and didn't notice the subtle areas in which his development lagged behind. He began to speak in short sentences by around 15 months. "Open the gate, go see Mommy?" J. began to sing parts of a few simple songs. He could also accurately name almost any shape, clearly articulating the words. Not just square, circle, triangle, but quickly moving on to even more complex shapes, like cross and octagon! He could also accurately name the color of each shape in his shape sorter. At 18 months he could count to 10, and he especially enjoyed counting the stairs as he climbed them. By 20 months J. could sing the entire alphabet song from memory. Before the age of two he learned to recite his address. By two years of age he could accurately name every capital letter, just from playing with his Fridge Phonics magnets. We read the book Ten Wriggly Wiggly Caterpillars, and within a couple weeks he was recognizing and naming the numbers,as well as counting the caterpillars. He appeared to understand the meaning of numbers, to grasp the fact that numbers indicate quantity.

In other ways, however, J.'s development seemed to lag. But there weren't really glaringly obvious red flags, at least not for us as first time parents. For example, J. liked blocks, but if they fell when he was trying to stack them, it was all over. He wanted us to build a tower so that he could knock them down. So I bought him duplo, and bristle blocks. I didn't really think much of it at the time. I believe that my son pointed to show us things, but when we pointed, he looked at our hands instead of what we were pointing at. He forgot to look at us when we would throw a ball to him to catch. There was also no pretend play developing.

My son did make eye contact during social interactions, but only briefly, and his gaze quickly and frequently shifted elsewhere. What we didn't realize then, was how much information is missed when eye contact is not maintained. Neurotypical children learn during the first year of life that the eyes convey important information. We often don't realize how many clues we gather by looking at another person's eyes. For example, most of us realize intuitively that what a person is looking at usually offers a valuable clue about what he or she is thinking. Most of us know, by looking at another person's eyes, in which general direction that person is looking. Most of us are able to use that information to guess what the other person is looking at and thinking about. But this information is often missed by an ASD child, as are subtle, or even fairly obvious mood changes in others. And looking back through a number of photos of J. in the first year or two of life, I saw only one in which J. is gazing directly into the eyes of another person. In that photo, he was less than 2 weeks old.

As my son gradually weaned from the breast to solid foods, our cuddle time seemed to rapidly disappear. He really had very little interest in being held when he was not nursing. He was in constant motion, but he didn't focus on any one thing for very long. My husband liked to refer to his behavior as "constant motion, constant destruction." J. had a real talent for getting into things he shouldn't. All the high spots in our house were filled with items that we needed to place out of reach. It looked like we were preparing for a flood. Even simple things, like the board books, needed to be kept out of reach when we weren't sitting and reading with J. Otherwise, J. would literally eat the books. Quite a few of the board books ended up having large bites taken out of them. The corners apparently were the best part!

When J. was around two years old, we began to enter a stage which I now like to refer to as "playdate disasters." J. absolutely enjoyed getting together with other children, but the visits sometimes were not as enjoyable for his friends. One of the problems we saw appeared to be impulsive behaviors combined with a lack of age appropriate awareness of cause and effect. Several incidents come to mind. The first one involved a set of wooden play food that we had recently acquired. I brought the toys out for him to share with his young friends who had come to visit. They children played nicely for a while, side by side, though not interacting, as I chatted with their mother nearby. Suddenly and without warning, J. picked up a wooden apple (which closely resembled a ball) and threw it at one of the children with all his might, striking his friend in the head. J. had thrown the toy hard enough to leave a "knot" on his friend's head, but he appeared totally dumbfounded by the outcome of his actions. I spoke to my son about the incident and he apologized to the friend when asked. However, within 6 months we had a similar incident, where J. struck the same child in the back with a wooden, toy sword with a great deal of force. This was not an act of anger. J. was equally dumbfounded by his friend's reaction, as he apparently believed that this was the normal, expected use of the toy. Finally, at 3 years of age, J. was playing with a group of children who were chasing each other around with blades of grass, tickling. J. picked up a rock and, when he had caught up with another child, hit the child on the head. He looked shocked when the other child began crying, as if it were totally unexpected. Fortunately, this was the last of these type of incidents, but, needless to say, we found it a bit difficult to find playdates for J. at this point.

The final red flags for an autism spectrum diagnosis were more subtle. A friend or two had pointed out that our son had an unusual manner of speaking during his third year. One suggested that we speak to our pediatrician about it, but was very vague about what it was that she was concerned about. Now that I know more about the speech patterns associated with Aspergers, I would guess that what she was referring to was a rather monotone manner of speaking, with little or no inflection. Since J. also had a rather advanced vocabulary for his age, she might have been referring to a pattern of careful and precise speech that is typical for Asperger's children, earning them the label of "little professor." Whatever it was that she noticed, our pediatrician was apparently not familiar with, because he found no specific problem at that point.

We did notice, that our son had an unusual manner of both asking questions and responding to them. However, since he was our first child, we assumed that this was a part of normal speech development, and were unaware that this signified a problem. If someone asked J. "How are you?", he would respond with some form of repeating the question, such as "How am I?" If J. wanted to ask an adult for something, he would phrase the question in a very odd manner. The most memorable example of this occurred when J. was about 28 months old. I had brought him to a McDonald's with a large play area so he could have a little outdoor time in a safe area. J. had to go down a short flight of steps to get to the play area. He had a tendency to be overly cautious about stairs, so even though he was holding the railing, he also wanted to hold my hand. Except that I was not sitting at the table nearest to the stairs. Another adult was sitting at that table, probably the father of another child. J. looked up at the man, and asked "Do you want to hold Mommy's hand?" Yes, I wished for a hole in the floor to swallow me up, but the man thankfully realized what J. meant, and responded "No, I think you want to hold Mommy's hand." It wasn't until years later that I became aware that these are forms of echolalia, which frequently occurs in toddlers with autism. J. also repeated lines from movies frequently, which is yet another form of echolalia. Verbal autistic children do often echo back what they hear, but it can be and is often delayed so they repeat what they have heard later on and in another context. This is clearly what we saw with our son, but unfortunately did not understand it well enough to bring to the attention of our pediatrician.

To be continued...

Want to see some video clips comparing normally developing infants and toddlers with children with social cognitive deficits, such as autism? Autism Speaks has a wonderful autism video glossary that you can use if you register (for free).


  1. This is so interesting to read.. I had no idea that there were any symptoms so early. Thank you so much for sharing!

  2. Thank you for sharing. I am starting to wonder if my son is headed down the path of a sensory disorder. I just feel like something isnt quite right. He doesnt grasp concepts I think he should and almost never makes eye contact. He wont let us too close to him and is always pushing us away. But he's smart. At 14 months he is already recognizing letters.
    I guess time will tell.
    Thanks for sharing

  3. Several things I recognize from my own childhood, though obviously older. I remember striking a child hard at playgroup when I was about three because he wouldn't let me play with the toy helicopter (I was obsessed with helicopters for a while as a kid). The playgroup attendent sat me down on a stool to think about what I'd done, and I didn't feel bad at all. I was just confused that I'd done something wrong, because I knew that kids who sat on this stool had all of the adults angry at them. When the attendent came to let me out of my time out, all I said was, "I can't believe my feet have grown that big. They actually look really enormous." 'Actually', 'fault' and 'except' were three of my favourite words as a toddler.

    I would also repeat lines from movies a lot, as well as copy the actions, emotions, reactions and motions of cartoon characters, which led to my physical communication being very 'exaggerated'.

    Thanks for sharing, this was really interesting!

  4. My 7 year old nephew was diagnosed with autism when he wad around 2 years old. He never liked being held, he seemed to be in a world of his own. His development skills were far from normal. He goes to school and does well. He will never be able to fully care for himself. He is not potty trained and is a very picky eater. He will devour McDonald chicken mcnuggets! We love him so much and we worry about my brother and SIL. They have a rough road ahead:) They have another son age 5 who is fine. Thank you for sharing your story.