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Dr Anna Maw
Consultant pediatrician at Cambridge University NHS Trust in the UK. A child doctor specializing in brain development and neurology. She has three children.
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Stage 4 – 9 months

Autism spectrum disorders

It's often during the toddler years that parents first worry that their toddler may be developmentally delayed. They see other toddlers walking, talking and interacting with their parents differently and understandably, this gives cause for concern. Most parents at one time or another will worry that their toddler seems behind or 'different'. So how do you know if your concerns are well-founded?
In Short
If you are worried about some aspect of your toddler’s development speak to her doctor, pediatrician or health visitor. It is very important that any concerns are raised and checked out.

Autism spectrum disorder (ASD) is a condition that affects social interaction, communication, interests and behaviour. It includes Asperger syndrome and autism and affects around 1 in 100 people. Children are now diagnosed from around two years of age.

Signs of autism spectrum disorders in babies, toddlers and older children respectively include a lack of smiling, imitation, babbling and cooing, little interest in attention-seeking and becoming self-reliant, a lack of pointing and gesturing, repetitive or stereotypic behaviours, poor eye contact and delayed physical development.

Early intervention can make a huge and positive difference to your toddler and your ability to relate to her.

Regular assessments of your toddler's development should continue throughout the toddler years.

What should I do if I’m worried about my toddler’s development?

It’s important that if a parent feels concern about their toddler’s development, it’s taken seriously. False reassurance isn’t helpful and you as a parent are the world expert on your own toddler.

If you are worried about some aspect of your toddler’s development, speak to your child’s doctor or health visitor. Take a list of observations you have made and maybe even a video if you think it will help. Your toddler may then be referred to a local child development team or paediatrician to be formally assessed. Try not to worry about this. Either they will be able to reassure you or they will be able to assess her needs, diagnose what the problem might be and then offer interventions that will help support and promote her development.

If you feel you are not getting the help you need you can always contact a national support group or charity. They are generally run by parents who are keen to support parents going through the difficulties they have faced.

What are autism spectrum disorders or ASD?

It is in the toddler years that many parents begin to worry about autism spectrum disorders. Autism spectrum disorder (ASD) is a condition that affects social interaction, communication, interests and behaviour. It includes Asperger’s syndrome and autism. In the UK 1% , or 1 in 100 people will have an autism spectrum disorder and statistics from the United States report that around 1 in 70 children are formally diagnosed with autism spectrum disorder. This formal diagnosis doesn’t usually happen until after the age of two but researchers such as Simon Baron-Cohen at Cambridge University and American psychologist Ami Klin have developed assessment programmes that can pick up signs of ASD in babies and young toddlers. Baron-Cohen states that the differences between Asperger’s syndrome (which is sometimes called ‘high functioning’ autism) and autism is that autistic people generally have language delay and below average IQ (as measured with an IQ test) whereas people with Asperger’s syndrome are more likely to have above average IQ and no language delay (just the so-called ‘social blindness’.)

The benefits of early diagnosis of autism spectrum disorders

Early diagnosis and intervention can help an autistic child’s development and coping skills so it is important to be aware of your baby and toddler’s development. Some autistic children lack ‘normal’ behaviour but there are also some behaviours that are more classic – e.g., shrieking, lining up toys and stimming (see below).

Some signs of autism spectrum disorders in babies, toddlers and young children

Some early signs that might give parents cause for concern include:

Smiling behaviour

Full-term babies of around 6-8 weeks of age will make full eye contact and smile in response to your smile. Autistic children do smile and laugh but it can often be an ‘unshared’ smile. Some autistic children can make good eye contact and laugh – when tickled, for example. There is a big spectrum, amongst all toddlers, in the socially shared aspect of smiling and laughing. Even from a young age, some children will immediately look to others for social reference and share a smile. It’s often the sign of a gregarious or extrovert nature – sharing a laugh is more fun than laughing alone.

If your baby isn’t smiling in response to your smile or laughing by the time she’s six months old, you should talk to your GP.

Lack of imitation

Babies and toddlers learn through imitation. Emotion and facial expression expert Paul Eckmann was able to demonstrate that our facial expressions are universal (that is, they’re the same throughout history and different cultures) and that children copy our facial expressions because it helps them to fundamentally understand a situation through social referencing. It also gives positive physical feedback. So when we smile, the muscles used for smiling promote feel-good chemicals in our brain. When we pull a fearful face or a disgusted face, our brain responds as if we are feeling those emotions. Our facial expressions and our emotions are inextricably linked.

Autistic children are less likely to make eye contact or to look at your face. This feeds into a lack of imitation and so empathy. A lack of imitation in autistic children, therefore, means that they are less able to understand people’s motivations and internal states. They cannot ‘read’ people – our language is so multi-layered (and often non-verbal) that they often take everything that’s said literally, just relying on spoken word and missing the nuances that make human communication so rich. It also leaves them open to vulnerability, as sarcasm and lies can be lost on them.

If you notice that from around nine months old your baby still doesn’t take part in turn-taking with you, or copying your expressions or gestures, speak to your GP.

Lack of babbling and cooing

Babbling is something that babies from all cultures and language backgrounds do. Babies in China babble in an identical way to babies in Iceland or Borneo. Babies begin to babble from about four months of age with classic ‘baa baa daa daa’ noises. It can be quite a solitary activity and you may hear your baby babbling away in their cot or while kicking on a mat.

The human language instinct is incredibly powerful. Early cooing and babbling are vital first steps where babies make a standard repertoire of noises with their mouth and vocal cords and hear themselves making all those noises.

If you notice that your baby didn’t make cooing or babbling noises by the time she is six months old, or the babbling was delayed or sounds different to other babies, it’s really important to speak to your GP.

Lack of attention-seeking along with self-reliance

We frequently praise toddlers who can amuse themselves for long periods of time. However, attention-seeking behaviour is actually a really important part of a child’s social and emotional development. When a toddler uses you as their secure base, they explore and come back to you, explore and look at your face, explore and chuckle for a reaction. Finally, they may come back and cuddle you or ask to be picked up.

This attention-seeking behaviour is about sharing time and space with their primary caregiver and monitoring their emotions. Toddlers can be famously insensitive to other people’s behaviours and emotions.

If you notice that your toddler rarely tries to get your attention or share a moment it may be a sign that she struggles to relate to other people in a straightforward way, and it is worth discussing this with your GP.

Lack of pointing and gesturing

Before spoken language, there is a huge amount of communication that happens via body language and gesturing. You will realise the power of this form of communication if you have ever been in a country where you cannot speak the language. It is amazing how much you can communicate with facial expression, smiles and simple gestures. Before their first birthday, babies generally wave ‘bye bye’, point or gesture to be picked up.

Pointing is particularly interesting because it is asking a person to look at and notice what is being pointed at. It seems simple, but it is a huge jump in cognitive development. It means your toddler realises that another individual doesn’t automatically share their literal or emotional point of view. Try to notice how and when your toddler gestures. If you notice that she doesn’t point or try and get your attention by the age of 15 months it’s really important to speak to your GP.

Repetitive or stereotypic behaviours

Some children on the autistic spectrum display repetitive behaviours which are thought to calm them when they feel overloaded with information. This is called ‘stimming’, or self-stimulation. It can include running up and down in a straight line, flapping their wrists, spinning, or sometimes more troubling behaviours like head banging.

On a personal note, in my family, my siblings and I each have a child who loves to ‘stim’ by running up and down. If all three of them are at their grandparents’ house it is funny to see each of them choose their little route and run up and down with a look of complete concentration, or joy, on their faces. Only one of the three children is autistic and I wonder what it means about the possible genetic predisposition in our family to these behaviours. This is not copying behaviour but seems to be a shared trait. I ask my daughter what she’s thinking about when she has a stimming session and she usually says she’s having fun imagining a fantastic story or thought – it’s as if somehow, stimming helps her to process and think.

Similarly, both her father and I will pace around if we are talking to someone on the phone…luckily we were born in the time of cordless and mobile phones, as the old coiled wires would have limited us. Again, we find it easier to process our thoughts as we move and maybe this is what autistic children who exhibit repetitive behaviours do.

Notice if your toddler is beginning to display repetitive or compulsive behaviours, particularly if she gets very distressed when she is prevented from carrying out the behaviour.

All children have their own idiosyncrasies so it is not to say this is diagnostic in itself but may point to autism along with other behaviour.

Lack of reaction to their name

We are primed to notice and react to our name being called out. Chances are, if you hear your name called out or mentioned in a busy restaurant you will look up and try and spot the person who spoke – it’s called the ‘cocktail party effect.’

From about seven months, babies begin to respond and look up when their name is spoken. A lack of response to her name can be an early sign of autism. If there is a lack of reaction to your voice, particularly if you are out of your baby or toddler’s peripheral vision this can, of course, also be a sign of hearing problems so it may be important to have your toddler’s hearing tested in the first instance. However, if your baby or toddler seems to respond to noises but doesn’t react especially to her name discuss this with your GP or health visitor.

Poor eye contact

Films like Rain Man and Mercury Rising have meant that limited eye contact is probably one of the most well-known signs of autism. But why is a lack of eye contact such a key sign?

Some autistic children find direct eye contact overwhelming whereas others don’t respond as they don’t seem to recognise the important communication that goes on between two people making eye contact.

Eye contact and following eye direction is so important to human communication that some evolutionary biologists think it’s the reason that human beings (unlike other animals) have eye whites. With the evolution of the whites of eyes around our irises, we are able to accurately assess where another human being is looking from a considerable distance.

One of the most fascinating and enlightening things I have ever read about people with Asperger’s syndrome or autism was a study carried out by Ami Klin and recounted by Malcolm Gladwell in his book Blink. Klin invited autistic and Asperger’s adults to watch the film ‘Who’s Afraid of Virginia Woolf?’, a film full of double meanings and knowing looks.

This film was a complete mystery to Klin’s subjects because they were unable to understand all the subtext that we take for granted. Not only that, but they didn’t treat the human face as something special, something giving out vast amounts of information about the person.

When one very bright Asperger’s participant was monitored watching a particularly intense scene in the film, Gladwell reported that the man spent more time looking at the light switch in the scene than he did looking at the faces of Richard Burton and Elizabeth Taylor. He was ‘mind blind’ and could only process a literal understanding of words exchanged to understand a person’s internal feelings. Sarcasm or passive aggressiveness would be lost on him. Imagine trying to understand the complex world of human interaction if you were mind blind and unable to take on another person’s point of view.

Persistent lack of eye contact in your toddler can be a sign of autism, as eye contact is such a vital part of communication, and helps us comprehend other people’s feeling and motivations. Children on the autistic spectrum are more likely to look at moving objects, in fact, so while you’re working with your toddler and helping them register facial expressions, it can help to remove other distractions which take her attention away from you. Don’t try to talk to her with the television on in the background because she won’t respond. It can also help to have a series of preparatory signals before you speak to your toddler – say her name, then say ‘look’ and accompany the world look with a sign, e.g., index finger and middle finger pointing at each of your eyes.

Delayed physical development

Some autistic children also have delayed physical development. This is because autism is very often diagnosed alongside other conditions, such as dyslexia, dyspraxia, attention deficit hyperactivity disorder (ADHD) and learning disabilities.

It’s always worth speaking to your toddler’s doctor if you have noticed that your toddler was very late in her physical milestones as it may indicate an underlying problem (not just autism) and early intervention is always better. If there is no underlying problem your toddler will not be harmed by having a full assessment by your children development team. However, if they do find a problem there may be lots of interventions and treatments that can help your toddler – hearing problems manifest themselves in very similar behaviours to autistic behaviours. Your baby or toddler’s hearing is something that must be checked as early as possible as there are sensitive periods in babyhood and toddlerhood that are vital for full language development. For example, Chinese people cannot hear a difference between the English words ‘lice’ and ‘rice’ (which doesn’t matter at all if you are speaking Mandarin) simply because they didn’t hear those words as babies. Now the ‘language’ part of their brain doesn’t respond to the difference in the two sounds.

There are examples like this in all languages. We cannot hear the subtleties in the !Kung language because we haven’t heard their unique click language as babies. If you did bring up a white, European baby with the !Kung, they would be able to perceive all the different click sounds that are un-hearable to other people around the world and speak the language too.

Trust your instincts and don’t be falsely reassured

As parents we tend to worry about our toddlers on multiple levels. Understandably, friends and family try to put parents’ minds at ease with tales of late walkers, later talkers and personal theories about toddler development.

There is a very strong culture in parenting today (from parents, psychologists and extended family) of reassurance and acceptance of toddlers’ development and milestones. This relaxed environment helps save parents from worrying needlessly over minor differences in their toddler’s development.

However, false reassurance is ultimately not helpful to parents and certainly not to the toddler with autism. Early intervention can make a huge and positive difference to your toddler and your ability to relate to them and help them develop.

So if you really feel in your gut that there’s something troubling you about your toddler’s behaviour or development, even if you can’t quite put your finger on it, it’s worth talking to your doctor about it.

However, don’t be complacent as this culture of reassurance can extend into the health care professionals. It’s really hard to know what to do when an ‘expert’ dismisses your worries. Sadly ,this means that if you are concerned as a parent you need to educate yourself about normal development, normal language acquisition and normal behaviour so you can pinpoint the differences with your toddler.

It can feel counter-intuitive to question the information from an expert. However, parents often talk about their frustration when a health professional hasn’t listened to them. A good health professional will give weight to your concerns and listen to your information. The ultimate aim is to check – really check – that all is well. Good sources of support include expert charities, such as ICAN, which offers information, checklists and runs a helpline.

There are many amazing health care professionals working in our communities. Doctors and health visitors have good general knowledge but they may not have much specific experience with autism spectrum disorders. They should and can be your gateway to expert help for special needs.

It can seem really daunting to go down the route of having your precious child labelled as special needs or having an Education, Health and Care Plan (HEC). Again try to think of this as giving them a gateway to more help and support which will result in many of their special needs being met rather than glossed over.

How to get help for your toddler

Your toddler will already have had regular assessments in terms of their development and these should continue in the toddler years.

The first year

Between 9-12 months your doctor or health visitor will talk to you about your baby and assess her development. This is a good time to discuss any concerns you have and talk about any developmental milestones that are delayed or absent. Sometimes you will be given a development questionnaire to complete.

One to three years

At 30 months (around two and a half years) your doctor or health visitor should carry out another review of your toddler’s development (things can be a little different from local authority to local authority so make sure you are attending reviews and ask for a meeting if you want to discuss your toddler’s development and there is no assessment due). You can have quick discussions at your local well-baby clinic but it’s best to arrange a proper meeting if you want to discuss things in detail. Also, if your toddler attends a nursery her assessment might be done there along with her early years progress check at age two.

The review should include physical, cognitive, language and emotional/social development, including hearing, speech, social skills and behaviour.

The development review is partly designed to identify if your toddler may have an autistic spectrum disorder. If problems are identified then she can be referred to a pediatrician or your local Child Development Unit (CDU). The team of health professionals working in these centres have a wealth of experience in all kinds of development delays and problems and include pediatricians, educational psychologists and speech therapists.

It is the role of your toddler’s pediatrician or Child Development Unit to determine and coordinate the help you and our toddler will need.

You may be offered:

  • Toddler talk groups
  • Speech therapy training for parents
  • Special needs dentists (experienced with reluctant or frightened children)
  • Specialist assessment
  • Hearing tests
  • Individual speech therapy support
  • Play visitors.
Early Years Support Teacher

Once your toddler is under the care of your local CDU unit (or equivalent) you will be guided through the services she will need. You will also be given assistance with the paperwork for any financial support that your toddler qualifies for – this will be different from country to country so try to get information from your national ASD support groups. Importantly, your toddler will be partnered with an Early Years Support Teacher who will assist with the subsequent educational help she will need. This Early Years Support Teacher will work closely with your toddler’s nursery if they attend. Remember, in the UK, if your child does have identified special needs and attends a nursery then you will be able to consider a DCATCH (Disabled Children’s Access to Childcare) grant. This gives money to your nursery to provide one-to-one support for your toddler. My nephew was awarded full-time one-to-one support in the nursery. This revolutionised his enjoyment of the nursery and marked a real turning point for him.

Your Early Years Support Teacher will arrange a series of observations and these form the beginning of the Education and Health Care Plan (EHC) process for your child. If you begin this process before your child starts school then she can enter school with a support worker already in place.

In all cases, the sooner you act the better. It can seem that parents are asked to be experts in too many areas. A good rule of thumb is if you have concerns, then talk to your doctor. It is their job to correctly refer your child. Once she has been referred to appropriate services then you will be guided through the steps you need to take. There is a great deal of support out there, so there is never a need to struggle alone without support.

Parenting a child with special needs is demanding. Get support that is available to you. Your child will develop and you will celebrate each bit of progress. Last week we were cheering because my son’s autistic classmate had told her first lie. Theory of mind! The speed and direction of the development of a child with special needs will be individual as it should be for every child anyway.
Real mum story. Katie, mum to Ivan 4 years.

References and further reading

Baird, Charman, Baron-Cohen, Cox, Swettenham, Wheelwright & Drew (2000) ‘Screening Instrument for Autism at 18 Months of Age: A 6-Year Follow-up Study’ The American Academy of Child and Adolescent Psychiatry. Volume 39, Issue 6, Pages 694–702

Eckman (2006) ‘Darwin and Facial Expression: A Century of Research in Review. Academic Press

Klin et al (2002) ‘Visual Fixation Patterns During Viewing of Naturalistic Social Situations as Predictors of Social Competence in Individuals With Autism.’ Arch Gen Psychiatry 59(9):809-816

Malcolm Gladwell (2005) ‘Blink – The Art of Thinking Without Thinking.’ Penguin.

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This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Essential Parent has used all reasonable care in compiling the information from leading experts and institutions but makes no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details click here.