Is My Child Autistic? Missed Milestones That Matter

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An interview with Dr. Elizabeth Borges Harstad

I used to panic when I called and my very verbal toddler did not respond. His hearing was fine. Was he ignoring me or was he just spacey? At four, he preferred to play alone. Did that mean he’d missed a developmental milestone or was he just was shy? His preschool director expressed concerns about delayed social skills and dropped autism as a possible explanation. After a year of appointments with various specialists, a developmental clinic concluded he was not on the spectrum. Through that grueling process, I experienced how tough it can be for lay parents to identify whether their child has a developmental delay and also how daunting it is to face the reality that your child might have a spectrum disorder. I asked Dr. Elizabeth Harstad, a developmental pediatrician at Boston Children’s Hospital, to offer some guidance for parents who may be experiencing this difficult moment. — Alejandra Nathan, TMC Contributor

At what age does autism become apparent in children? What are the early warning signs I should look for if I suspect my child is on the autism spectrum?

Although the average age at which a child is diagnosed with an autism spectrum disorder in the United States is around four years old, most parents who ultimately get a diagnosis report have had concerns about their child’s development or behavior by the time the child is just 18 months old. It is important for parents to know the early warning signs of an autism spectrum disorder and to seek medical evaluation if they have concerns about their child’s development or behavior.

Early warning signs for an autism spectrum disorder include:

  • By nine months, child does not babble or make sounds back-and-forth with you
  • By one year, child does not respond to his/her name being called
  • By one year, child does not point to objects
  • Child avoids making eye contact
  • Child moves his/her body in repetitive ways, e.g., hand flapping or body rocking
  • Child demonstrates a delay in language or child who can speak does not attempt to use language to communicate
  • Child has any developmental regression or loss of skill

Autism spectrum disorders are characterized by deficits in social skills and communication, and restricted, repetitive behaviors or interests. Therefore parents should pay attention to their child’s social and language skills as well as their child’s play skills and body movements.

What are appropriate play and language skills my child should be demonstrating by three, four, and five?

The following is a list of appropriate play and language skills that a child is expected to develop by each of the following ages:

Age at which skills are expected Play and social Skills Language skills
At 3 years of age
  • Pretends to play different characters with you or talk for dolls or figurines
  • Can take turns in games
  • Enjoys playing with and imitating other children
  • Speaks three-word sentences and can use some pronouns
  • Follows a two-part command
  • Understands most sentences
At 4 years of age
  • Engages in fantasy play
  • Plays simple games that involve turn taking
  • Would rather play with other children than by himself
  • Speaks in five- to six- word sentences
  • Can name friends when asked
  • Answers “wh” questions (when, what, who, where)
At 5 years of age
  • Wants to please friends
  • Shows concern and sympathy for others
  • Can distinguish reality from fantasy
  • Can tell a simple story using full sentences
  • Speaks very clearly
  • Uses future tense

When is the right time to seek an assessment and what practitioners should be involved?

The right time to seek an assessment is any time that you have significant concerns about your child’s development or behavior. You may have concerns because your child is not achieving developmental milestones as you expect he/she should. If your child loses skills he/she used to have (e.g., stops using words to communicate after he/she has learned how to talk), you should see your health care provider immediately for further input and assessment.

If you have concerns in between regularly scheduled check-up times, you should make an appointment with your child’s regular health care provider specifically to discuss the concerns. Your child’s health care provider can often ask follow up questions and then help refer the child for further evaluation if that is deemed necessary. If your child is referred for further evaluation there are several different types of providers who may be able to conduct the assessment, including developmental behavioral pediatricians, child psychologists, pediatric neurologists, or psychiatrists.

Do you have pointers for parents who are in the process of figuring out whether their child is on the spectrum? And what about after their child has gotten a diagnosis of autism spectrum disorder?

Having concerns about your child’s development or behavior can be very stressful. Some parents may be scared to seek input from their child’s health care provider for fear of what they may find. However, it is important to remember that early detection of a developmental problem and intervention for that problem will likely help to improve a child’s developmental trajectory.

It is important to take action if you have concerns about your child’s development or behavior. Take action by having your child evaluated by his/her health care provider and following through on any recommendations for further assessment. Take action by educating yourself about child development and developmental conditions, such as autism spectrum disorders.

The following websites can be helpful resources to families who are in the process of figuring out whether their child is on the spectrum: the CDC’s “Detect Autism Early,” Healthy Children’s “Early Signs of Autism Spectrum Disorder,” and First Signs.

When a child is given a diagnosis of an autism spectrum disorder, parents often experience a range of emotions, including disbelief, confusion, sadness and fear. They may feel overwhelmed or some feel relief at finally knowing what is going on with their child. It is normal for parents to experience a range of emotions. However, all parents want to know what to do next to help their child, and it is important to focus on taking action once your child is given a diagnosis of an autism spectrum disorder.

It may feel overwhelming trying to figure out the best way to seek intervention for your child. Although you may hear about many different types of intervention (including special diets, correction of vitamin or mineral deficiencies, chelation, treatment with vitamins or over the counter supplements), research studies show that behavioral interventions for autism spectrum disorders can improve functional outcomes for many children, and the earlier the intervention is started, the better. The interventions for autism spectrum disorders that have the most evidence of being effective are intensive behavioral interventions, such as Applied Behavioral Analysis (ABA). There are many other types of behavioral interventions that are often recommended, including the Treatment and Education of Autistic and Related Communication-Handicapped Children (TEACCH) program, Floortime intervention, and the Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Model, among others.

Behavioral intervention programs may be implemented through Early Intervention services for children less than 3 years of age or through school programming for older children. And private therapies may be implemented as well. All behavioral intervention programs should have a low student-teacher ratio and should be provided intensively year round. Speech therapy and social skills groups are often supplements to the behavioral interventions mentioned above. Each child’s specific intervention plan should be tailored to address his/her own strengths and weaknesses with the goals of improving skills in the areas of social skills, communication, and play behaviors, and decreasing repetitive and maladaptive behaviors.

For parents who are looking for more detailed resources to better understand autism spectrum disorders and recommended interventions, the following books may be helpful:

A Practical Guide to Autism: What Every Parent, Family Member, and Teacher Needs to Know” by Fred R.Volkmar and Lisa A. Wiesner

Autism Spectrum Disorders: What Every Parent Needs to Know” by American Academy of Pediatrics, editors Alan I. Rosenblatt, MD, FAAP and Paul S. Carbone, MD, FAAP

What advice, reminders, or encouragement would you offer to parents who are in the midst of this difficult moment with a child?

First, any parent who is reading this is already taking action to learn more about autism spectrum disorders, which is exactly what concerned parents should be doing. You are not alone. In recent years, the number of children diagnosed with autism spectrum disorders has increased, which may be in part due to increased awareness about the condition. Each year more research is under way to better understand the causes of autism and the most helpful intervention strategies. The earlier an autism spectrum disorder is identified, the earlier targeted intervention strategies can be implemented to improve a child’s functioning.

You are, and will continue to be, your child’s biggest advocate. Allow yourself some “me” time, because caring for a child with special needs is challenging and you deserve some time to re-charge, which will help you to be the best parent you can be. Align yourself with a team of people who can help support your child’s development. This can include your child’s health care providers, teachers, and therapists. By intervening early and working with professionals to closely follow your child’s progress, you can help your child reach his/her full potential.

Elizabeth Borges Harstad, MD, MPH is a physician at Boston Children’s Hospital. She specializes in developmental and behavioral pediatrics, autism spectrum disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), and learning disorders. She is co-author of a case study curriculum for the Centers for Disease Control and Prevention (CDC) called “Early Warning Signs of Autism Spectrum Disorders” which is used to train pediatric residents to identify early signs of autism spectrum disorder.

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