Expert: James Michael Roan - 8/3/2008

Question
Hello.

I'm making myself crazy thinking about whether our 9 month old son has autism or another diagnosis fitting with ASD.  I just want to be able to help him as soon as possible if he needs it.  This is our first child and I feel like my fears are definitely rooted in real obersvances but wonder if I'm overracting.  My husband thinks he may be "delayed" and friends think he's "serious" but perfectly normal like both of his parents.  

This will be a little lengthy with the list of my concerns.

1.  His head was really small at birth but has grown at a very rapid rate.  He was born at 36 and 1/2 weeks but did not grow the last 10 days.  At birth head circumfrance 31 cm; 39 at 9 weeks and now 46 and 1/2 at 9 months.

2.  Many of his social skills seem to be delayed.  Did not really smile until 10 - 12 weeks and even at that point it was very difficult to get a smile until about 4 months.

3.  Does engage in eye contact - particularly with strangers - and also with us but seems to avert his gaze rather quickly when playing.  One friend with a background in early childhood development characterized it as "uncomfortable with the face to face".  In retrospect I feel like we might have spent a lot of our time playing with him from behind rather than face to face in the early months.  Could this be contributing?

4.  Does not respond to name.  It seems that he turns his head to us when we say his name from afar and/or walk into the room but does not when we are near him.  Also, does not imitate sounds though he does babble a lot.  He makes several consonant sounds and strings two together like ba-ba, da-da.  Recently he's started doing a lot more aye yi yi than consonants.  He doesn't seem to recognize a lot of words but he will "turn the page" when reading a book and seems to respond to no.  

5.  He hates to go to sleep and will sometimes buck wildly when being held before bed.  To be fair, this seems to be more from overtiredness than anything else.  Many times he's just fine being rocked.  In fact, he likes to be held a lot.  In his most recent childcare setting, he cried or fussed all the time and quieted immediately upon being held.  We hold him quite frequently at home but he's also more comfortable being on the ground playing with us.

5.  Does not seem particularly social with other babies.  He was with a very loud and active 3 year old and 1 year old.  The provider described him as not knowing what to do with them and wanting to play by himself next to her.  We were recently with a friend's children (3 and 18 months) and he seem very interested in them staring at them and such and would smile occasionaly and take toys from them but as they got louder and more in his face he got really upset and cried.  He responds very well to men and older children.

6.  He doesn't wave.  He doesn't point at things but seems to look in the direction I point.  Can't tell if he's looking at my hand or what I'm pointing at.  He also is more likely to grab my hand and move it than look at me if he does or doesn't want something. He does lift his arms to be picked up and he will take nearly anything you offer him.  Occasionally, he will offer something he is playing with to you or the dog but it is rare and somewhat recent.

7.  For the past two weeks, I have been trying to give him more solids (cut fruit, meat, etc.) but everything except crunchy things make him gag and try to throw up.

8.  Most of our friends say his is "really interactive" but I don't really feel that way at home.  He does smile many times when we do and he laughs occasionaly but it doesn't happen super often.  About 1/3 of the time he laughs we have no idea what he's laughing at.  He does play peekaboo but you really have to hide (like below the bed or behind the corner).  He just looks away if you put the cloth or blanket over your head.  I don't think he initiates this game but if he does something like tickle my toe and I laugh, he will do it again and again.  I'm assuming that is what is meant by initiating?

Lastly, he seems to be right on in all of his physical stuff.  He can sit up (6 months) and get himself into a sit from his stomach (8 months).  He can roll both directions but doesn't seem to find a need to.  He's not pulled up yet but started crawling about a week ago.  He can grasp things with thumb and fingers but doesn't do that frequently.

I'm sorry this is so long.  In a way I feel like my fears are based on a lot of little things and the feeling that he is different so I included what I could think of.  We just had our 9 month appt. and the doctor said he would characterize our baby as a normally developing 9 month old with some deviations that we need to keep an eye on.  He said he wouldn't give us a referral because there weren't serious enough delays for state assessment.  Should we try to refer ourselves?  If there is reason for concern then how do we "make" them take us for a referral.  Thank you so much.  I've been making myself sick with this.

Answer
Hi Barbara;

I assume you live in the UK? I'm not sure how to make them refer you for assessment, however, if you come armed with defensible data they will, most likely, refer to cover their backs.

I do see some areas for concern, so I'm going to send you in this email a lot of data. The last narrative is quoted from this spring's issue of a journal article. If you want the whole article (you should so you can print highlight and give to pediatrician) then email me at: roanpsych@gmail.com

First, some comments. Pointing comes on around at 12-15 months as do gestures like waving, etc.

Possible symptoms at 6 -12 months:

-Not making eye contact with parents during interaction
-Not cooing or babbling
-Not smiling when parents smile
-Not participating in vocal turn-taking (baby makes a sound, adult makes a sound, and so forth)
-Not responding to peek-a-boo game -Passivity and decreased activity
-Extreme distress reactions
-Fixation on objects



Here are selected excerpts from the article:
Source: Crane, Jennifer L., Winsler, Adam. Early Autism Detection: Implications for Pediatric Practice and Public Policy, Journal of Disability Policy Studies 2008 18: 245-253

A typically developing infant begins to vocalize in a social manner as early as 2 months of age (Werner, Dawson, Osterling, & Dinno, 2000). During the second 6 months of life, typically developing infants begin to exhibit a greater amount of social babbling, such as verbal turn taking, and nonverbal behaviors, such as pointing at objects. Infants seek attention from others in social
situations through imitative vocalizations, directing the attention of others through nonverbal behavior (pointing), greeting others, and requesting objects. Infants and toddlers later diagnosed with ASD have been shown to lack many of these typical behaviors through both retrospective video analysis and parental report (Baranek, 1999; Watson et al., 2003). The AAP (2001b)
states that parents report noticing differences in their child’s social behavior around 7 months of age, on average. Parental concern about early cognitive or language development often predicts a later diagnosis of an ASD (AAP, 2001b). The problem with retrospective parental report is that memories are affected by the stress of raising a child with ASD and what they remember may be
incorrect or exaggerated, so these reports are limited for use in empirical research (Watson et al., 2003).

This research highlights a constellation of infant behaviors that are indicative of later ASD diagnosis (Volkmar, 1999; Werner et al., 2000). Table 1 outlines a number of studies using retrospective video analysis and specific behaviors found to be significantly different for infants later diagnosed with ASD. This constellation of behaviors includes impairments in social attention (eye contact, responding when called by name), affective responsiveness (social smiling), and prelinguistic vocalizations. The constellation of behaviors associated with later diagnosis of ASD can be outlined as follows: Infants later diagnosed with ASD often fail to respond to their names, fail to orient toward people, and show less verbal and nonverbal communicative behaviors. The
DSM–IV states that children with autistic disorder must have qualitative impairments in social interaction; qualitative impairments in communication; and restricted repetitive and stereotyped patterns of behavior, interests, and activities (American Psychiatric Association, 1994). Although it may be difficult to observe an infant or toddler having restricted interests and stereotyped behavior, the first two of these criteria have been identified through specific behavioral deficits in infants younger than 12 months of age. An infant who ignores parental attention, who does not watch the parent for social cues, and who does not respond to his or her name likely has measurable difficulties in communication and socialization characterized by ASD and outlined in the DSM–IV. The DSM–IV criteria for diagnosis of ASD can be relevant for use in infants and toddlers if clear and concise definitions of infant and toddler behaviors related to DSM–IV criteria are developed for use by practitioners.

Finally, recent research has found that observed behavioral changes in children later diagnosed with ASD are preceded by abnormal cranial growth. First, many ASD infants are born with relatively small heads followed by a sudden, excessive increase in head size between the ages of 2 months and 14 months (Courchesne et al., 2003). Courchesne et al. state that this type of sudden acceleration in rate of head growth can also serve as an early sign of ASD. The compelling evidence discussed here indicating biological markers for ASD suggests that brain morphological variables could be used effectively as part of an overall screening program for ASD.

Table 1
Infant Behaviors Related to Autistic Spectrum Disorders Identified by Retrospective Video Analysis:


Study: Maestro et al. (2002)   
Age of Children: 6 months or younger      
Behaviors: Poor social attention, failing to seek contact, excessive
exploratory activity with objects

Study: Baranek (1999)   
Age of Children: 9–12 months   
Behaviors: Poor visual orientation, delayed response to name, excessive mouthing of objects

Study: Adrien et al. (1991, 1993)   
Age of Children: Younger than 12 months   
Behaviors: Paradoxical reactions to sounds, poor social attention, lack of social smiling, hypotonia (low muscle tone),extremely quiet

Study: Osterling and Dawson (1994)   
Age of Children: First birthday party   
Behaviors: Failing to orient to name, not looking at the face of another person, no pointing at objects

Study: Osterling, Dawson, and Munson (2002)   
Age of Children: First birthday party   
Behaviors: Failing to orient to name, no looking at the face of
another person

Study: Rosenthal, Massie, and Wulff (1980)   
Age of Children: 13–24 months   
Behaviors: Lack of shared interaction with mother

Study: Losche (1990)   
Age of Children: 13–24 months   
Low frequency of social interactions, no symbolic play or goal-directed actions



Kind regards,
James