According to a 2012 National Center for Health Statistics data brief, about half of all children in the United States with an autistic spectrum disorder are diagnosed at age five or older However, many parents are suspicious much sooner. As part of autism awareness month, we bring you clues in toddler development that can alert you to a potential issue. This post follows up on our earlier post “How can I tell if my baby has autism?“
Pediatricians often use a questionnaire called the M-CHAT (Modified Checklist for Autism in Toddlers) as a screening tool. This test can be downloaded for free. In our office we administer the M-CHAT at the 18-month well child visit and again at the two-year well visit, but the test is valid down to 16 months and in kids as old as 30 months. Not every child who fails this test has autism, but the screening helps us to identify which child needs further evaluation.
At 15-18 months of age, children should show the beginnings of pretend play. For example, if you give your child a toy car, the toddler should pretend to drive the car on a road, make appropriate car noises, or maybe even narrate the action: “Up, up, up, down, down, rrrroooom!” Younger babies mouth the car, spin the wheels, hold it in different positions, or drag a car upside down, but by 18 months, they perceive a car is a car and make it act accordingly. Other examples of pretend play are when a toddler uses an empty spoon and pretends to feed his dad, or takes the T.V. remote and then holds it like a phone and says “hello?” You may also see him take a baby doll, tuck baby into bed, and cover her with a blanket.
Eye contact in American culture is a sign that the child is paying attention and engaged with another person. Lack of eye contact or lack of “checking in” with parents and other caregivers can be a sign of delayed social development.
Kids periodically try to get their parents to pay attention to what they are doing. Lack of enticing a parent into play or lack of interest in what parents or other children are up to by this age is a sign of delayed social development. Ask yourself, “Does my child bring me things? Does he show me things?” Also, although they may not share or take turns, toddlers should still be interested in other children.
Many typical two-year-olds like to line things up. They will line up cars, stuffed animals, shapes from a shape sorter, or books. The difference between a typically-developing two-year-old and one that might have autism is that the typically-developing child will not line things up the exact same way every time. It’s fine to hand your child car after car as he contently lines them up, but I worry about the toddler who has a tantrum if you switch the blue for the green car in the lineup.
Two-year-olds should speak in 2-3 word sentences or phrases that communicate their needs. Autism is a communication disorder, and since speech is the primary means to communicate, delayed speech may signal autism. Even children with hearing issues who are speech-delayed should still use vocal utterances and gestures or formal sign language to communicate.
Atypically terrible “terrible twos.” Having a sensory threshold above or below what you expect may be a sign of autism. While an over-tired toddler is prone to meltdowns and screaming, parents can often tell what triggered the meltdown. For example, my oldest, at this age, used to have a tantrum every time the butter melted on his still-warm waffle. Yes, it seemed a ridiculous reason to scream, but I could still follow his logic. Autistic children are prone to screaming rages beyond what seems reasonable or logical. Look also for the child who does not startle at loud noises, or withdraws from physical contact because it is overstimulating.
By three years, children make friends with children their own age. They are past the “mine” phase and enjoy playing, negotiating, competing, and sharing with other three-year-olds. Not every three year old has to be a social butterfly but he should have at least one “best buddy.”
Regression of skills at any age is a great concern. Parents should alert their child’s pediatrician if their child stops talking, stops communicating, or stops interacting normally with family or friends.
It’ s okay to compare. Comparing your child to other same-age children may alert you to delays. For example, I had parents of twins raise concerns because one twin developed communication skills at a different pace than the other twin.
Although you may wonder if your child has autism, there are other diagnoses to consider. For instance, children need all of their senses intact in order to communicate well. I had a patient who seemed quite delayed, and it turned out that his vision was terrible. He never complained about not seeing well because he didn’t know any other way of seeing. After my patient was fitted with strong glasses at the age of three, his development accelerated dramatically. The same occurs for children with hearing loss—you can’t learn to talk if you can’t hear the sounds that you need to mimic, and you can’t react properly to others if you can’t hear them.
If you or your pediatrician suspect your child has autism, early, intensive special instruction, even before a diagnosis is finalized, is important. Every state in the United States has Early Intervention services that are parent-prompted and free for kids. The sooner your child starts to works on alternate means of communication, the quicker the frustration in families dissipates and the more likely your child is to ultimately develop language and social skills. Do not be afraid of looking for a diagnosis. He will be the same child you love regardless of a diagnosis. The only difference is that he will receive the interventions he needs.
Julie Kardos, MD and Naline Lai, MD
©2018, 2013 Two Peds in a Pod®