Autism can present in a number of ways across a continuum of severity – so is referred to as a ‘spectrum’.  There are a number of different diagnoses given, including – ‘autism’, ‘infantile autism’, ‘Kanner’s autism’, ‘autistic spectrum disorder’, ‘classic autism’.  For children who don’t fit exactly into the criteria for autism, ‘autistic traits’, ‘PDD-NOS’ (Pervasive developmental delay – not otherwise specified) are sometimes used.  For children on the spectrum who fit the criteria and still function well in neuro-typical settings, ‘higher functioning autism’ is used, and ‘Aspergers Syndrome’ is typically considered to be part of the same continuum.  More recently it has been argued that ADD and ADHD should also be included as part of the autistic spectrum.

To be diagnosed with autism, children will need to show evidence of the ‘Triad of Impairments’: 

The impairment of communication may show itself in some or all of the following ways:

• Delayed or complete lack of development of spoken language, with no alternative means of communication automatically developed to compensate
• There may be difficulty in initiating or sustaining a two-way conversation. You can often get the impression that the child is talking ‘at you’ rather than ‘to you’
• A stereotyped and repetitive use of language, often centering around the child's special interest
• The child may be able to ask for their own needs but does not understand that words can be used to convey emotional and social information
• Poor comprehension of non verbal communication – not understanding body language or facial expressions, for example
• Literal understanding of words; no understanding of irony or sarcasm
• Pedantic speech – an emphasis on factual correctness, for example, possibly also delivered in a monotone
• Pronoun reversal (for example getting terms such as 'me' 'you' and 'them' confused)
• Make factual comments often irrelevant to situation
• Impairment affects both expressive and receptive language (ie not always understanding what they say or what they hear or read)
• Poor control of pitch, tone and intonation.

The impairment of social interaction may show itself in some or all of the following ways:

• Impaired use and understanding of non verbal behaviours, for example of eye contact, facial expression and body postures
• Difficulty developing peer relationships
• Lack of spontaneous seeking to share enjoyment, for example pointing
• Lack of social or emotional reciprocity – not understanding others’ thoughts and feelings
• Difficulty relating to others
• Any interaction is often very one-sided.

There appears to be three main types of impairment in social interaction in children with autism. These are as follows:

• The 'aloof' child who may appear rather withdrawn and indifferent to other people, and may be difficult to comfort when distressed
• The 'passive' child who will not make spontaneous approaches to other people but will accept contact if initiated by others
• The 'active but odd' child who will approach other children spontaneously but this will often be in an odd or inappropriate manner. Often they may pay little attention to the responses of those they have approached.

- Children can move from one interaction style to another as they develop.

The impairment of social imagination may show itself in some or all of the following ways:

• Inability to play imaginatively with objects, toys or other people
• Tendency to select for attention minor aspects of things in the environment instead of an understanding of the whole picture. For example focusing on the wheel of a car instead of the whole vehicle.
• Difficulty empathising with other people or seeing another point of view.
• Repetitive and stereotyped activities. These can take many different forms. From a very simple repetitive body movement, for example flicking fingers, to an intense attachment to certain objects, to a fascination with certain topics such as 'Star Wars', train timetables, dates and astronomy.
• Children with autism can be extremely rigid in their thinking and can have great difficulty coping with any change. They may insist on certain things being the same, for example people sitting in the same places at the dinner table or in the car, or going the same route to places.

It is harder to detect autism in very young children, but these are some things to look out for if you are concerned:

1) Does the baby respond to his or her name when called by the caregiver? Within the first few months of life, babies respond to their own name by orienting toward the person who called them. Typically babies are very responsive to the voices of familiar people, and often respond with smiles and looks.  Infants later diagnosed with autism often fail to respond to their own name most of the time. They also are often selectively responsive to sounds. They may ignore some sounds and respond to others that are of the same loudness. They may fail to respond to their parent calling their name, but immediately respond to the television being turned on. It is not unusual for parents to suspect their child has a hearing loss.

2) Does the young child engage in "joint attention"? Near the end of the first year of life, most infants begin to join with their caregivers in looking at the same object or event. To aid in this process of "joint attention", typical infants begin to shift their gaze from toys to people, follow other's points, monitor the gaze of others, point to objects or events to share interest, and show toys to others.   Young children with autism have particular difficulties in jointly attending with others. They rarely follow another's points, do not often shift their gaze back and forth from objects to people, and do not seem to share "being with" the caregiver as they watch and talk about objects, people, or events. They also tend not to "show" a toy to the parent.

3) Does the child imitate others? Typical infants are mimics. Very young infants can imitate facial movements (e.g., sticking out their tongue). As early as 8-10 months, mothers and infants say the same sounds one after another, or clap or make other movements. Indeed, imitation is a major part of such common infant games as pat-a-cake.  Young children with autism, however show less imitation of body and facial movements and less imitation with objects.

4) Does the child respond emotionally to others? Typical infants are socially responsive to others. They smile when others smile at them, and they initiate smiles and laughs when playing with toys and others. When typical infants observe another child crying, they may cry themselves, or looked concerned. Somewhat older infants may crawl near the person, pat, or in other ways offer comfort. These latter behaviors are suggestive of empathy and are commonly observed among children in the second year of life.  In contrast, children with autism may seem unaware of the emotions of others. They may not take notice of the social smiles of others, and thus may not look and smile in response to other's smiles. They also may ignore the distress of others.

5) Does the baby engage in pretend play? Although children start to play with toys around six months, play does not take on a pretend quality until the end of the first year. Their first actions may involve pretending to feed a doll or brush the doll's hair. Nearer their second birthday, children engage in truly imaginative play as dolls may take on human qualities - talking or engaging in household routines.  In contrast, the child with autism may not be interested in objects at all, paying more attention to the movement of his hands, or a piece of string. If interested in toys, only certain ones may catch his interest, and these may be used in a repetitive way. They may be more interested in turning a toy car upside down and spinning the wheels than pushing the car back and forth. Generally, pretend qualities are nearly absent in the play of children with autism under 2 years of age.

Concerns in any of the above areas should prompt a parent to investigate screening their child for autism – ask to see a Paediatrician or visit a child development centre and don’t take no for an answer from a GP, Health Visitor or anyone who does not have direct experience with autistic children. 

Again, on the NAS website there is such good information, it seems senseless for me to attempt to reproduce it – there is a good article by Judith Gould - www.nas.org.uk Search under ‘Information for GP’s’ for a concise article, and then around the site if you want more general information.  Some parents I've met are unhappy with the ‘establishment’ views of the NAS.  However, it is the best source of general information to begin with, and the PARIS database has been very useful to me too (linked from the NAS site).   There are some other sites with general information on the links pages of this website.

Health Professionals often use diagnostic tools such as the CHAT questionnaire – if possible download and print a copy, and make notes against it – this will help you gather together the information to discuss with your Paediatrician or other health professionals – so much of what I was concerned about in the early days didn’t really sound important, but all the little pieces put together and logged were more convincing.  See the NAS website for more information about the CHAT questionnaire.

www.nas.org.uk search for ‘Checklist for Autism in Toddlers (CHAT)’

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