What are the early behavioural signs of autism?

Baby stare @ Paul Whiteley

"Autism is a developmental disorder presenting in early infancy". I think most people would agree with this statement; even those who know very little about autism and its intricacies. I can remember years ago using various videos (yes before DVDs et al there were videos) to demonstrate to groups of students how autism might manifest itself in young children and how presentation can differ from child to child depending on lots of different factors.

I struggle to remember the name of the particular program, but one video in particular gave a very personal, very moving account of a young girl with autism, showing home videos of the child growing up accompanied by a mum's description of her and the presentation of her autism. In one scene, the child is shown in her cot aged somewhere between 3 and 6 months old. It was always striking to me how 'detached' the child seemed even at that early age and based on just a few short minutes of commentary and pictures. The lack of eye contact pinpointing the potential for something in her future development.

Fast forward back to modern times (yes with DVDs and Blue-Ray and portable media) and an interesting paper by Barbaro & Dissanayake* brings me to this post looking at some of the various research done on potential early behavioural markers of autism spectrum conditions. I hasten to add that I have sort of touched upon this topic in a very early post on this blog (here) but consider this a bit of a more detailed update.

The Barbaro paper indeed highlights the lack of eye contact in their analysis of potential early markers of autism, alongside another important skill again already discussed on this blog, pointing. 

But what of the other research done in this area?

• As one might imagine, there is a considerable body of research examining potential early markers of autism. Some names pop up more consistently than others in this area of investigation, one of them being Dr Robyn Young. Dr Young's papers seem to confirm quite a few things that people have suspected for a while. So for example, parents of children with autism are pretty good at spotting when development is not quite as it should be**. Other papers have also said as much, bearing in mind that the experiences when communicating those concerns to certain healthcare professionals might not exactly be 'optimal' in some cases (see this post). 
• Using home videos as potential screening tools is another area where some important data have been collected. This paper by Dr Young and colleagues*** describes how even with a relatively small participant group, several discriminating features were apparent in pre-verbal children who went on to receive a diagnosis of autism including gaze aversion and issues with 'proto-declarative showing'. Notice again the emphasis on social communicative functions (as per the ADTree classifier work), bearing in mind that pointing generally comes a little later than eye contact in child development terms. Similar joint attention findings were also reported in this study by Watson and colleagues****.
• Another quite famous name in this area of research is that of Dr Sally Ozonoff (yes, she of the MIND Institute) and her observations down the years. In particular, her paper reviewing the potential usefulness of family home movies and the early development of autism***** deserves mention. 
• It is however when it comes to examining onset patterns in autism that Dr Ozonoff really comes into her own as per this paper****** (full-text) describing the dimensionality of onset patterns over dichotomous categories.  Again, parents are seen as key partners in 'predicting' autism (see this paper******* full-text). Interestingly, Dr Ozonoff in quite a few of her papers makes mention of the fact that her data does not seem to suggest that symptoms are present at birth as was suggested by Kanner, but rather emerge over time and show a regressive or diminishing factor. A good example is in this study******** (full-text) which prospectively looked at the early signs of autism and suggested that the period between 6 and 12 months seems to be an important one; again re-emphasising the social-communicative features to be paramount. 
• I should also make reference to this paper by Turner-Brown and colleagues********* which has received some publicity on the First Year Inventory for screening at 12 months of age, just to keep up to date.

I admit that I've only really scratched the surface with this post and indeed only paid lip-service to important concepts like regression; aspects of which have been covered in other posts (see here). I would perhaps refer to an additional reference on the topic of regression and onset patterns with a link to this paper by Cohen-Ophir and colleagues********** (full-text). They reported on three case studies charting a slightly different progression into autism outside of the categorisations of (a) slow / subtle regression and/or (b) rapid regression (or indeed (c) the delays + regression phenotype) suggestive of initial developmental delay, a period of rescuing skills falling into typical development, followed by regression into classic autism. 

There are also a few other areas of potential interest to the issue of early behavioural presentation neatly summed in this paper by Clifford and colleagues************ on temperament in high risk infants and this paper by Flanagan and colleagues************ on head lag (I know this is more presentation rather than behavioural).

So to answer the question to the title of this post, what are the early behavioural signs of autism? It seems that social-communicative factors such as issues with eye contact and later pointing might be possible red flags, but also realising that the heterogeneity noted in the presentation of autism to some degree also mirrors onset patterns and the presentation of early behaviours. 

----------

* Barbaro J. & Dissanayake C. Early markers of autism spectrum disorders in infants and toddlers prospectively identified in the Social Attention and Communication Study. Autism. June 2012.

** Young RL. et al. Parental identification of early behavioural abnormalities in children with autistic disorder. Autism. 2003; 7: 125-143.

*** Clifford S. et al. Assessing the early characteristics of autistic disorder using video analysis. JADD. 2007; 37: 301-313.

**** Watson LR. et al. Communicative gesture use in infants with and without autism: a retrospective home video study. American Journal of Speech-Language Pathology. July 2012.

***** Palomo R. et al. Autism and family home movies: a comprehensive review. Journal of Developmental & Behavioral Pediatrics. 2006; 27: S50-S68.

****** Ozonoff S. et al. The onset of autism: patterns of symptom emergence in the first years of life. Autism Research. 2008; 1: 320-328.

******* Ozonoff S. et al. How early do parent concerns predict later autism diagnosis? Journal of Developmental & Behavioral Pediatrics. 2009; 30: 367-375.

******** Ozonoff S. et al. A prospective study of the emergence of early behavioral signs of autism. Journal of the American Academy of Child & Adolescent Psychiatry. 2010; 49: 256-266.

********* Turner-Brown LM. et al. The First Year Inventory: a longitudinal follow-up of 12-month-old to 3-year-old children. Autism. July 2012.

********** Cohen-Ophir M. et al. Autism in early childhood: an unusual developmental course - three case reports. Case Reports in Psychiatry. 2012.
DOI: 10.1155/2012/946109

*********** Clifford SM. et al. Temperament in the first 2 years of life in infants at high-risk for autism spectrum disorders. JADD. August 2012.

************ Flanagan JE. et al. Head lag in infants at risk for autism: a preliminary study. American Journal of Occupational Therapy. 2012; 66: 577-585.

---------

Barbaro J, & Dissanayake C (2012). Early markers of autism spectrum disorders in infants and toddlers prospectively identified in the Social Attention and Communication Study. Autism : the international journal of research and practice PMID: 22735682