Early Signs of Autism in Infants - Literature review Example

Early Signs of Autism in Infants Loyola Marymount Mudhawi Alshaalan Dr. Ani Shabazian EDES5401:Infancy Fall The cases ofautism have increased in the recent years, even as options for diagnosis and management for the disorder have also increased. Among infants, detecting this disorder can be difficult because it is difficult to differentiate mere developmental delays from autism symptoms during infancy. Nevertheless, parents of infants later diagnosed with autism commonly mention the presence of delays in speech and in gesturing, including pointing and interacting socially with other people as signs shown by their infants during their early years. Motor delays and issues in play and interaction with other children were also considered early signs of autism. Less babbling was also noted as one of the signs. In some cases, regression was also observed for some infants where some developments were seen in the child’s development. There is a need to evaluate these early signs further in order to ensure early detection of autism as well as early interventions for the disorder. Early Signs of Autism in Infants Introduction The increasing prevalence of Autism Spectrum Disorders (ASD) has risen in the past few years and based on 2006 reports from the Centers for Disease Control (CDC), in the US alone, 5.5 to 5.7 children would likely be diagnosed with ASD. Reasons for such increase mostly relate to increased awareness of ASD and the expansion of the diagnostic determinants for ASD which have led to better diagnosis of the disease (National Research Council, 2001). Moreover, children under the Individuals with Disabilities Education Act (IDEA) have also seen an increase across different states (IDEA, 2004). Also, the prevalence of this disease in Europe has also increased, most likely due to the better monitoring in these countries of child development. It is therefore important to consider what the early signs are in diagnosing autism among infants. An assessment of various studies shall be presented in this article, indicating contrasting opinions on diagnosis as well as the current accepted practices and beliefs in diagnosing this disease. Body Autism, background Autism was initially considered an inborn disorder of affective contact by Kanner (1943), but information gained on autism has since progressed and expanded to cover a more encompassing definition. Kanner’s (1943) original concepts highlighted the fact that children with autism are born without social tendencies. While his understanding of the disease is somewhat accurate it was later modified with the advent of more clinical experiences and studies. For instance, Kanner (1943) used to think that children with autism were of normal intelligence, however it is very much apparent that while significantly uneven profile of abilities have been observed, most individuals with autism function within the intellectually deficient range. Kanner’s (1943) observation of children with autism not manifesting other medical issues was also changed especially as there was a high risk for seizures observed among autistic children (Volkmar & Nelson 1990). It also became apparent that autism is genetically based, with siblings at a 20 to 50 higher risk in also being autistic (Volkmar, Chawarska, & Klin, 2005). The understanding of autism has evolved with time and Kanner (1943) highlighted two qualities – autistic children have unusual behaviors which were qualified to refer to resistance to change or insistence of sameness. As such, these children find difficulties adjusting to change. In 1980, autism was officially recognized as a disorder and qualified as a Pervasive Developmental Disorder (Volkmar, et al., 2005). The acceptance of this condition as a disorder took a while because of controversies in the recognition of its symptoms as tantamount to a disorder. Signs noted by parents Parents indicate an age range where they often express concern about their child’s development, with 90% of these parents recognizing some abnormality in their child by the time the latter is at 24 months (De Giacomo & Fombonne, 1998). Delays in speech and concerns about their child’s hearing are often observed, other concerns include the fact that their child may be ‘too good’ or is very irritable (Stone & Lemanek, 1990). However, specifically associating these symptoms with autism is still an unclear process. Available data so far focus on parental reports. More prospective studies are needed, and still the understanding of the data is very much complicated due to the glaring pace of change and the different meanings taken from the presence of autism-related behavior within specific time periods (Lord, 1995). For instance, the pre-intended use of gestures including the reach-and-grasp gestures in trying to get some object is often apparent before 9 months of age, however, it also usually becomes associated with eye contact and implies intentional communication (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979). Following the first year of development, there would now be gaps in the expected gestures including nodding or pointing which would also be a cause for concern. What makes the diagnostic process even more complicated is the fact that early symptoms usually change with time (Lord, 1995). Finally, with the impact of specific situations, changes, new developments, demands of activities, and changes in the environment, there may be a variability in the child’s presentation, mostly in infants and young children (Volkmar, et.al., 2005). Incidents of regression can also be problematic for the child (Rogers & DiLalla, 1990). Other terminologies are also associated with regression, including setback autism and developmental stagnation. These terms cover various elements of the actual phenomenon, where the disorder development in some children may be more gradual or may imply a rapid loss of language or social interactions (Kobayashi & Murata, 1998). In other instances, the issue mostly relates to the failure to make progress (Sipersein & Volkmar, 2004). In other rare instances, the child’s symptoms may progress normally for about three to four years where normal language is observed, including self-care ability, and then gradually these abilities are lost, with classic signs of autism often emerging. Childhood integrative disorder is often applied in these cases, with available indicating unfavorable outcomes when compared to the usual type of autism (Volkmar & Rutter, 1995). The link between these subtypes and their applicability as clinical phenomena is still not fully embraced in medical quarters. In the study by Osterling, Dawson, & Munson, 2002), there were limited differences seen between regressive and nonregressive autism. However, in the study by Rogers and DiLalla (1990), outcomes in the regression group were not very promising. For the non-regressive group, dysmorphic features may also be apparent (Lainhart, Ozonoff, Coon, & Krasny, 2002). In effect, in relation to Kanner’s (1943) understanding of the disorder, autism can be considered an early onset disorder, however, there are some instances where regression has been observed. It is possible that these cases indicate a specific type or subtype of the disorder. This issue has not yet been resolved. Unusual social development Kanner’s (1943) study focuses on unusual social development. Research that followed has managed his initial impression in different ways, for instance, infants with autism may limit their eye contact and may not be too socially responsive (Maestro, Muratori, Cavallaro, Pei & Stern, 2002). They may also not be as engaged in motor or vocal mimicking and may not manifest issues in arousal or unusual sensory reactions (Dawson, Osterling, Meltzoff, & Kuhl, 2000). Limited comparative or normative information often manifests issues in the interpretation of findings, while in the Klin, Volkmar, and Sparrow (1992) study, preschool children were not manifesting social behavior which usually would be seen in children before they reach one year of age. For instance, children with autism did not assume anticipatory gestures; they did not reach familiar people, and they did not show much interest in other children or their peers. They also did not participate in simple social activities. In a retrospective study by Adrien, Perrot, Sauvage, Leddet and Larmande, (1992), aside from parent report data, the analysis of home movies or videotapes indicates other possible sources of research. This study has also confirmed early emergence in the developmental differences among infants having autism. Maestro, et al., (2002) also assessed early videotapes of infants who were later diagnosed with autism, being compared with age-matched developing infants. Infants who were later diagnosed with autism did not show as much visual attention in relation to social stimuli. They did not smile as often, they did not talk as much, and they did not explore as much. However, these infants were also not different in their repetitive activities. In a study by Werner, Dawson, Osterling, and Dinno (2000) of 8-10 month old infants, they indicated that those who were later diagnosed with autism were also less likely to respond to their names. Similar results were seen in the study by Osterling and Dawson (1994) who covered 12 month old infants. Considering typically developing comparison groups have limited the scope of these findings, with differences seen reflecting general development issues, instead of the effects of autism per se (Volkmar, et.al., 2005). A stricter approach covers the use of the developmentally compromised comparison group. In considering a wider range of behaviors, Osterling and colleagues (2002) studied 12 month old infants having autism with infants manifesting mental retardation only. There were significant differences seen in the child’s orientation, looking at other people, their gestures, and in carrying out repetitive actions. While such data are limited in some areas, early signs of autism seem to cover limited social interests in the first few months of life, less social engagement and less social interactions. The differences in the non-social elements are not as apparent or obvious. From 6 to 12 months, differences are now more obvious in terms of communication, including limited vocalization in general, as well as decreased reaction to their name. Infants with autism seem to be less interested in people even as other infants are already fully interacting with objects and with other people (Bates, Bretherton, Snyder, Shore, & Volterra, 1979). On the other hand, some behaviors often observed by patients have not been clearly observed as areas of difference via videotape analysis. These issues may not be as specific when autism is considered; on the other hand, issues in determining differences may be more related with the nature of the available videotapes of the infant. Retrospective studies on parental observations about their children indicate some significant insights in the early diagnosis of children with autism. Some parents of these children who later were diagnosed with autism recall issues and delays in development of their children during the first few months of their life; however, a significant population of parent-respondents also indicate how notable issues in development were seen during the second year of the child’s life (Young, Brewer, & Pattison, 2003; Gray & Tonge, 2001). Differences are seen in the different issues or concerns which parents had during their child’s development, mostly in relation to delays in speech development, which are considered common delays and common signs later attributed to autism (Coonrod & Stone, 2004). Other issues include extreme behavioral differences and differences in socialization, communication, play, and motor development (Young, et.al., 2003). Some concerns on sleep and feeding of their children have also been noted by parents (Werner & Dawson, 2005). For about 20% to 50% of children with autism, parents often recall patterns of regression where speech is lost and socialization is regressed in the second year of the child’s life. Home videos of children Palomo, Belinchon & Ozonoff (2006) also considered home videos of children later diagnosed with autism where they note early signs of atypical development by the time the children were in their first birthday and in the months following. Evidence also implies differences in various developmental areas. Social-communicative findings cover atypical patterns in social relations, imitation, including more negative affect and ambiguity in expressions (Maestro, et.al., 2002; Baranek, 1999). Infants who are later diagnosed with autism later manifest less flexibility, less variations in their preferences, and inappropriate object-related play when compared to patients without autism (Colgan, Lanter, McComish, Watson, Crais, & Baranek, 2006). Studying infants having older siblings with autism seems to be an encouraging approach in assessing early development in autism (Yirmiya, Gamliel, Shaked, & Sigman, 2007). Such infants have a higher risk for developing autism, higher than the risk seen in the general population. In relation to this approach, new studies have been seen in order to identify qualities which differentiate autism from other development disorders (Wetherby, Watt, Morgan, & Shumway, 2007). In these prospective studies, specific measures in behavior have been gathered during development, with assessments carried out for autism carried out from 24 to 36 months when more reliable and recognizable diagnosis of the disorder can be made. At present, studies have indicated that at 12 to 18 months of age, infants who were later found as autism were differentiated from other infants to be high risk in terms of impairments, and delays in the following areas: visual (fixation on objects and prolonged visual inspection of objects); motor (lesser levels of activity and delays in fine and gross motor skills; play (delays in motor imitation and limited toy play); social communication (atypical qualities in eye gaze, in name response, imitation, and social interest); language (delays in babbling and verbal comprehension); and general cognitive development (slower acquisition of new skills (Bryson, Zwaigenbaum, & Brian, 2007; Landa & Garret-Mayer, 2006). Majority of studies have mostly considered the differences between infants later diagnosed with autism and those without, although various features also differentiate autism from language and other development issues during this early age (Wetherby, et.al., 2007). There may be a sub-group of infants considered as having issues which match autism from the ages of 13 to 14 months (Landa & Garret-Mayer, 2006). Even with later onset, symptoms are very much apparent from 18 to 24 months of age. Prospective autism studies have shown the feasibility of detecting early signs of the disorder using intensive monitoring tools and by studying high risk cohorts (Landa & Garret-Mayer, 2006). While there are differences in the onset and the precise quality of these signs, children having autism often manifest atypical behavior across different variables by the time they are two years of age. According to the American Academy of Pediatricians, autism screening is recommended from 18 to 24 months of age as a usual part of evaluating the development of the child. The screening process can take place over several sessions. The Checklist for Autism in Toddlers (CHAT) is the only autism screening tool considered within the geographically identified cohort; it is comprehensive and is highly sensitive and specific. Applying the original criteria, including gaze monitoring, pointing to show, and pretend play, about 18% of children later diagnosed with the disorder were detected using CHAT (Zwaigenbaum, et.al., 2009). Even with less specific criteria, the screening’s sensitivity was only at 38%. A modification of this tool was introduced through the Modified Checklists for Autism in Toddlers (M-CHAT). This is a main questionnaire which covers different items in CHAT but also includes a wider range or signs (Zwaigenbaum, Bryson, Lord, Rogers, Carter, Carver & Yirmiya, 2009). Through the M-CHAT, a follow-up interview was made possible with the parents interviewed with more detail on the symptoms he observed in their child. All in all, the M-CHAT provides a framework in carrying out a diagnosis on autism among children. Conclusion Based on the discussion above, it is apparent to note that it is difficult to diagnose an infant with autism because only until they are older can some signs of developmental delays or atypical behavior can be noticed by the parent. Most of the time, these signs are not expected during infancy, but parents are quick to express how their child who may later be diagnosed with autism have actually manifested issues in development during his early days. The different studies above indicate common threads, but they also indicate differences in terms of how autism can be diagnosed during the child’s infancy. Despite these differences, the authors highlight the importance of early diagnosis in order to ensure the early implementation of interventions which can help promote improved outcomes for the child in his or her future. References Adrien, J., Perrot, A., Sauvage, D., Leddet, I., & Larmande, C. (1992). Early symptoms in autism from family home movies. Evaluation and comparison between 1st and 2nd year of life using I.B.S.E. scale. Acta Paedopsychiatry, 55, 71–75 Baranek, G. (1999). Autism during infancy: a retrospective video analysis of sensory-motor and social behaviors at 9–12 months of age. Journal of Autism Development Disorder, 29 (3), 213– 224 Bates, E., Bretherton, I., Snyder, L., Shore, C. & Volterra, V. (1980). Vocal and gestural symbols at 13 months. Merrill Palmer Quarterly, 2, 407–423 Bates, E., Benigni, L., Bretherton, I., Camaioni, L., & Volterra, V. (1979). The emergence of Symbols: cognition and communication in infancy. 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