International Conference:  Signs of autism in infants: recognition and early intervention

UCLA May 2006 (summarized by Veronique Bure)

The focus of the conference was to share findings related to studies of infants who later in their life, developed an autism spectrum disorder.  The different researches targeted the establishment of a scale for the detection of early signs of deviant development, the relation between those signs and the brain development, the methodology of research and the possible early interventions with infants showing poor or avoidant social behaviors.

The studies have been conducted  simultaneously and independently  in different countries : England, Israel, Italy, ,.France, .Canada, Usa, and even though they are broached from different angles( neurology, pediatric, psychology, linguistic) the conclusion are convergent  if not  totally about causality, at least about a list of   ‘ 'red flags’ behaviors, present in more than 80% of the studied infants,  as indicators of a risk to develop further an autism disorder. 

The studies are very heterogeneous regarding the number of infants participating in the program,  varying from a set of identical twins ( University of Edinburgh)  to   150 babies, siblings of children with autism,( University McMaster, hospital for sick children  Canada), and regarding the social, cultural, economical background of the families.. All of them involve the study of home videos of the babies before they had been diagnosed with a developmental disorder, and the  study of home videos of control groups, either in the same family, or in the same socio cultural environment in order to take into consideration cultural and sub cultural specificity in child raising. All studies have been conducted over periods exceeding 2 years.

 It was amazing watching babies from extremely diverse background and countries, India, England, Italy, Hungary, Canada,  reach similar development  milestones in the same time frame whether in case of a typical  development or  in pre autistic development

Results,

 As I am presenting a summary of abstracts of longitudinal studies,  I had to select the most relevant findings and to focus mostly on similarities found in almost all infants who later developed an autism disorder whether with an early onset or late onset. I , therefore,  mostly list behaviors than can be used as markers for risk and that can be more easily identified by non specialists, thus by parents. 

  Here are the major signs used as markers. (More detailed explanation follows)

Major signs; from birth to 12 months

• Impairment in body posture, motor planning ( rigidity, disorderly movements).
• Lack of social behaviors  such as : look at, follow  caretaker's line of regard,  research of contact, enjoy together, vocalize to and with.   Overall avoidance of contact. 
• Do not orient to name
• Incapacity disengaging.
• Mood and affect disorder
• Shared consciousness does not build , limited imitation, comprehension, anticipation
• Incapacity to distribute attention in relation with the environment.
• Seems to enjoy objects better than people.

The first 6 months

 For more information  on typical development  see the page on  development milestones.

As a reminder babies prefer people to object, react to people only, during  the first three months of their life. They  have good oral motor control to allow feeding and cooing,  they  build up and direct most of  their motor activity toward  reacting, reaching, communicating with people.  They show preference in caregiver at 3 to 5 months, and can decipher emotions of face of caregivers as early as 4 months old.. They have very limited interest in objects.  They display an amazing capacity for anticipation: stretching  and orienting their body to be pick up when they see caregivers, oral motions to anticipate feeding time, pedaling to express the joy  of being soon  be pick up . 

It seems that there are two types of personalities in infants who later develop ASD.

The (too) quiet type: prefers to be on his own, does not turn toward caregiver but smiles when caregivers intrude her/his space, good sleeper, eater, develops normal milestones for interest in object (3- 5 months ) but  has a lot of difficulties disengaging from his interest, with things. Does not sustain reciprocity with caregivers.   Contact never escalate to sheer enjoyment. Does not respond to being called from afar. 

The ‘ difficult baby’, hyperactive, crying, who is difficult to soothe, has poor sleep and eating patterns, fights when cuddled, prefers to have his back against caregivers than his chest. 

Both type of personality were present in the studies and had in common the following early signs;

• They display abnormal body posture

1)      ,Motor planning difficulties 

2)     Some motor deviations either lateral or bilateral, evidenced in the way they use their body. 

3)     Atypical body  tone : hyper or hypo tonicity

4)      A lack of anticipatory posturing on being picked up

•  They do not orient to their names,
•  They demonstrate difficulties  disengaging their attention,
•  They have sensory oriented atypical behaviors (intense attention to  irrelevant items such as light, rubbing hands, eye squint mannerism, avoidance to touch ).
• Show restricted mutual enjoyment with parents, do not build excitement or  joy when face to face with caregivers, even as young as 1-2 months old
• do not reciprocate babbling ( 3 months old)

Both groups ( hypo and hyper active babies) reach the milestone for attention to object on a timely manner.

Note that one or two indicators do not make your child at risk for ASD, There are difficult and quiet babies who later develop  very typically.

From 6 -12 months.

Typical baby.

Follows someone else‘s gaze, plays reciprocal games (peek e boo 7months)

Babies discover objects and their use through imitation of people and gain better control of their body through action planning and executing.  They develop verbal and non verbal communication tools..  They still prefer people to object.

 Atypical behaviors:

• Does not respond to name,

• Appearance of self absorption: lack of reaction to environment and people, of communicative gestures, of initiative in interactions

• Mood difficulties

• Avoid eye contact.

• Preoccupation with object, become fixated,.

•  Increasing disengagement difficulty,

• Enjoy (sometimes) atypical social interaction (repetitive games where people are used as object,  imperative pointing ( I want this) rather than inquisitive ( what is it?)

At this point, if your infant displays many of the above signs she/ he should be examined by a developmental paediatrician or neurologist.

12 to 24 months

Symptoms worsen or   become more obvious in late onset autism. The parents /child relation fails to develop and the child loses interest, does not develop a communication system. It seems that the amount of  the  attention/motivation directed toward building a relationship is then more and more directed toward the use of objects and of the child’ s own body  in a rigid and  often inappropriate manner.   This rigidity prevents further learning and interacting.,

 Yet,  pre autistic infants and toddlers can engage in short term  typical behaviors  These behaviors appear infrequently and are not sustained for long periods.  However the parents recall them as a comforting sign of typicality. They are not solid enough to build up lasting social interactions.

Evaluation tools

• The ads scale. The ‘Massie infant Scale of Mother infant attachment.
• Autism Observation Scale for Infants  ( Bryson and al.. In press)
• The Mifne approach Mifne publication Israel,

Neurological causes,

Everyone agrees on the genetic cause of autism, impacting the way the brain develops.

It seems as if, from the first month of life, pre autism manifests itself as a disorder of action planning.  Moving, uttering, looking, sometimes eating are impacted.  Autism appears to be at first a coordination disorder

The typical brain coordinates body movements to interact with the world.  While exposed to stimuli of their environment (parents being part of the environment) the infant builds neuronal axis in his brain. They are the white matter of the brain.  Connection between the brain regions is made through the white matter. There is an unprecedented white matter growth in all infants during the first 6 months of their life.  Through meaningful experiences and shared awareness, these axis specialize and some are no longer used, (pruning) in order to build efficient connections of the emerging self to the environment.   Experience functions as a catalyst of the brain shaping and of the emergence of  personality.  In pre autism the pruning does not occur, and the connectivity of the brain does not function well ( head circumference of  infants and toddlers abnormally  increase  at the age where their symptoms worsen).  As a result  the infant with pre autism does not  coordinate well his body actions with  his environment, which in turn prevents  him form learning.  EEG recordings show that all areas of the cortex are impacted, as well as parts of the cingulated, the amygdales, the corpus callosum,  and that there is a cascading negative effect of all areas of the brain,

The brain is designed to compensate deficiencies, (whether because of its plasticity or its developmental genetic programming) that is why early intervention  could in a majority of cases  reverse or alter the course of autism. .As most of the development of the brain occurs after birth, with the  highest vulnerability  during the  6 first months extending to the first year, it is probably at that age that intervention is most effective.…

Intervention mostly involves engaging the infant in social interactions and trying to trigger reciprocity.

Positioning is very important for the infant to be able to attend interaction (difficulty in action planning and physical discomfort prevent for engaging). The goals are to, step by step, build the connectedness, the mutual joy, the share consciousness that spontaneously emerge in an infant parent relationship,,

 It is extremely demanding on the parents who feel rejected by their infant and therefore guilty and failing in their parenting skills.  As the child fights being held and cuddled, the parents cannot develop the adequate holding, talking, interacting skills they would with a typical infant which in turn further impacts the connectedness of the infant.  They need a lot of support and guidance. Therapists have to be creative, respectful, open minded and assessing progress constantly.  The role of the therapist is to guide and to model strategies for parent not to substitute them.

Other interventions such as the introduction of a diet , intensive auditory therapy have not proved effective in longitudinal , independent studies.  The relation autism/vaccination has been ruled out by the panel of scientists as it had previously by many other..

 Some tips

 Holding your child on your lap, while you are comfortably sitting on the floor your  back supported, with your legs bent. baby‘s feet against your chest, singing, massaging, catching each glimpse from the child and building on it.  Optimum positioning for the baby implies that her/his body is supported to reduce the difficulty in motor planning and that your are facing her/ him. ( baby on her/his back in bathtub, on rug, in hammock).

Try to engage your baby as often as possible.  At least 8 times a day, impose interaction with the child, as long as the child can sustain the intrusion in his world. t

Massaging, playing in bathtub, use of bubbles, water mattress, rolling, divers motions, trying to understand the infant rhythms and to disrupt it slowly with reciprocal, gentle babbling, talking, silence, gaze tracking.  Try blowing air on her/his body, tickling, rocking, squeezing.. Vary approaches according to infant‘s response..  Don’t be discouraged, seek help, enjoy every success.