LWW/IYC AS188-01 May 30, 2003 11:17 Char Count= 0 Infants and Young Children Vol. 16, No. 3, pp. 201–214 c 2003 Lippincott Williams & Wilkins, Inc. Toddlers With Autism Developmental Perspectives Linda R. Watson, EdD; Grace T. Baranek, PhD; Pamela C. DiLavore, PhD Recent research has greatly expanded our knowledge about the early development of children with autism and related disorders. Familiarity with this literature will improve the ability of professionals to appropriately diagnose and intervene with young children with autism. This article reviews the literature pertaining to the development of children with autism under the age of 3 years. We ex- amine findings on affective development, sensory processing and attention, praxis and imitation, communication, play, and motor features and stereotyped behaviors, and discuss the interrelation- ships among these different aspects of development. Screening and diagnostic tools with specific applicability to young children with autism are reviewed as well. Key words: affect, assessment, autism, communication, play, sensory processing, toddlers ECENT research has greatly expanded EVIDENCE REGARDING EARLY Rour knowledge of the early development DEVELOPMENT of children with autism and related disorders. An increased understanding of how autism The first attempts to study the early de- is manifested in very young children holds velopment of children with autism relied on promise for improving our ability to diagnose parents’ retrospective reports of their chil- children at a younger age and to offer appro- dren’s early development (eg, Hoshino et al., priate interventions that address the needs 1982; Ornitz, Guthrie, & Farley, 1977). This of very young children with autism and their approach provided intriguing insights into the families. The purpose of this article is to sum- early development of children with autism marize the current evidence base related to prior to their diagnoses. Concerns about the development of children with autism un- this research methodology, however, include der the age of 3 years, and to discuss assess- questions about the accuracy of parental re- ment instruments that have particular applica- call of early development after a period of bility to screening for and diagnosing autism several years has elapsed, and the possible in young children. influences of the subsequent knowledge of a child’s diagnosis on that recall. Over the past decade, newer research using different methodologies has helped to confirm much From the Divisions of Speech and Hearing Sciences of the information from parent recollections, (Dr Watson) and Occupational Sciences (Dr and to significantly elaborate upon that in- Baranek), Department of Allied Health Sciences, and the TEACCH Division (Dr DiLavore), Department of formation. This research includes prospective Psychiatry, Medical School, University of North studies of children referred to a diagnostic Carolina at Chapel Hill. clinic at age 2 because of concerns about pos- We thank Vesna Costello for her helpful assistance in sible autism (eg, Gillberg et al., 1990; Lord, preparation of the manuscript. 1995), studies related to the development of Corresponding author: Linda R. Watson, EdD, Depart- screening instruments for autism in young ment of Allied Health Sciences, CB # 7190, Medical children (eg, Baron-Cohen et al., 1996; Stone, School, Wing D, University of North Carolina at Chapel Hill, NC 27599-7120 (e-mail: Linda [email protected]. Lee, et al., 1999), developmental studies edu). of toddlers with diagnosed or suspected 201 LWW/IYC AS188-01 May 30, 2003 11:17 Char Count= 0 202 INFANTS AND YOUNG CHILDREN/JULY–SEPTEMBER 2003 autism (eg, Charman et al., 1997; Stone, shorter durations of looking at people, rela- Ousley, Hepburn, Hogan, & Brown, 1999; tive to children with typical development and Swettenham et al., 1998), and retrospective those with developmental delays. In research studies of home videotapes made of infants with the same sample of children, Charman and young children who were later diagnosed et al. (1997) demonstrated that children with with autism (eg, Adrien et al., 1993; Baranek, autism were unlikely to look at and show fa- 1999; Osterling & Dawson, 1994). cial concern for an experimenter expressing We organize our discussion of the de- distress, but children in the other 2 groups of- velopment of young children with autism ten did so. by the developmental domains of affective development, sensory processing and atten- Sensory processing, attention, tion, praxis and imitation, communication, and self-regulation play, and motor features and stereotyped be- There is some controversy regarding the ex- haviors. We recognize, however, that develop- tent to which unusual sensory symptoms are ment is integrated in complex ways across do- manifest in young children with autism, and mains, and that the concepts of researchers more controversy with respect to the nature investigating one domain of development of these difficulties. Phenomenological narra- overlap with those of researchers investigat- tives from persons with autism recalling their ing other domains. Our discussion addresses childhood experiences (eg, Grandin, 1997), some of these interrelationships. as well as retrospective reports from parents of children with autism and/or reports from Affective development their clinical charts (eg, Dahlgren & Gillberg, Limitations in facial expression are listed as 1989; Greenspan & Weider, 1997; Hoshino a possible symptom of autism under the cat- et al., 1982; Ornitz et al., 1977) attest to nu- egory of “nonverbal social behaviors” in the merous symptoms reflective of sensory pro- Diagnostic and Statistical Manual of Men- cessing and/or attentional disturbances dur- tal Disorders, 4th Edition (DSM-IV, Amer- ing the first 3 years of life. Among these ican Psychiatric Association, 1994). In typ- symptoms are hypersensitivities to sound, ical development a broad range of facial aversion to social touch, avoidance of cer- expressions is in place by 2–3 months of age, tain food textures, lack of response to pain, and smiling in response to the smiles of oth- poor orientation to visual stimuli, and over- ers is observed reliably by 6 months. In gen- focused attention or preoccupations with eral, fewer facial expressions are seen in tod- various sensory features of objects (eg, dlers with autism, and fewer are directed to watching things spin, licking objects). These other people. In addition, these children are unusual behaviors may range from mild to se- more likely to show ambiguous facial expres- vere, perhaps moderated in part by the child’s sions. For example, retrospective parent re- coping/self-regulatory abilities and environ- ports have been more likely to describe in- mental supports, and may interfere with par- fants and toddlers with autism as “having an ticipation in a variety of daily activities (eg, expressionless face” (Hoshino et al., 1982) picky eater, temper tantrums in noisy environ- than to apply this description to children with ments, sleeping problems). other developmental disabilities or children It is unclear whether or not sensory fea- who are typically developing. Retrospective tures described in young children with autism video research has indicated a lack of social are completely unique to this diagnosis. S. J. smiling in infants with autism (Adrien et al., Rogers, S. Hepburn, and E. Wehner (unpub- 1993). lished data), using a parent report instrument, Swettenham et al. (1998) demonstrated reported higher levels of sensory symptoms that 20-month-old infants with autism had in 2–4-year-olds with autism as compared deficits in social orienting, as noted by to children with Down syndrome, but not LWW/IYC AS188-01 May 30, 2003 11:17 Char Count= 0 Toddlers With Autism 203 compared to children with fragile X syn- dren with respect to the order of difficulty of drome. Analyses of home movies taken of in- motor imitation, but that children with autism fants who were later diagnosed with autism overall show less proficiency. Rogers and (Adrien et al., 1992; Baranek, 1999) doc- Pennington (1991) hypothesized that infants ument specific patterns of subtle sensory- who later exhibit autism would not have the attentional symptoms that differentiate clin- ability to engage in neonatal imitation because ical groups during the first year of life, of an innate impairment of this important so- often prior to the time that parents are cial ability, but there is no research evidence cognizant of the child’s diagnosis. Interest- available related to neonatal imitation in in- ingly, infants later diagnosed with autism ap- fants who are later diagnosed with autism. In pear to be differentiated from infants with early intervention programs for children with other developmental disabilities more on the autism derived from a variety of perspectives, basis of their hyporesponsiveness to both imitation is considered a pivotal skill. The social and nonsocial stimuli than by hyperre- literature confirms that the development of sponsiveness. Some symptoms intensify dur- skills in other areas, such as play and language, ing the second year while new symptoms is closely tied to the child’s ability to imitate. also emerge (Adrien et al., 1993), suggest- Stone, Ousley, and Littleford (1997) found that ing the importance of a developmental per- for 2-year-olds with autism, the imitation of spective to understanding these unusual be- actions on objects is more closely tied to the haviors. Some researchers (Baranek,