Autism spectrum disorder (ASD) is a developmental disability that can cause significant social, communication and behavioral challenges. ASD affects 1 in 54 children in the United States and is over 4 times more common among boys than girls.[1]
While some children show signs of autism in infancy, most are not diagnosed until after age 2. This is partly because developmental delays and differences are not always apparent before then. However, early intervention can greatly improve outcomes for children with autism. Therefore, understanding how autism may present in toddlers is crucial for early detection and treatment.
One of the core features of autism that often emerges by age 2 is difficulty with communication. This includes challenges with language, speech and nonverbal communication skills. Early signs of communication differences provide important clues for identifying autism in young children.
Language Skills
Many 2 year olds with autism experience delays in language development. They may be slow to start talking and have limited vocabulary for their age. Common signs include:[2]
– Not saying any words by 18 months.
– Using less than 50 words by 24 months.
– Not combining 2 words together like “drink milk” by 24 months.
– Losing previously acquired language skills.
– Echoing others words and phrases meaninglessly, known as echolalia.
However, language ability varies greatly in toddlers with autism – some may have advanced vocabularies but struggle to communicate effectively. Approximately 25-30% remain minimally verbal throughout childhood.[3]
Comprehension Challenges
In addition to delayed language production, toddlers with autism often have trouble understanding others. Difficulty following simple instructions like “give me the ball” is a red flag. They may also demonstrate:[4]
– Limited joint attention – not looking at objects others point to.
– Difficulty responding to their name being called.
– Trouble understanding gestures, facial expressions and tone of voice.
These comprehension issues indicate they are struggling to process and interpret language, not just produce it.
Speech and Articulation
Many toddlers with autism have abnormalities in their speech quality and vocal patterns. They may:[5]
– Speak with an unusual rhythm, tone, speed or volume. Speech may sound robotic, musical or high-pitched.
– Exhibit speech impairments like stuttering, repetition of syllables or difficulty pronouncing certain sounds.
– Use odd intonation, stressing the wrong word in a sentence.
– Reverse pronouns, saying “you” instead of “I”.
– Repeat words, phrases or TV jingles meaninglessly, known as echolalia.
– Be highly verbal with advanced vocabularies but poor speech clarity.
Unusual speech patterns tend to be more apparent as expressive language expands between ages 2-3. A speech evaluation can help determine if articulation delays are present.
Nonverbal Communication
In addition to spoken language, toddlers use eye contact, gestures, facial expressions and body language to communicate. Autism often involves challenges and differences with nonverbal communication skills, including:[6]
Eye Contact:
– Reduced eye contact. May avoid looking at faces or glance only briefly at eyes.
– Difficulty reading emotions from eyes and facial expressions.
– Unusual gaze – may look at people from the side or seem to “look through” people.
Gestures:
– Limited pointing or gesturing to communicate needs and interests.
– May lead others by the hand or push/pull rather than point things out.
– Reduced showing objects they find interesting.
– May use unusual hand and finger mannerisms or posturing.
Facial Expressions:
– Flat or exaggerated facial expressions. Smiles may seem “off”.
– Difficulty conveying and understanding emotions through facial cues.
Body Language:
– Poor integration of eye contact, gestures, facial expression and body posture.
– Unusual body postures or movements, like flapping, spinning, or toe-walking.
– Awkward interactions with unfamiliar physical contact. Dislikes hugs/cuddles.
These nonverbal differences can contribute to struggles interacting socially with others. Toddlers with autism often seem to be “in their own world” and lack typical back-and-forth relating.
Play and Social Communication
Play is an important early form of social communication and language development. Many autistic toddlers show differences in how they play, including:[7]
– Restricted, repetitive play activities without variety or imagination. For example, lining up toys instead of pretend play.
– Limited imitation of other’s actions and play.
– Tendency to play alone. May seem oblivious to other children.
– Difficulty sharing interest orobjects with others. Prefers playing with parts of toys rather than whole object.
– Challenges taking turns and engaging in joint attention during play.
– Lack of pointing or showing things of interest to others.
– Trouble participating in symbolic imitation games like patty cake or peekaboo.
These social communication delays during play provide important clues about autism prior to age 3. Toddlers with autism often seem content playing alone and lack drive to socially engage with others through play.
Other Developmental Issues
While communication and social differences may be most prominent, other developmental domains are also often affected in toddlers with autism, including:[8]
– Cognitive: May have uneven skill development, with delays in some areas and strengths in others. Intellectual disability and developmental regression may occur.
– Motor: Clumsiness, unusual gait, poor coordination. Unusual posture, movements and mannerisms like hand flapping or toe walking.
– Sensory processing: Heightened or reduced sensitivity to light, sound, touch or pain. Aversion to loud noises, textures, tastes or smells. Intense interest in sensory aspects of environment.
– Behavior: Rigid routines, repetitive behaviors, obsessive interests, distress with change/transitions. Self-injury, aggression, tantrums may occur with communication frustrations.
– Self-care: Feeding issues like limited diet, messiness, or using hands vs utensils. Potty training difficulties are common. Struggles with dressing, bathing and self-help skills.
Multidisciplinary assessment helps identify needs across developmental domains, not just communication. Prompt intervention improves outcomes.
Screening and Diagnosis
Several autism-specific screening tools can identify potential symptoms by age 2, including the:
– M-CHAT-R: Validated checklist for autism screening at 18 & 24 month pediatrician visits. Assesses social, communication and play behaviors.
– First Words Project: Screens language development between 12-24 months during well-child checks.
– Communication and Symbolic Behavior Scales (CSBS): Evaluates 7 key social-communication markers from 12-24 months old.
| Screening Tool | Age Range | Domains Assessed |
|---|---|---|
| M-CHAT-R | 16-30 months | Social interaction, communication, play, repetitive behaviors |
| First Words Project | 12-24 months | Language and communication milestones |
| CSBS | 12-24 months | Eye gaze, sounds, gestures, understanding, object use, engagement, joint attention |
If screening indicates possible ASD, further diagnostic evaluation is needed to confirm autism spectrum disorder and rule out other conditions. The gold standard autism diagnosis includes:
– Developmental history from caregivers
– Direct observation of behaviors
– Administration of an autism diagnostic tool such as the ADOS-2 or STAT
– Input from a multidisciplinary team with ASD expertise
Early diagnosis allows children to start ASD-specific therapies as soon as possible to improve social, communication and behavioral development. Ongoing support will be needed to address evolving needs across childhood.
Communication Strategies for Caregivers
Parents and caregivers can implement strategies to enhance communication development in toddlers with autism, including:[9]
– Provide choices: Offer two options they can select between to build expressive language.
– Narrate activities: Verbalize what you are doing as you engage with them.
– Use visuals: Use pictures, symbols or signs to augment verbal language.
– Follow their lead: Imitate their actions and sounds to build reciprocal engagement.
– Closely observe: Pay attention to their nonverbal cues and respond contingently.
– Limit demands: Ask simple yes/no or choice questions rather than open-ended queries.
– Add structure: Use schedules, warnings for transitions, and timers to reduce frustration.
– Provide consistency: Stick to routines and predictable patterns when possible.
– Meet sensory needs: Limit loud noises, textures, and other sensitivities to reduce distress.
– Encourage interaction: Sensitively intrude into their activities and promote joint engagement.
– Give processing time: Allow 5-10 seconds for them to respond before repeating prompts.
– Reward attempts: Praise all efforts to engage, use words, and interact.
Adapting communication style to the child’s abilities and challenges promotes social and language growth. Specialized therapies build critical communication skills.
Conclusion
Autism spectrum disorder involves significant challenges with social communication skills and restricted, repetitive behaviors that emerge in early childhood. Many toddlers with autism show differences in language, speech, nonverbal communication and play by age 2. However, developmental variation is common. Some exhibit few overt symptoms as toddlers but difficulties increase later. Early screening, diagnosis and intervention are crucial to support positive outcomes. Understanding the many ways autism can impact communication abilities in young children is key for early identification. With loving support and appropriate therapies tailored to their needs, children with autism can make remarkable progress.