Nathan's mother attempts to engage him in a round of "itsy bitsy spider," a social game that incorporates eye contact, imitation, gesture and social interaction. Though most typical developing children enjoy, initiate and prolong this sort of game, Nathan can only participate in a passive manner. His mother must sing the song, guide his hands, ask for his eye contact and pull him back to play again. Without her guidance Nathan simply walks away from the social interaction. Both Nathan's inability to participate and his disinterest in this interaction may be warning signs for autism.
Lack of joint attention is another possible warning sign for autism. Christian K. (2 years 9 months old with autism) is being read to by his father from a children's book. Christian K. shows very little interest in the book. He turns the pages before his father has finished reading and never points or makes eye contact with his father.
Lucas, a young boy on the spectrum, runs and hides in a favorite corner when his therapist comes. He often seeks refuge in this corner during therapy sessions and/or when confronted with social situations. He also often echoes his therapist questions and statements, rather than responding to them, another early warning sign.
Lucas's mother tries unsuccessfully to engage Lucas in a game of legos. Lucas does not show an interest in this age appropriate toy or the prospect of interacting with his mother; rather, he disengages from her, focusing instead on some stray coins, staring at the wheels of a truck and eventually wandering off. Both Lucas' repetition of the word "coins" and his fixation on the truck wheels may reflect an intense sensory interest.
To help grab Lucas's attention, Georgia reads Lucas a homemade storybook, where pictures of Lucas and his home have been used as the illustrations. She uses this story book to prepare and help Lucas understand the process of getting a haircut. Despite her efforts, Lucas does not fully engage in the activity or even seem to recognize himself in the pictures.
Though Lucas seems more interested in this picture book, he does not look back at his therapist Georgia as many typically developing children might. He does not seem to be interested in her reactions to the book or in sharing his enjoyment. Further, Lucas shows great difficulty in imitating and understanding the emotions Georgia demonstrates for him. He repeats "I'm angry." and smiles.
A lack of eye contact can be a warning sign for autism. Although both Evan's mother, Raquel, and the evaluator, Connor, persistently try to elicit eye contact and a smile from Evan, he avoids direct eye contact throughout the interaction. Though Evan eventually offers a brief smile after several attempts, he does not look at his mother who is directly in front of him.
Excessive rocking combined with odd finger and hand mannerisms can be a warning sign for autism. Sal, the oldest of the three children on the spectrum, exhibits these behaviors while watching a cartoon with his brothers. Although all of the boys seem interested in the cartoon, none of them share their enjoyment with one another, another warning sign.
Social Communication and Social Interaction
Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history
Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Restricted and Repetitive Patterns of Behavior
Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history
Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).
Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).