Not long ago, a family came to see me with concerns that their toddler wasn't communicating like other 18-month-olds. We don't expect a lot of speech at that age, but this little boy wasn't waving bye-bye, or turning when his parents called his name or bringing them his favorite toys to share his enjoyment.

So, after speaking with their pediatrician, they called their county's early intervention program, whose providers began to work with him, and they also called me to meet with him. As a developmental pediatrician for many years, I evaluated him and concluded that he had an autism spectrum disorder, or ASD. Armed with this diagnosis, his parents were able to enroll him in speech and occupational therapy. As I continue to monitor this little boy's progress, I'm delighted to see a steady increase in his level of engagement with his parents during our office visits.

During the 40 years I've been in practice, I've watched as cases of autism, a neurodevelopmental disorder affecting communication and behavior, have quickly risen. Once rare, ASDs are now believed to impact about 1 child in 68 - or 1.5 percent of the child population, with symptoms ranging from mild to severe. Parents most often become concerned when they notice a delay in their toddler's language, though other times it's a pediatrician or other specialist who first detects something atypical in the child's development.

Until recently, many pediatricians encouraged concerned parents to watch and wait, suggesting that the child might outgrow the behaviors and delays. Today, we know it's important to intervene early - 18 months is a frequent target. This can make a big difference in helping kids with ASD to learn new skills and more functional behaviors.

That said, it's important to know that intervention at any age can be extremely helpful, and it's never too late to start. Even when parents worry they have lost time by starting later, they have probably already been doing more for their child than they might realize: Just singing nursery rhymes or playing peek-a-boo offers support similar to what many interventions provide.

With all the attention that autism has been receiving, you may worry when you notice minor differences between your toddler and his or her peers. Many of these differences are simply typical variations in human development. But if you see several (not just one) of these red flags, it's probably worth talking with your pediatrician:

  • Inconsistent response to name : Your child often appears to ignore your calls or not hear them.

  • Not waving or pointing : Toddlers between 12 and 14 months should point to something they want and - more importantly - point to share enjoyment or excitement by 14 to 16 months.

  • Speech delays : These can include little or no speech; echolalia (when I say "Hi, Joe," the young patient responds by echoing the phrase back to me); pronoun reversal; or using what I call "packaged language" instead of more spontaneous speech (I treated one boy who, at almost 3, did not say "Mama" or "Dada," but often used phrases like, "Ready, set, go").

  • Repetitive movements : Many children without ASD exhibit some of these in the toddler years, but if you see flapping hands, body rocking, spinning or toe walking along with language delay, it may be more significant.

  • Sensory issues : Either seeking out sensory input like loud noises or firm pressure, or avoiding it; or becoming upset by sounds, textures, bright colors or strong smells.

  • Rigidity : It's not unusual for a toddler to throw a tantrum if she gets the blue cup when she wanted the red one, but for some children this goes a step farther: certain things - whether it's the route home from the library or where the ball gets stored - must be a certain way, or a severe meltdown results. If this happens with your child, speak with your pediatrician.

  • Motor delays : Children should walk independently by 15 to 18 months. If your child is not walking by 15 months, consult with your pediatrician.

  • Lack of social smiles : Babies under a year old should respond to a smile or smile back.

Beginning intervention as soon as possible will give you, as well as your child, the tools you need to facilitate development in the areas of concern. Every state offers free early intervention services (though they may go by different names), and many states require insurance companies to cover additional services like speech or occupational therapy.

If you are concerned that your toddler may have an ASD, here are some steps you can take:

  • Speak with your pediatrician . Your pediatrician should refer you to early intervention services and arrange for an audiology appointment - either through early intervention services or a hearing specialist, to rule out hearing issues. Your pediatrician should also refer you to a specialist - like a developmental pediatrician, child neurologist or child psychiatrist - to help determine whether your child has an ASD or another disorder, and to help put a treatment plan in place.

    If your pediatrician wants to "wait and see," and you are uncomfortable with this approach, you can guide him or her. For example, say, "Maybe I should speak to a specialist; whom would you recommend?" Meanwhile, you can self-refer to early intervention services.

  • Expand on your child's interests to encourage back-and-forth play. For example, if your child likes taking things in and out of containers, get a toy shopping cart and pretend food, and act out a trip to the market. If he requests that you blow more bubbles by putting the bottle in your hand, seeming to ignore the person attached to it, hold your hand near your face so he connects your actions with you instead of your hand.

  • Feed your child whole, nutritious foods to keep her body healthy. One rule of thumb is that anything you can store on a shelf should not be eaten in large quantities.

  • Downplay electronics. A little screen time is OK, but kids with ASDs tend to have more challenges with fixation, and should spend the bulk of their time playing and engaging.

As a parent, if you have concerns, follow your gut and seek the support you believe your child may need; there are no downsides to interventions, and most would benefit typically developing children as well. The earlier we can develop pathways to help build on play, communicative intent and interaction with others, the better the outcome for any child with ASD.

For more information and resources on autism, visit the American Academy of Pediatrics' website or the Autism Spectrum Disorder site of the Centers for Disease Control and Prevention.


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Dr. Charles Conlon, a Mid-Atlantic Permanente Medical Group developmental pediatrician who has been practicing for almost 40 years, is located at Shady Grove Medical Center in Rockville, MD. He is board certified in pediatrics and neurodevelopment disabilities, earned his MD at Georgetown University School of Medicine and completed a residency at National Naval Medical Center and a fellowship at Kennedy Krieger Institute.