Recognizing Autism Symptoms: From Early Childhood to Diagnosis
Autism Spectrum Disorder (ASD) is characterized by deficits in social functioning (connecting with others) and behavioral functioning (acting in a way that is seen as atypical to most people). These two categories of function type and level each include specific measurable symptoms. The symptoms are shown on the chart below and then explored on the following page.
For a person to be diagnosed with autism, symptoms must be present in the early stages of development, most typically measurable before school age. Determining whether symptoms were present at an early age often requires extensive interviewing of caregivers about early life behavior – questions about emotional attunement, reciprocal play, repetitive behaviors, etc. This can be difficult since symptoms are often not obvious until later in life when socializing and self-care becomes more complicated. Unfortunately, many young people with more subtle autism symptoms get misdiagnosed early in life. To understand and best prepare for assessment see the article on “Psychological Testing.”
A diagnosis also requires that the symptoms cause significant impairment in social, occupational, or other areas of daily functioning. It is not necessary for each symptom to always cause impairment, but it is expected that one or more symptoms cause consistent impairment in a critical part of daily life. For more on the severity of symptoms see “The Spectrum” article.
Social Symptoms
To qualify for an ASD diagnosis a person must have previously or currently exhibit all three of the following social struggles. For Level 1 autism, these symptoms can be subtle and may not be as obvious until teenage years or later. Some of these symptoms may present differently based on race, gender, and culture. For more on these differences refer to the articles on “Gender” and “Cultural Differences” in autism.
Deficits in social-emotional reciprocity: E.g., struggling with back-and-forth in conversations, failing to properly start or respond to social interactions, or sharing at a rate that is atypical (too much or too little) when compared to others in the conversation.
Deficits in non-verbal communication: E.g., misaligned verbal and non-verbal speech (looking angry while sounding happy), poor eye contact (too much or too little), a flat affect (lack of facial expression), poor understanding of social nuance like sarcasm, or difficulties in using and understanding body language.
Deficits in developing, maintaining, and understanding relationships: E.g., struggling to match behavior to a social context (e.g. acting silly or loud at a funeral), struggling to make and keep friends, not demonstrating interest in others, or struggling with imaginative play at an age where that is typical.
Behavioral Symptoms
To qualify for an ASD diagnosis a person must have previously or currently exhibited at least two of the following behavioral patterns:
Stereotyped or repetitive behaviors:
E.g., repetitive movements (e.g. hand flapping, rocking, walking on tiptoes), limited use of objects (e.g. intense focus on a limited number of items), or odd use of speech (e.g. making the same sounds repeatedly).
Adherence to Routines and Sameness:
E.g., suffering significant distress when a routine or pattern is interrupted, overly rigid thinking patterns, insisting on eating the same food for every meal, or verbal or non-verbal rituals whose interruption is distressing.
Restricted and Fixated Interests:
E.g., any abnormally rigid attachment to, and fixation on, a specific topic, item, or interest. Common restricted interests are television shows, math, drawing, mechanical items, animals, sports, fantasy, etc.
Hyper or Hyposensitivity to Sensory Input:
E.g., hyper (heightened) or hypo (lessened) sensitivity to sensory stimulation, such as being overwhelmed by touch or textures or noise (e.g. irritation with seams in clothing), needing to excessively smell items, indifference to temperatures or pain, or abnormal fascination or indifference to visual stimuli.
Symptoms that are NOT necessary for an autism diagnosis
Many people incorrectly assume that a person with autism must have other types of symptoms. While these other symptoms may correlate with autism, they are not a necessary part of the diagnosis. There are, however, common specifiers, like the ones listed below, that may accompany an autism diagnosis due to their common co-existence in individuals with ASD diagnosis.
Intellectual Impairment
Intellectual impairment is defined as cognitive deficits that negatively impact the ability to learn new information and engage in daily activities (APA, 2024).
Diagnosing clinicians can qualify an autism diagnosis with a specifier that identifies “with or without accompanying intellectual impairment.” This identification does not affect an ASD diagnosis.
Although intellectual impairment is not necessary for an ASD diagnosis, it is estimated that ~30% of people with ASD do have an intellectual impairment (Christensen et. al, 2016).
Language Impairment
Language impairment is typically marked by having no intelligible speech (being non-verbal), using only single words, or use of only limited phrases.
Diagnosing clinicians can qualify an autism diagnosis with a specifier that identifies “with or without accompanying language impairment.” This identification provides more specificity on the person’s communication capacity and does not affect an ASD diagnosis.
Language impairment is most often associated with autism in terms of the individual’s “receptive language” (Reindal et. al., 2021). Receptive language generally refers to the ability to receive information from others and reciprocate in kind, e.g. answering questions, following directions, or making bigger connections in a conversation. Language impairment can also impact “expressive language” which means the ability to convey content to others.
Associated Medical or Genetic Condition or Environmental Factor
Diagnosing clinicians can indicate that an autism diagnosis has an associated medical or genetic condition, or environmental factor that may correlate or otherwise impact autism symptoms.
Medical and genetic conditions include disorders such as Rett syndrome, Down syndrome, epilepsy, or genetic anomalies.
Environmental factors may include issues like fetal alcohol syndrome or very low birth weight.
Other Neurodevelopmental, Mental, or Behavioral disorders
Diagnosing clinicians can indicate that an autism disorder has an associated neurodevelopmental, mental, or behavioral disorder that may not necessarily qualify as a separate diagnosis. If this type of specifier accompanies an ASD diagnosis it implies that the symptoms are correlated with the autism diagnosis.
Examples of these disorders include ADHD, anxiety, depression, Tourette’s disorder, conduct disorders, sleep disorders, and many others.
Case Study
What follows is a case study about a girl with autism which includes notes of specific symptoms in order to demonstrate how they show up in daily life.
Meet Sarah:
Sarah is a 7-year-old, cisgender girl who lives with her biological parents. Sarah can consistently be found playing with her collection of toy cars (restricted interest). She's fascinated by the way the cars move and enjoys lining them up in precise order. She's also very sensitive to loud noises and bright lights, often covering her ears or becoming overwhelmed in busy environments like shopping malls (sensory sensitivity).
Sarah's parents noticed these behaviors early on, but it wasn't until she started school that they began to realize something might be different about her. While Sarah is exceptionally intelligent and has a remarkable memory for details, she struggles to make friends and often prefers to play alone (relationship troubles). She finds it challenging to understand social cues and frequently misinterprets others' intentions (poor social skills).
At school, Sarah's teachers notice that she excels in certain subjects, particularly math and science, where she can focus intently on the tasks at hand. However, she finds it difficult to participate in group activities (poor reciprocity) and often becomes frustrated when the school schedule changes for things like parent-teacher conferences (adherence to routines).
Despite her efforts to fit in, Sarah often finds herself feeling isolated and misunderstood. She longs for connection and friendship but struggles to talk to people unless they start the conversation (poor reciprocity) or want to talk about cars (restricted interest). This sense of loneliness weighs heavily on her, leading to feelings of frustration and sadness. When Sarah is sad or frustrated, she gets very quiet and non-responsive, but sometimes she yells at her parents and sibling and scratches her forearms repeatedly.
Sarah is often overwhelmed by simple tasks like getting dressed in the morning (sensory sensitivities) or attending a crowded event. Loud noises, bright lights, and certain textures can trigger intense reactions, causing Sarah to retreat into herself or to become agitated and flap her hands (repetitive behavior).
Sarah’s parents have worked with her school to get accommodations for her to receive the support of a para-professional for when she’s in groups, if there is a change in her schedule, or if she’s struggling with a certain topic. Sarah is also working with a mental health therapist on tools she can use to better regulate her emotions and improve her social skills. Her parents are also learning how to celebrate and utilize Sarah’s strengths and interests to teach new skills and build resiliency. One metaphor that has really helped her is talking about how cars change gears when speeding up or slowing down, and that she must do the same depending on her environment. Sarah will make exaggerated gear shift sounds when walking into a crowded place knowing that she has to speed up her emotion regulation to manage the new stress.
As Sarah continues her journey, she inspires those around her with her determination and strength. Though her path may be filled with challenges, she approaches each day with courage and resilience, embracing her unique identity and finding joy in the small moments of triumph such as finishing school assignments and spending time with peers outside of school.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Pages 31-59.
APA, (2024). What is Intellectual Disability? Retrieved from: https://www.psychiatry.org/patients-families/intellectual-disability/what-is-intellectual-disability
Christensen DL, Baio J, Van Naarden Braun K, et al. (2016) Prevalence and characteristics of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2012. MMWR. Surveillance Summaries 65: 1-23.
McDuffie AS, Lieberman RG, Yoder PJ. Object interest in autism spectrum disorder: a treatment comparison. Autism. 2012 Jul;16(4):398-405. doi: 10.1177/1362361309360983. Epub 2011 Dec 1. PMID: 22133872; PMCID: PMC4106682.
Reindal, L., Nærland, T., Weidle, B., Lydersen, S., Andreassen, O. A., & Sund, A. M. (2021). Structural and pragmatic language impairments in children evaluated for autism spectrum disorder (ASD). Journal of Autism and Developmental Disorders, 1-19.
