Every childcare provider at one time or another has cared for a child who seemed different in some way. Behavioral concerns, difficulty transitioning or socializing with other children, and/or delayed speech and language development may be signs of a developmental disorder.

Autism is the third most common developmental disorder, after mental retardation and cerebral palsy. The incidence is around one in 500 children. Four out of five children with autism are boys. The cause of autism is unknown, but there appears to be a strong genetic component. It is believed that autism develops from the interplay between genes and the environment. It is known that if a woman contracts rubella, a viral infection, during pregnancy, then congenital rubella syndrome can occur, and potentially cause congenital defects including mental retardation and autism.

Autism is not a specific disease but is an umbrella term for a wide spectrum of disorders. Because such a wide variation in the symptoms is presented, the correct term is Autism Spectrum or Autism Spectrum Disorder (ASD).

Autism is characterized by “deficits in social reciprocity” that may include a range of back-and-forth actions, such as gestures, smiling, play, attention, and conversation. Ritualistic and obsessive type behaviors also may be present.

In recent years, there has been an increase in number of children diagnosed with the Autism Spectrum, and the reasons are not yet clearly understood. Because the symptoms of autism begin to occur around the same time as the certain vaccinations, such as the MMR vaccine, are administered, some parents see vaccines as the cause of autism. However, research has shown that there is no link between autism and the MMR vaccine or its ingredients.

There are two kinds of autism: static and regressive. The static form is present from birth. The regressive form involves a loss of function beginning at about 15 months. Both have elements of language delay and communication problems.

The earliest signs of autism can be present as early as two months of age, when children developing normally begin to reciprocate smiles with their parents. Between four-nine months, the normal child also will exhibit certain social milestones, such as showing interest in faces, showing joy toward his parent, and becoming oriented to his name. However, one of the signs of autism that childcare providers are most likely to see involves the lack of development of normal play behavior.

At around one year of age, a child should start to engage in functional play, using objects as they are intended. For example, if the child’s play does not involve the imaginative play of making toy cars zoom around the room, but instead consists only of lining up cars in a row over and over again, there may be reason for concern.

Autistic children often engage in repetitive behaviors, such as opening and shutting toy car doors, spinning car wheels, or lining up rows of toys. Typical behaviors seen include hand flapping, jumping up and down, head banging, and rocking back and forth. When observing children at play, consider these questions:

Is pretend play present? Does the child point at things and people? Does the child play with other children? Does the child engage in age-appropriate play, such as with manipulatives? Does the child talk about what he is doing?

Observe the child’s social interactions, such as his behavior when greeting another child or an adult. Does the child say something appropriate such as “Hi” when greeted? Does the child respond to your greeting? Do the child’s eyes follow a point; for instance, when you point at an object and say “look at that!”? Does the child recognize your presence?

Parents may be the first to sense something is not quite right. Here are some common comments from parents that may indicate a developmental concern:

• Does she have hearing problems? Does she say words and talk to other children?
• When he was left alone in his room, instead of playing with his toys, he organizes them; all his red trains together, all his books in one corner, all his stuffed animals in another.
• He never wants to play peek-a-boo or make eye contact.
• She does not like to be touched and held. She arches her back and resists being cuddled.
• She relates words with feelings, rather than understanding that they stand for a person or object. Mama means happiness and is not used just for mom. When she sees Dad coming home from work, she cries out, “Mama!”

Early diagnosis and therapy are important for any developmental delay. Caregivers and parents should watch for signs, including ‘red flags,’ that require immediate evaluation by a medical professional. For instance, the loss of any social or language skill at any age--when a child takes a step backwards in his development--is a red flag that should not be ignored.

Delayed milestones are also absolute indications for immediate evaluation:

• No big smiles or warm expressions by six months of age or thereafter.
• No back and forth sharing of sounds, smiles or facial expressions by nine months of age.
• No babbling and pointing by 12 months of age.
• No single words by 16 months of age.
• No spontaneous two word phrases by 24 months of age.

Early intervention and parental education and support are crucial to providing care for autistic children. Speech and occupational therapy, as well as behavior management, are usually part of the plan. Early intervention up to the age of three usually is home based. Program-based intervention starts when the child reaches three years old and can include spending time in a center-based childcare program. Autistic children make progress when they can be given opportunities to interact with other children.

Early intervention leads to better outcomes for these children and their families. Being in a group care environment is often part of the therapy plan. The childcare provider should be included in the care plan. Childcare providers should ask for resources and/or communicate with the therapist to assist in maintaining a seamless treatment plan for the autistic child.

Linda Maywood, MSN, CPNP, Childcare Health Consultant, The Children’s Clinic, Long Beach, CA

Autism Society of America, 7910 Woodmont Ave., Ste. 300, Bethesda, MD 20814-3067; 800-AUTISUM; www.autism-society.org

First Signs, Inc., PO Box 358, Merrimac, MA 01860; 978-346-4380; www.firstsigns.org

Autism and PDD Support; www.autism-pdd.net

Autism Information Center, Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities; www.cdc.gov/ncbddd/dd/ddautism.htm

Autism Resources; www.autism-resources.com