Autism is a neurodevelopmental disorder that causes significant social, communication and behavioral challenges. Autism affects each person in different ways, and symptoms can range from very mild to severe. People with autism share some similar symptoms, such as problems with social interaction. But there are differences in when the symptoms start, how severe they are, and the exact nature of the symptoms.

Once autism is diagnosed, it will last throughout a person's life. It will never go away; however, symptoms may improve over time. Some children with autism show hints of future problems within the first few months of life. In others, symptoms may not manifest until 24 months or later. Some children with autism seem to develop normally until around 18 to 24 months of age and then they stop gaining new skills, or they lose the skills they once had. Studies have shown that one third to half of parents of children with autism noticed a problem before their child's first birthday, and nearly 80%-90% saw problems by 24 months of age.

It is important to note that some people without autism might also have some of these symptoms. But for people with autism, the impairments make life very challenging.

Parents, caregivers, family members, teachers, and others who spend a lot of time with children can look for "red flags." Some may mean a delay in one or more areas of development, while others are more typical of autism.

A person with autism might:

• Not respond to their name by 12 months of age
• Not point at objects to show interest (point at an airplane flying over) by 14 months
• Not play "pretend" games (pretend to "feed" a doll) by 18 months
• Avoid eye contact and want to be alone
• Have trouble understanding other people's feelings or talking about their own feelings
• Have delayed speech and language skills
• Repeat words or phrases over and over (echolalia)
• Give unrelated answers to questions
• Get upset by minor changes
• Have obsessive interests
• Flap their hands, rock their body, or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look, or feel

Social skills

Social issues are one of the most common symptoms in autism. People with autism do not have just social "difficulties" like shyness. The social issues they have cause serious problems in everyday life.

Examples of social issues related to autism:

• Does not respond to name by 12 months of age
• Avoids eye-contact
• Prefers to play alone
• Does not share interests with others
• Only interacts to achieve a desired goal
• Has flat or inappropriate facial expressions
• Does not understand personal space boundaries
• Avoids or resists physical contact
• Is not comforted by others during distress
• Has trouble understanding other people's feelings or talking about own feelings

Typical infants are very interested in the world and people around them. By the first birthday, a typical toddler interacts with others by looking people in the eye, copying words and actions, and using simple gestures such as clapping and waving "bye bye". Typical toddlers also show interests in social games like peek-a-boo and pat-a-cake. But a young child with autism might have a very hard time learning to interact with other people.

Some people with autism might not be interested in other people at all. Others might want friends, but not understand how to develop friendships. Many children with autism have a very hard time learning to take turns and share-much more so than other children. This can make other children not want to play with them.

People with autism might have problems with showing or talking about their feelings. They might also have trouble understanding other people's feelings. Many people with autism are very sensitive to being touched and might not want to be held or cuddled. Self-stimulatory behaviors (e.g., flapping arms over and over) are common among people with autism. Anxiety and depression also affect some people with autism. All of these symptoms can make other social problems even harder to manage.

Each person with autism has different communication skills. Some people can speak well. Others can't speak at all or only very little. About 40% of children with autism do not talk at all. About 25%-30% of children with autism have some words at 12 to 18 months of age and then lose them.Others might speak, but not until later in childhood.

Examples of communication issues related to autism:

• Delayed speech and language skills
• Repeats words or phrases over and over (echolalia)
• Reverses pronouns (e.g., says "me" instead of "I")
• Gives unrelated answers to questions
• Does not point or respond to pointing
• Uses few or no gestures (e.g., does not wave goodbye)
• Talks in a flat, robot-like, or sing-song voice
• Does not pretend in play (e.g., does not pretend to "feed" a doll)
• Does not understand jokes, sarcasm, or teasing

People with autism who do speak might use language in unusual ways. They might not be able to put words into real sentences. Some people with autism say only one word at a time. Others repeat the same words or phrases over and over. Some children repeat what others say, a condition called echolalia. The repeated words might be said right away or at a later time. For example, if you ask someone with autism, "Do you want some juice?" he or she might repeat "Do you want some juice?" instead of answering your question. Although many children without autism go through a stage where they repeat what they hear, it normally passes by three years of age. Some people with autism can speak well but might have a hard time listening to what other people say.

People with autism might have a hard time using and understanding gestures, body language, or tone of voice. For example, people with autism might not understand what it means to wave goodbye. Facial expressions, movements, and gestures may not match what they are saying. For instance, people with autism might smile while saying something sad.

People with autism might say "I" when they mean "you," or vice versa. Their voices might sound flat, robot-like, or high-pitched. People with autism might stand too close to the person they are talking to, or might stick with one topic of conversation for too long. They might talk a lot about something they really like, rather than have a back-and-forth conversation with someone. Some children with fairly good language skills speak like little adults, failing to pick up on the "kid-speak" that is common with other children.

Many people with autism have unusual interest or behaviors.
Examples of unusual interests and behaviors related to autism:

• Lines up toys or other objects
• Plays with toys the same way every time
• Likes parts of objects (e.g., wheels)
• Is very organized
• Gets upset by minor changes
• Has obsessive interests
• Has to follow certain routines
• Flaps hands, rocks body, or spins self in circles

Repetitive motions are actions repeated over and over again. They can involve one part of the body or the entire body or even an object or toy. For instance, people with autism might spend a lot of time repeatedly flapping their arms or rocking from side to side. They might repeatedly turn a light on and off or spin the wheels of a toy car. These types of activities are known as self-stimulation or "stimming."

People with autism often thrive on routine. A change in the normal pattern of the day-like a stop on the way home from school-can be very upsetting to people with autism. They might "lose control" and have a "melt down" or tantrum, especially if in a strange place.

Some people with autism also may develop routines that might seem unusual or unnecessary. For example, a person might try to look in every window he or she walks by a building or might always want to watch a video from beginning to end, including the previews and the credits. Not being allowed to do these types of routines might cause severe frustration and tantrums.

Some people with autism have other symptoms. These might include:

• Hyperactivity (very active)
• Impulsivity (acting without thinking)
• Short attention span
• Aggression
• Causing self injury
• Temper tantrums
• Unusual eating and sleeping habits
• Unusual mood or emotional reactions
• Lack of fear or more fear than expected
• Unusual reactions to the way things sound, smell, taste, look, or feel

People with autism might have unusual responses to touch, smell, sounds, sights, and taste, and feel. For example, they might over- or under-react to pain or to a loud noise. They might have abnormal eating habits. For instance, some people with autism limit their diet to only a few foods. Others might eat nonfood items like dirt or rocks (this is called pica). They might also have issues like chronic constipation or diarrhea.

People with autism might have odd sleeping habits. They also might have abnormal moods or emotional reactions. For instance, they might laugh or cry at unusual times or show no emotional response at times you would expect one. In addition, they might not be afraid of dangerous things, and they could be fearful of harmless objects or events.

A number of the behavioral symptoms of autism are observable by 18 months of age, including: problems with eye contact, not responding to one's name, joint attention problems, underdeveloped skills in pretend play and imitation, and problems with non-verbal communication and language.

In general, the average age of autism diagnosis is currently three years old. In many cases, a delay in the child's starting to speak around age two brings problems to parents' attention, even though other, less noticeable signs may be present at an earlier age.

Studies also show that a subgroup of children with autism experiences a "regression," meaning they stop using the language, play, or social skills they had already learned. This regression usually happens between the first and second birthdays.

Researchers are still learning about the features of regression in autism, and whether the features differ from those shown by individuals who show signs of autism in early life.

Date First Published : April 2, 2007;
Date Last Updated : October 30,2008

One of the hallmarks of autism is a lack of interest in or connection with other people. 1 Although other senses, like hearing or touch, may also be impacted by autism (see Sensory Issues), it is the "social sense" 2 - our intuitive understanding of how to read, reach out to, and successfully interact with other human beings -- that is most intensely affected.

An infant seems uninterested in making eye contact, never smiles, or can't bear to be held. A toddler rocks in a corner, watching his own fingers flick before his face in seeming fascination, oblivious to a parent's attempts to engage him. A child wanders the playground in circles before stopping to stare at the pattern of veins in a fallen leaf, uninterested in the other kids and unable to engage in the recess activities going on around him

This is not the way it's supposed to be. Human infants are hardwired to seek out faces, as opposed to other objects in the environment,3 and to prefer the sound of a human voice over any other sound,4 paying special attention when that voice is loaded with strong emotion.5 Even before they can talk, very young children begin to initiate social connection with a parent by pointing to an object and then alternating their gaze from parent to object and back again, one of a series of behaviors that involve joint attention.6 The communication is clear: "Check out that pretty toy! Isn't that the coolest thing you've ever seen? Isn't it great we can enjoy it together?" A parent understands intuitively, delighting in the shared experience, smiling, making eye contact, gushing over the toy. The child revels in this supportive feedback, encouraged to find more things to share. Sharing feels good.

The sharing isn't just warm and wonderful, either. It's essential, and not just to emotional well-being. The brain, especially in the first years of life, does not only record what happens to us, but builds itself in response to external and internal experiences, particularly social and emotional ones. What this means is that the line between the purely physical (brain structures and chemistry), and the social-emotional or psychological (feelings and shared meaning) has been blurred. Brain structure and experience are interconnected.7,8

Infants on the autism spectrum lack the overriding interest typical infants display for human faces and voices.9 They tend not to seek out their parent's gaze, and so cannot initiate or respond to attempts at shared enjoyment,10 even if they are very much attached to their parent. If the brain is indeed developing in part based on interaction and experiences typical infants help create, it's a double whammy for the child with an ASD. Not only do they suffer from that initial social deficit, but its lack contributes "to a disturbance in social experience that is so robust as to compromise subsequent neurological and behavioral development."11 This explains why experts are so adamant about early intervention. Whatever was wrong to begin with may be getting even more wrong with time.

Wherever a person falls on the autism spectrum, they are affected by this tendency to not pay attention to the social world.12 They may focus on objects instead of people.or look over a conversational partner's shoulder instead of into their eyes. One study showed this by tracking the gaze of people watching a video. Typical people watching a dramatic scene tended to focus right on an actor's eyes. People with ASDs, in contrast, tended to look at mouths or, if they were on the more disabled end of the spectrum, inanimate objects like light switches on the wall.13 Lacking whatever programming drives most of us to focus in on human faces, voices, and gestures means individuals with ASDs - from those that are mentally retarded to those with high IQs14 -- are missing masses of social information.15

People with ASDs not only have a hard time noticing the social world; they have a hard time interpreting it. Early problems with gaze and joint attention, it is believed, come to impact their theory of mind.16 Theory of mind simply refers to the understanding that other people have their own thoughts, perceptions, and intentions separate from one's own. It is part of seeing others as separate beings with their own agendas. To accommodate others, to predict their future behavior, to manipulate or please them, you must have this inbuilt capacity to guess something about who they are and what they might do or desire. Individuals with ASDs lack this ability to a staggering degree.

Because they cannot read social cues, including facial expressions,17 body language, or tone of voice, 18 people all across the autism spectrum are at a disadvantage. Another person may look at his watch ("You're boring me" or "I've gotta go, I'm late!"), use a sarcastic tone, grimace to show increasing annoyance, quirk their eyebrows in disbelief - all of it lost on the person with an ASD. They cannot "see" the social signals that bombard us every day. Neither can they respond appropriately. How could they? They never received the message that was sent: I'm bored. I'm late. You're making me mad.

As a result of all this, individuals with ASDs look "odd" to the outside world. They may stop in the middle of the sidewalk to stare at a fan revolving in a storefront window, oblivious to the crowds of people trying to get by. They may pick their nose in public with no consciousness that this is not OK; walk away in the middle of a conversation; or talk on and on about a topic of no interest to the listener. They may bump into other people, as if they did not see them, or as if they had misjudged how much space was available.

Even higher functioning individuals who are trying to pay attention, who want to connect, constantly commit social mistakes, alienating their peers. 19 In fact, if you are trying to evaluate a child's ability to read the social world, relationships with peers are key. Adults will often adapt to a child's unique way of interacting. Peers will seldom do so. It is in relationships with peers that social issues become most glaring. 20

In summary, those with ASDs may seem aloof, or run right up to strangers and start conversations on obscure topics. They may be lost in their own thoughts, or trying unsuccessfully to connect. Either way, people all across the autism spectrum suffer from an inability to understand the complex dance that characterizes the social world.

Social Issues - References

1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington DC: Author.
2. Gray, C. (2002). The sixth sense II. Arlington, Texas: Future Horizons.
3. Valenza, E., Simion, F., Cassia, V.M., & Umilta, C. (1996). Face preference at birth. Journal of Experimental Psychology: Human Perception and Performance, 22(4), 892-903. Abstract
4. Fifer, W.P., & Moon, C.M. (1994). The role of the mother's voice in the organization of brain function in the newborn. Acta Paediatrica Supplement, 397, 86-93.
5. Grossmann, T., Striano, T., & Friederici, A.D. (2005). Infants' electric brain responses to emotional prosody. NeuroReport, 16(7), 1825-1828. Abstract
6. Mundy, P., & Burnette, C. (2005). Joint attention and neurodevelopmental models of autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.650-681). Hoboken, NJ: John Wiley & Sons.
7. Sullivan, R., Wilson, D.A., Feldon, J., Yee, B.K., Meyer, U., Richter-Levin, G., Avi, A., Michael, T. Gruss, M., Bock, J., Helmeke, C., & Braun, K. (2006). The international society for developmental psychobiology annual meeting symposium: Impact of early life experiences on brain and behavioral development. Developmental Psychobiology, 48(7), 583-602. Abstract
8. Quartz, S.R., & Sejnowski, T.J. (1997). The neural basis of cognitive development: A constructivist manifesto. Behavioral and Brain Sciences, 20, 537-596. Abstract
9. Osterling, J.A., Dawson, G., & Munson, J.A. (2002). Early recognition of 1-year-old infants with autism spectrum disorder versus mental retardation. Developmental Psychopathology, 14(2), 239-51. Abstract
10. Mundy, P. (1995). Joint attention and social-emotional approach behavior in children with autism. Development and Psychopathology, 7, 63-82.
11. Mundy, P., & Burnette, C. (2005). Joint attention and neurodevelopmental models of autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.650-681). Hoboken, NJ: John Wiley & Sons. Page 673.
12. Carter, A.S., Davis, N.O., Klin, A., & Volkmar, F. (2005). Social development in autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.312-334). Hoboken, NJ: John Wiley & Sons.
13. Klin, A., Jones, W., Schultz, R., Volkmar, F., & Cohen, D. (2002). Visual fixation patterns during viewing of naturalisitic social situations as predictors of social competence in individuals with autism. Archives of General Psychiatry, 59, 809-816. Abstract
14. Klin, A. (2000). Attributing social meaning to ambiguous visual stimuli in higher-functioning autism and asperger syndrome: The social attribution task. Journal of Child Psychology and Psychiatry, 41(7), 831-846. Abstract
15. Dawson, G., Meltzoff, A.N., Osterling, J., Rinaldi, J., & Brown, E. (1998). Children with autism fail to orient to naturally occurring social stimuli. Journal of Autism and Developmental Disorders, 28(6), 479-485. Abstract
16. Baron-Cohen, S. (1995). Mindblindness: An essay on autism and theory of mind. Cambridge, MA: MIT Press.
17. Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001). The "Reading the Mind in the Eyes" test revised version: A study with normal adults, and adults with Asperger Syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry, 42(2), 241-251. Abstract
18. Rutherford, M.D., Baron-Cohen, S., & Wheelwright, S. (2002). Reading the mind in the voice: A study with normal adults and adults with Asperger Syndrome and high functioning autism. Journal of Autism and Developmental Disorders, 32(3), 189-194. Abstract
19. Shea, V., & Mesibov, G.B. (2005). Adolescents and adults with autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.288-311). Hoboken, NJ: John Wiley & Sons.
20. Carter, A.S., Davis, N.O., Klin, A., & Volkmar, F.R. (2005). Social development in autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.312-334). Hoboken, NJ: John Wiley & Sons

Date First Published : April 2, 2007;
Date Last Updated : October 30,2008

Communication and language issues are one of the core areas of difficulty for individuals with ASDs.1 Considering the extent of the social deficits they face, this is not surprising. After all, communication, whether verbal and nonverbal, is social. If you tend not to look at faces, if you tend not to pay attention to the human voice, and if you tend not to tune in to verbal and nonverbal feedback from other people, it will be hard for you to acquire speech and to use it naturally. It will also be hard for you to somehow acquire body language, facial expressions, and other nonverbal forms of communication that are the rule for your culture.

Just as with social issues, there is a range of communication and language difficulty across the autism spectrum. Some individuals with an ASD never speak, behaving as though they are deaf, even though hearing tests show they can hear in the normal range. Some experience significant speech delays or ongoing speech impediments. For another group, a few words or phrases are gained only to be lost during the toddler years - a process called regression. This is a "red flag" for autism, because such a loss is practically unknown in other developmental disorders. It is thought to occur in about 25% of children with ASDs.2

Many children, both typically developing and non-autistic but developmentally delayed, have speech problems of some kind. Research has shown, however, that some specific speech difficulties are more common in children with ASDs than in children with other issues. Among these are echolalia -- where children repeat words or phrases that have been spoken by someone else either immediately or later -- and pronoun reversal, which is when a child says "you" when they should be saying "I" or "me".3 For example, a child might say, "You want a cookie" instead of "I want a cookie" when he's trying to get a caregiver to give him a treat.

Even individuals with a normal IQ and rich vocabulary may have a hard time not only with what they are saying, but with how they say it, or prosody. They may speak in a monotone, fail to put the rising inflection in their voice that usually comes at the end of questions, speak very slow or fast, and otherwise sound strange to other people's ears. Just as they are not focused on others' body language, it is likely they may not clue into others' intonation patterns and so fail to copy or fully understand them. Says one group of researchers, "Odd intonation patterns associated with autism seem to be one of the most immediately recognizable clinical signs of the disorder." 4

Individuals with ASDs are also known for taking speech very literally, struggling to make sense of puns, sarcasm, humor, metaphors or any other play on words that even very young "typical" children understand intuitively. If someone who had made a major mistake at school or work said, "I'm in hot water now!" a person with an ASD might be puzzled. The speaker was not standing in any water, so how could it be hot?

Pragmatic language, which is sometimes referred to as the "art of conversation," is also a challenge for people with ASDs. When to enter a conversation, taking turns controlling the topic, taking turns speaking, making comments to show interest in what the conversational partner is saying, and gracefully exiting the conversation -- all of these are part of pragmatic language. Individuals with ASDs often talk on and on about a topic that is their passion, regardless of the interest of the listener. It is often said that they tend to talk at other people instead of with them.5 Individuals with Asperger's syndrome are particularly known for using "pedantic" speech, that is, for using advanced vocabulary words and complex phrases to hold forth on a beloved topic like a "little professor" -- something which, at least in childhood, does not endear them to their peers.6

Where a person falls on the autism spectrum will likely determine what kind of language and communication challenges they face, but there is little doubt that there will be challenges in this area. Those who are supporting a person with an ASD need to keep in mind that the person they care about is challenged not just in language, but in grasping what language is about: communication and connection between different minds. (See Social Issues.)

Communication and Language - References

1. American Psychiatric Association. (2004). Diagnostic and statistical manual of mental disorders (4th ed., rev.). Washington DC: Author.
2. Lord, C., Shulman, C., & DiLavore, P. (2004). Regression and word loss in autistic spectrum disorders. Journal of Child Psychology and Psychiatry 45(5): 936-955. Abstract
3. Tager-Flusberg, H., Paul, R., & Lord, C. (2005). Language and communication in autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.650-681). Hoboken, NJ: John Wiley & Sons. Page 347
4. Tager-Flusberg, H., Paul, R., & Lord, C. (2005). Language and communication in autism. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.650-681). Hoboken, NJ: John Wiley & Sons. Pg. 348
5. Paul, R. (2005). Assessing communication in autism spectrum disorders. In F. Volkmar et al. (Eds.), Handbook of Autism and Pervasive Developmental Disorders (pp.799-816). Hoboken, NJ: John Wiley & Sons. Page 807
6. South, M., Ozonoff, S., & McMahon, W.M. (2005). Repetitive behavior profiles in asperger syndrome and high functioning autism. Journal of Autism and Development Disorders, 35(2), 145-158. Abstract