Do Children With Autism Reach Developmental Milestones on Time?

A developmental milestone is a sign of typical child development. Children reach dozens of developmental milestones between birth and adulthood. Early milestones include social smiles, rolling over, and sitting up. Later milestones involve the acquisition of language, social, physical, and emotional skills, and intellectual abilities.

Children with autism tend not to reach all of their developmental milestones at the appropriate times. But that statement is a huge oversimplification of the reality because:

• Many autistic children reach early developmental milestones on time or early, but then lose ground.
• Most autistic children reach some of their developmental milestones on time or early, but reach others late or not at all.
• Some autistic children reach some of their developmental milestones extraordinarily early but reach others extraordinarily late.
• Children with autism can appear to gain important skills—but in fact be unable to use those skills in real-world situations.
• Many children with autism have so-called "splinter" skills, which can be very advanced but which are not useful in daily life.
• Autistic children, particularly girls who are high-functioning, are sometimes able to hide or overcome some developmental delays.

With so few absolutes, it's no wonder both parents and practitioners can find it hard to spot autism, especially in very young or very high functioning children. There are, however, a few developmental markers that are most likely and most obvious when a child is autistic.

The CDC divides developmental milestones into groups: movement/physical, cognitive, language/communication, social/emotional. They list specific levels of achievement for each age, starting with 1 month and moving through adolescence. While they make it clear that children may not reach any given milestone at the precise age described, they also suggest that parents keep an eye out to be sure their child is at or close to normal.

Most children with autism are diagnosed at a relatively young age—often by the age of 3. Here is a simplified list of milestones for 3-year-olds from the CDC:

Social and Emotional

• Copies adults and friends 
• Shows affection for friends without prompting 
• Takes turns in games
• Shows concern for crying friend
• Understands the idea of “mine” and “his” or “hers”
• Shows a wide range of emotions 
• Separates easily from mom and dad 
• May get upset with major changes in routine  
• Dresses and undresses self 

Language/Communication

• Follows instructions with 2 or 3 steps
• Can name most familiar things
• Understands words like “in,” “on,” and “under”
• Says first name, age, and sex  
• Names a friend
• Says words like “I,” “me,” “we,” and “you” and some plurals (cars, dogs, cats)
• Talks well enough for strangers to understand most of the time
• Carries on a conversation using 2 to 3 sentences

Cognitive (learning, thinking, problem-solving)

• Can work toys with buttons, levers, and moving parts 
• Plays make-believe with dolls, animals, and people 
• Completes puzzles with 3 or 4 pieces 
• Understands what “two” means
• Copies a circle with pencil or crayon 
• Turns book pages one at a time 
• Builds towers of more than 6 blocks 
• Screws and unscrews jar lids or turns door handle 

Movement/Physical Development

• Climbs well 
• Runs easily
• Pedals a tricycle (3-wheel bike) 
• Walks up and down stairs, one foot on each step 

There are many reasons why children miss developmental milestones. In most cases, there's no particular cause for concern. That's because:

• Children are different from one another and, naturally, develop at different rates.
• Children who are born prematurely may miss milestones but usually catch up.
• Boys are often slower to develop than girls, but almost always catch up.
• Many children are so focused on certain milestones that they may miss others. For example, a very physically adept child may reach advanced physical milestones and then later catch up on social milestones.
• Early medical challenges may slow development—but most children are able to catch up to their same-age peers.
• Certain correctable challenges, such as difficulty with hearing, can slow early development but have little impact on long-term development.

So when should parents be concerned about autism? CDC provides a short list of issues that should raise red flags.

• Can’t work simple toys (such as peg boards, simple puzzles, turning handle)
• Doesn’t speak in sentences
• Doesn’t understand simple instructions
• Doesn’t play pretend or make-believe
• Doesn’t want to play with other children or with toys
• Doesn’t make eye contact
• Loses skills he once had

While these issues can be signs of autism, however, they may not be. Autism is more likely when children have more than one of these issues or have other related issues in the social/emotional or communication realms.

Sometimes, children with autism miss multiple milestones and have clear and obvious developmental delays. Often, however, missed milestones can be masked or even invisible. This is because children with autism aren't simply delayed; they learn and behave differently from their typical peers.

In addition, autism is rarely obvious from birth. Many children with autism develop normally for a period of time and then either slow down, develop idiosyncratically, or actually regress. Because of these issues, it can be tough to spot autism just by watching for missed developmental milestones.

Here an example of how autism can make it difficult to monitor milestones accurately in a 3-year-old.

Johnny is 3 years old. He was born at full term and met all his milestones through age 2. He has a vocabulary of many words, some of which are scientific terms that are well above the 3-year-old level. He is also able to say multi-word sentences such as "I want juice," or "cookie starts with C." Johnny can also count to 20. Based on this description, it sounds like Johnny is doing well, and has met and exceeded most of his communications and cognitive milestones.

But Johnny is both bright and autistic. As a result, he has memorized a number of three-word sentences from TV.  If you listen closely, you will notice that he is not responding to real situations in the moment. Instead, he is "replaying" speeches from Sesame Street, in exactly the same style and tone as the characters in the show. He can count to 20, but only when he does so in the same voice as the "Count" from the TV show.

When tested, it becomes clear that Johnny cannot reorder vocabulary words to create novel sentences. He can only talk about dinosaurs when he is reciting snippets from documentaries. And while he is able to recite his numbers, he cannot actually count objects.

It may take Johnny's parents a long time to notice that Johnny's language skills are not exactly delayed—but they are idiosyncratic. Teachers may even think he is precocious—and, of course, he IS precocious in certain ways. Before they see any significant issues, adults in Johnny's life may need to see other challenges arise, such as difficulty with play skills, eye contact, or social interaction.

Some children with autism have severe cognitive delays, behavioral challenges, or physical "stims" (rocking or flapping) that make it obvious that something is wrong. But many autistic children have few or mild delays, challenges, or stims. When that's the case, developmental delays may be hard to spot.

Here are a few groups of children whose developmental delays may not be obvious until social, emotional, or communication demands increase (usually after grades 1 or 2):

• Girls: Autism generally causes children to be quiet, socially withdrawn, and less likely to raise their hands or speak out. They may appear "dreamy" or inattentive. These behaviors are culturally appropriate for girls in most parts of the world. Thus, young autistic girls who are not meeting developmental milestones may slide under the radar. They are often labeled as "shy and quiet," and, perhaps, not terribly bright. It may take quite a while for parents and teachers to notice other symptoms.
• Children with impressive intelligence or splinter skills. Quite a few children with autism are very bright or have surprising skills that are far beyond their years. For example, some children with autism can solve complex puzzles, read at a very young age, or show impressive math, music, or computer skills. They may also have advanced vocabularies in their areas of special interest. When this is the case, parents and teachers may not notice that the same child who can solve complex math equations is unable to play imaginatively or catch a ball.

If you think your child has developmental delays and may be autistic, take action. Ask your pediatrician to screen your child for delays, with a special emphasis on social, communication, and emotional skills.

If your intuition was incorrect, you've lost nothing but an hour of time and a load of anxiety. If your child does, indeed, have developmental delays you've taken action promptly and can expect to quickly access resources and programs that can help him or her to overcome any challenges.

Bottom line, you have nothing to lose and everything to gain by taking prompt action!