Journal of Autism and Developmental Disorders, Vol. 29, No.

3, 1999

Autism During Infancy: A Retrospective Video Analysis of Sensory-Motor and Social Behaviors at 9-12 Months of Age
Grace T. Baranek1

This retrospective video study explored the usefulness of sensory-motor measures in addition to social behaviors as early predictors of autism during infancy. Three groups included 11 children with autism, 10 with developmental disabilities, and 11 typically developing children. Home videos were edited to obtain a 10-minute cross-section of situations at 9-12 months for each subject. Using interval scoring, raters coded several behavioral categories (i.e., Looking, Affect, Response to Name, Anticipatory Postures, Motor/Object Stereotypies, Social Touch, Sensory Modulation). Nine items, in combination, were found to discriminate the three groups with a correct classification rate of 93.75%. These findings indicate that subtle symptoms of autism are present at 9-12 months, and suggest that early assessment procedures need to consider sensory processing/sensory-motor functions in addition to social responses during infancy. Furthermore, prior to a time that they reported autistic symptoms, caregivers used compensatory strategies to increase the saliency of stimuli in order to engage their children more successfully; these strategies may provide a window for earlier diagnosis.
KEY WORDS: Home movies; autistic symptoms; developmental disabilities; early diagnosis; sensory processing; social responsiveness.

INTRODUCTION An accurate diagnosis of autism appears reliable no earlier than 2 to 3 years of age (e.g., Lord, 1995) despite the overwhelming conviction that it is a neurodevelopmental disorder of prenatal origin (Bailey, Phillips, & Rutter, 1996; Gillberg & Coleman, 1992; Rutter & Schopler, 1987; Volkmar, Stier, & Cohen, 1985). The early elusiveness of autism leads to speculation about whether symptoms actually do exist in infancy and if so, whether they are too subtle to be detected reliably. Earlier diagnosis appears limited by (a) our knowledge of the early development in those infants later diagnosed with autism, and (b) our reliance on conventional classification systems (e.g., DSM-IV; American Psychiatric Association [APA], 1994) based
1

Center for Development and Learning and Division of Occupational Therapy, CB #7255, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7255; e-mail: gbaranek@css. unc.edu

on the "triad" of behaviors (i.e., social, language, and behavioral symptoms) manifested in older children with autism. Both the presence of unusual behaviors (e.g., stereotypies) as well as the absence of typically developing behaviors (e.g., verbal language) are considered for diagnosis. Therefore, professionals are reluctant to diagnose autism prior to the age that a child would typically develop representational capacities and prior to expectations for production of consistent social initiatives such as sharing, offering comfort, and initiating joint attention. Moreover, the course of autistic symptomatology may change considerably with age; thus, symptoms during infancy may not appear at all like later manifestations of the disorder (Bailey et al, 1996; Gillberg et al, 1990; Watson & Marcus, 1988). Research has also shown that autistic symptoms are easier to recognize as they intensify or become more pervasive with age (Adrien et al., 1993; Lord, 1995; Wing, 1969), and parents' awareness of symptoms also varies with their child's stages of development (Stone & Hogan, 1993).
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0162-3257/99/0600-0213S16.00/0 1999 Plenum Publishing Corporation

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Early Predictors: Findings and Speculations The essential questions still remain: Can subtle autistic symptoms be identified during infancy, and if so, what measures would be relevant and sensitive to these early behavioral manifestations? Prospective studies of young children (i.e., 18-24 months) have highlighted the importance of social-communicative functions as early predictors of a later, more reliable diagnosis of autism (Baron-Cohen et al., 1996; Lord, 1995). The absence of typically developing, prelinguistic functions such as protodeclarative pointing, showing objects, joint attention, affective exchanges, pretend play, and imitation have been specifically cited as markers of autism in young children (e.g., Baron-Cohen et al., 1996; Dawson, Hill, Spencer, Galpert, & Walson, 1990; Lord, 1995; Sigman, Mundy, Sherman, & Ungerer, 1986; Stone, Lemanek, Fishel, Fernandez, & Altmeier, 1990) and these are thought to be precursors of later appearing deficits in social relatedness and communication. However, the predictive validity of these behaviors appears questionable prior to about 18 months of age. Perhaps some of these indicators may need to be down-graded in order to be applicable to the infancy period and/or markers in other domains of infant functioning need to be considered. Gillberg et al. (1990) suggested that abnormal perceptual responses as well as social deficits may be likely indicators of autism during infancy. Although social cognition and communicative functions have been investigated widely, there is a dearth of empirical information about the various qualitative aspects of sensory-motor behaviors (e.g., sensoryperceptual responses, arousal modulation, movement patterns, object manipulations, postural adjustments) that may be disrupted early in the development of children with autism. These types of difficulties are reported extensively in older children with autism (e.g., Adrien Ornitz, Barthelemy, Sauvage, LeLord, 1987; O'Connor & Hermelin, 1967; Ornitz, Guthrie, & Farley, 1977) as well as in retrospective accounts of the infancy period based on medical chart reviews and/or parental reports (Dahlgren & Gillberg, 1989; Gillberg et al., 1990; Kanner, 1943; Wing, 1969). An empirical study of sensorymotor functions early in the development of autism could reveal potential markers of autism that, while subtle, may prove foundations to later evolving symptoms either within or outside of the sensory-motor domain. Sensory-motor processes are salient from birth and thus may be easily observable throughout infancy prior to the development of abnormalities in many of the higher level representational capacities (e.g., symbolic thought; theory of mind) that currently have evoked much interest in research.

Baranek Furthermore, some sensory-motor behaviors may serve functions underlying several domains of behavior early in life. For example, gaze aversion is thought to subserve arousal modulation necessary for selfregulatory behaviors and early social interactions (Dawson & Lewy, 1989; Field, 1981). Both Kanner (1943) and Wing (1969) described a variety of very early developing autistic features that could be conceptualized as crossing the social/nonsocial distinction (e.g., deficient anticipatory postures, intolerance of physical handling, hypo- and hyperresponsiveness to sensory stimuli). Additionally, a variety of specific sensory-seeking behaviors (e.g., scratching fabrics, staring at lights) are also reported retrospectively during infancy. Many of these qualitatively different sensory-motor behaviors are not the focus of conventional assessments, and thus, potential markers of autism during infancy could be overlooked by practitioners. Retrospective Video Analysis Due to the impossibility of obtaining autistic infants as research subjects, researchers have been seeking other methods to identify signs of vulnerability early in development. With the advent of affordable video technology, families in increasing numbers have home videos which inadvertently provide documentation of their children's development. Retrospective video analysis has shown success as an ecologically valid methodological tool for earlier identification of children with various psychopathologies (Adrien et al., 1993; Grimes & Walker, 1994; Losche, 1990, Massie, 1977; Osterling & Dawson, 1994; Rosenthal, Massie, & Wulff, 1980). Although a myriad of methodological problems are encountered (e.g., difficulty controlling variables such as the age of subjects and length, content or structure of the video segments), retrospective video analysis currently appears to be an excellent option for accessing very early periods in development months or years before a child with autism is diagnosed. Several retrospective video studies conducted specifically in the autism realm suggest that young children with autism can be distinguished from typically developing children with respect to sensorimotor intelligence (Losche, 1990), orientation to social stimuli (e.g., looking/joint attention) (Osterling & Dawson, 1994), and less commonly, motility, sensory modulation, and attention (Adrien et al., 1993). Osterling and Dawson (1994), in a video study of first birthdays comparing autistic and typical groups, found that "looking at other persons" was the best single predictor of a later diagnosis of autism. One common problem with these

Autism During Infancy studies is the difficulty in obtaining an appropriate comparison group (i.e., children with mental retardation). One video study (Adrien et al., 1992) found that a combination of 19 social and sensory items differentiated children (6-48 months) with autism from those with mental retardation as well as those with typical development. However, few of the autistic subjects were under 2 years of age, which provided limited information on the usefulness of some of the items during the infancy period. The purposes of this study were to (a) explore the usefulness of sensory-motor variables in addition to social markers of autism during the infancy period; (b) identify variables that may indicate differences at 9-12 months of ageearlier than previously accomplished using retrospective video analysis (i.e., early prediction); and (c) discriminate between groups of children with autism (AUT), developmental disabilities (DD), and typical development (TYP) with respect to these variables (i.e., differential diagnosis). METHOD Participant Recruitment Participant recruitment was an arduous process, fraught with unexpected complications, and consequently was accomplished through several stages. An estimated 1,000 families were contacted through personal and professional contacts, advertisements, and direct mailings/distributions through hospital-based clinics, public and private schools, early intervention programs, and advocacy groups for children with autism and mental retardation. Initial recruitment criteria included that the child currently was above 2 years of age, and was diagnosed with either autism (for the AUT group) or mental retardation not associated with a physical syndrome (for the DD group), or was typically developing (for the TYP group). All families were required to have home videos of their child between birth and 2 years of age that they were willing to share in this research. Since there were few responses from families of children diagnosed with mental retardation following 2 years of recruitment, the criteria for the DD group were modified and expanded. One possible cause for this difficulty appeared to be that professionals were reluctant to label very young children with mental retardation and opted instead for less stigmatizing labels such as "developmentally delayed" or "cognitively delayed." Except in cases of an identifiable syndrome (e.g., Down syndrome), mental retardation was rarely diagnosed. Thus, the terminology in this study's re-

215
cruitment literature for the DD group in this study was changed to reflect "nonspecific or generalized" developmental delays, developmental disabilities, and cognitive impairments, and it was expanded to include those children with mental retardation associated with syndromes. The overall positive response rate to the direct mailings and distributions was about 10%, with greater success from those agencies that (a) catered to higher SES areas (e.g., suburbs), (b) collected the responses directly, or (c) provided follow-up after the initial requests were mailed. Generally, connections made through personal contacts and professional colleagues were often more successful than through those agencies with which less personal contact was possible. A total of 75 families agreed to participate, signed the informed consent, allowed an interview, and/or provided the research team with videos of their child between birth and 2 years of age. In the second stage of screening procedures, the study was narrowed further to include only those families that had provided good quality videos with sufficient content from 9 through 12 months adjusted age. Children were also excluded if they had significant visual, hearing, or physical impairments (e.g., cerebral palsy). Thirty-two children remained that met all of the selection criteria and whose families completed all necessary interview and observational procedures (as described below). Subject Demographics Thirty-two children, belonging to one of three groups AUT (n = 11), DD (n = 10), TYP (n =11), were the subjects in this study. Although their current chronological ages varied, all subjects were represented on video at the exact same age group (i.e., 9 through 12 months corrected chronological age). There were 19 boys (AUT = 10, DD=3, TYP=6) and 13 girls (AUT= 1, DD=7, TYP=5). Twenty-seven children (88%) were Caucasian (AUT=10, DD=8, TYP=9). The remaining five subjects had the following ethnic breakdown: one Hispanic (AUT= 1); two Asian (DD= 1, TYP=1); one African American (TYP= 1); and one Native American (DD= 1). The group of 11 TYP children were all normally developing with no history of developmental or learning problems reported by their parents. They were all functioning in the average range on the Vineland Adaptive Behavior Scales, Interview Edition, Survey Form (VABS; Sparrow, Balla, & Cicchetti, 1984) which was later administered by the investigator.

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Baranek retardation (MR): 0 = Average/Above average intelligence (85+); 1 = Borderline (70-84); 2 = Mild MR (55-69); 3 = Moderate MR (40-54); 4 = Severe/ Profound MR (<39). Level of MR was not significantly different between the AUT and DD groups, t (19) = .04, p > .05. In addition, all children in this study were assessed for their current level of developmental maturity/adaptive behavior using the VABS. The parent most familiar with his/her child's daily functioning was used as the informant, which in all but two cases were the children's mothers. The interviews were conducted at a location and time convenient to each family. Parents were sent a summary of the VABS results from this interview. Since the children's current chronological ages varied, developmental ages could not be used as a comparison. Therefore, the VABS composite standard score was used in the study as an index of current developmental maturity (DQ) to compare the groups. Overall DQ differences on the VABS Adaptive Composite Standard Score were not statistically significant for the AUT and the DD groups, t (19) = -2.02, p > .05. Also, the VABS Communication Standard Scores were not significantly different for these two groups, t (19) = -1.06, p > .05. (See Table I.) Of secondary interest to the study, supplemental medical and developmental information was obtained on the subjects and is thus summarized in Table II. The DD group was reported to have experienced more frequent (early) medical complications (e.g., jaundice, heart problems, recurrent infections) than either of the other two groups, x2 (2, N = 32), = 11.04, p < .005. As expected, age at diagnosis was also significantly later for the AUT group (M - 33 months), compared with the DD group (M = 3 months) groups, t (19) = 8.25, p < 001. Parents of both groups overwhelmingly reported onset of developmental problems early (i.e., prior to 18 months); however, the AUT group reportedly evidenced these problems significantly later than the DD group, t (19) = 5.54, p < .001. In addition, regression (usually noted as a loss of language) was reported by parents in 54% of the cases in the AUT group. Videotape Collection and Review Procedures Initially, all families were asked to provide any videotapes of their child that were taken under 2 years of age. Copies of the videos were made in a manner that was convenient to each family and coded by ID number to preserve confidentiality. Families were reimbursed for the cost of videotapes and postage. The specific ages and types of situations on the videos were

All AUT subjects were originally diagnosed by their physician or licensed psychologist using DSMIII-R or DSM-IV (APA, 1994) criteria and, in many cases, the Autism Diagnostic Interview-Revised (ADIR; Lord, Rutter, & LeCouteur, 1994) as well. Additionally, inclusion criteria for this study were (a) a confirmation of the diagnosis of Autistic disorder using the DSM-IV and (b) a score above 30 on the Childhood Autism Rating Scale (CARS; Schopler, Reichler, & Renner, 1988) administered by the investigator. The children with DD (n=10) each had a documented developmental disability or mental retardation reported in school or medical records. Specifically, this group included 6 children with Down syndrome, 2 with William syndrome, and 2 with nonspecific mental retardation/developmental disabilities. They all had CARS scores below 25 (nonautistic range). Subject Assessments The CARS was administered to the AUT and DD groups through an individualized parent interview and supplementary play observation of each child. Results of this assessment and all others are reported as group data in Table I. To compare the AUT and DD groups on critical variables, current developmental information was obtained. Levels of cognitive functioning (i.e., Intelligence Quotients/Mental Ages) were obtained from the children's current medical or school psychological reports indicating results of standardized assessments that were determined to be individually appropriate for each child based on their age and diagnosis. For this study, their scores were coded to reflect the overall level of mental

Table I. Current Subject Characteristics Autism M (SD) 63 (17) 2(1) Mild 56 (1 1) 63 (23) 53 (13)c 60 (8)c 73(14) 36 (5)c
DD M (SD) 65 2(1) Mild

Characteristic Chronological age (months) Level of MR VABS" Composite SS (DQ) Communication SS Daily Living SS Social SS Motor SS CARSb
a

Typical M (SD)
53 (25) 0 None 106 (7) 110 (10) 96 (6) 105 (7) 108 (11)

65(8) 71 (8) 65 (12)c 80(13) c 62(9) 20 (2)c

Vineland Adaptive Behavior Scales-Standard Scores. * Childhood Autism Rating Scale. c p <. 05 (t test, DD and AUT groups).

Autism During Infancy

Table II. Medical History of Subjects by Group Characteristic Premature (<36 weeks gestation) Signif. medical problemsb Experienced regression* Early onset (< 18 months) Autism (n = 11) (%) DD (n = 10) (%) Typical (n = 11) (%)

217

9.1
36.4 54.5 81.8

30 80 10 100
M (SD)
3.40 (7.44) 0.75 (0.79) 20.00 (1 child)

0 9.1

M (SD)
Age (months) at diagnosis" Age (months) parent first noticed problems" Age (months) at regression" " t test, p < .05 (DD & AUT groups). b f,p< .05 (DD & AUT groups). 32.55 (8.62) 13.86 (7.43) 20.33(2.94)

not limited initially, in order to obtain as much footage as possible before deciding how to edit the tapes. They included segments from family play situations, special events, and/or familiar routines (e.g., mealtime). Each tape was then screened for minimum quality standards. Any tape that was not in standard VHS format or speed was transferred to be compatible with VHS editing equipment. Once the tapes were received, they were reviewed in detail and logged according to the child's chronological age during each scenario and specific content. Chronological ages were calculated by full months, based on the child's birth date and corresponding dates appearing on the tapes themselves. [Note: For those children (n = 4) who were born prematurely (<36 weeks gestation), corrected chronological age was calculated for each video segment by adjusting for the amount of prematurity.] If the dates were not explicitly marked on the videos, or were not reliable for other reasons, the parents were contacted in order to verify the child's exact age in the scene. If ages could not be determined accurately (within 1 month), the video segments were discarded. As expected, the content of the videos varied substantiallysome families had several hours of tape with their child in a range of situations at different ages, whereas others only more limited footage. The 9- through 12-month age range was selected as a focus for this study for several reasons:(a) parents documented an abundance of sensory-motor and social skills emerging in their children at this age such that a sufficient amount of footage (representing a wide range of situations) was available and adequate for editing purposes, (b) it was the youngest age range available on tape with sufficient footage to code, and (c) it represented all groups of subjects prior to the development of substantial expressive language skills (i.e., words)

such that the autistic group would not be distinguishable from the others on this factor alone. To prepare for the editing process, all subjects' videos were previewed and marked for only those situations occurring at 9-12 months. All of the videos of children at this age group necessarily involved social interaction, since adults were always in the child's presence. Sensory-motor behaviors thus could be observed in the context of social play. Video Editing Procedures A research assistant who was unaware of the purposes of the study edited the videotapes. For each subject individually, she was instructed to randomly select a cross-section of scenes from the available footage at the designated 9- to 12-month age range, ensuring that the child was visible in all scenes. The various scenes were assembled into two 5-minute video compilations, for an exact total of 10 minutes per subject. These newly edited video segments were identified by the subject's ID number, followed by either segment 'A' or 'B'. An average of four scenes were represented in each of the two 5-minute segments per child. No significant differences were found with respect to the number of events in the video segments, F(2, 62) = 0.76, p > .05, average number of persons evident (n = 4), F(2, 62) =1.14, p > .05, amount of physical restriction, F(2, 62) = 1.32, p > .05, and level of social interaction/structure, F(2,62) = 1.34, p > .05. Those subjects with less than 10 minutes of usable edited footage were eliminated from the studya process that resulted in the final selection of the 32 children described previously. The order of the subjects was randomly mixed onto the final master tapes to be used later for coding purposes. Once the video editing was completed, a

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prerecorded audio track with an interval timing method was superimposed onto the master videotapes. This audio was added to, but did not replace, the sound track already on the videotapes. Thus, the raters could hear both the sounds occurring in the natural context and the directions for when to score the intervals. Video Coding Procedures The data collection format depended somewhat on the behavioral category being coded. The general categories of behavior included Looking & Gaze Aversion, Affect, Social Touch, Postural Adjustments, Responsiveness to Name, Motor & Object Stereotypies, and Sensory (Tactile, Auditory, Visual, and Vestibular) Modulation. These categories were developed from the literature and are summarized in Table HI. The detailed coding scale may be found in Baranek (1996). An interval scoring method was used for the majority of the variables in the categories listed above. One category was coded at a time. There were 20 consecutive 15-second intervals in each 5-minute segment of video. For each variable, frequencies were computed across the 20 intervals. Then, these frequencies were converted to rates (i.e., proportion of time behavior was observed over each of the two 5-minute segments). Proportion scores have been similarly used in other video studies (Grimes & Walker, 1994; Osterling & Dawson, 1994; Walker, Grimes, Davis, & Smith, 1993), and this method allowed a way to control for the relative rate at which children encounter less-frequent sit-

Baranek uations. A few remaining variables (e.g., intensity of affective expressions; level of object play; sensory modulation responsiveness/aversion) were quantified using a 4-point rating scale. These scores were recorded as an overall (mean) rating for the video segment. Since there were two 5-minute segments for each child, an average (mean) score was obtained for each behavior of interest (either frequency or rating) and used in the final statistical analyses. Interrater Reliability Two raters, blind to the hypotheses of the study, were trained to use the coding scale and forms. Training was accomplished through a review of the coding scale, followed by viewing of video samples of children not being used in the study. Interrater reliability was obtained by having the raters score approximately 7 to 10 (5-minute) video samples for each behavioral category. A conservative measure of interrater reliability was used by calculating percentage agreement (for positive instances) for each variable used in interval scoring method. Percentage agreement scores ranged from 78 to 100% (for positive instances) for individual variables. Additionally, intraclass correlations (ICCs) were computed for all behavioral categories (both frequency rates and rating scores). The ICC coefficients were as follow: Affective Expressions (.98), Affect Animation Rating (.88), Anticipatory Postures (.71), Orientation to Auditory Stimuli rates (.80), Auditory Responsiveness/Aversion Rating (1.0), Gaze

Table III. Description of Variables Used For Coding CATEGORY Affective expressions Looking Gaze aversion Response to name Social touch responses Anticipatory posture Motor stereotypies Object stereotypies Tactile modulation Auditory modulation Visual modulation Vestibular modulation Description of items Frequencies of positive and negative expressions (across all intervals); Qualitative rating of range and intensity of affective expressions Frequencies of looking at persons, camera, objects across all intervals Occurrences of gaze avoidance based on opportunities for face-to-face interactions Proportion of time child responds to name (based on opportunities); Number of prompts given by adult Occurrences of social touch aversion (based on opportunities for physical contact) Frequency of anticipatory postures (reaching) in response to adult gesture Frequencies of repetitive movements of arms and legs; and nonrepetitive unusual movements (e.g., posturing; SIB) across all intervals Frequencies of repetitive object interactions (e.g., Twiddle; Tap; Spin; Stare; Line-up; Rub; Mouth objects) across all intervals; Rating of overall quality/rigidity of object play Occurrences of orientation/attention to (nonsocial) novel tactual stimuli based on opportunities; Tactile responsiveness/aversion rating Occurrences of orientation/attention to (nonsocial) novel auditory stimuli based on opportunities; Auditory responsiveness/aversion rating Occurrences of orientation/attention to (nonsocial) novel visual stimuli based on opportunities; Visual responsiveness/aversion rating Occurrences of orientation to sudden/novel movement stimuli based on opportunities; Vestibular responsiveness/aversion rating

Autism During Infancy Aversion (.95), Looking Behaviors (.92), Motor Stereotypies (.92), Object Stereotypies (.95), Object Play rating (.78), Number of Name Prompts (.99), Response to Name rates (.98), Social Touch Responses (.95), Orientation to Tactile Stimuli rates (.97), Tactile Responsiveness/Aversion rating (.71), Orientation to Vestibular Stimuli rates (.89), Vestibular Responsiveness/ Aversion rating (.88), Orientation to Visual Stimuli rates (.92), Visual Responsiveness/Aversion rating (.76). RESULTS To explore the usefulness of the individual variables, first descriptive statistics were derived for all variables by group. Due to limitations inherent in using the random video sampling method, two categories (i.e., Vestibular Modulation, Anticipatory Postures) were eliminated, since more than one third of the subjects were not videotaped in situations that would elicit these types of behaviors. Additionally, a few individual variables of interest (e.g, spinning, lining up objects, self-injurious behavior) were excluded since they were extremely low in frequency (i.e., <10% cases) or did not occur at all in any of the subjects. For the remaining variables, a series of one-way analyses of variance (ANOVAs) were performed on each of the remaining variables to explore the data for potential differences between the three groups. See Table IV for all results of the descriptive statistics and ANOVAs. Nine variables were found to demonstrate group differences. Object Play Rating was significantly different between the groups, F (2, 29) = 4.890, p = .01, with the mean rating for the DD indicating more stereotyped, inappropriate play than either of the other two groups. Looking at Camera was also significant, F (2, 29) = 3.373, p - .04, again with the DD group demonstrating significantly less looking toward the camera/person at camera (37% of intervals) versus the AUT (57% of intervals) and TYP (59% of intervals). Unusual Posturing was significantly more frequent in the DD (13% intervals) and AUT (10% intervals) groups relative to the TYP (4% intervals) group, F(2, 29) = 3.141, p = .05. Number of Name Prompts was significantly different between the three groups, F (2, 29) = 3.106, p = 05, with the AUT group demonstrating more adult prompting needed in order to respond after their names were called (AUT = 1.1 prompts needed on average vs. DD = 0.4 and TYP = 0.2). Also of interest were the following findings and trends: Orientation to Visual Stimuli F(2, 29) = 2.979, p = .06, was less for the AUT group (responded visually 65% time, given such opportunities) than the DD

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(85%) and TYP (81%) groups. More common in the AUT group was Mouthing of Objects (AUT = 18%, DD = 9%, TYP = 8% of intervals), F(2, 29) = 2.829, p=.07 and Social Touch Aversions (AUT = 9%, DD = 2%, TYP = 1% of opportunities), F(2, 29) = 2.713, p = .08. Visual Staring/Fixation on Objects was more common in the DD group (6% of intervals) versus the AUT (1%) and the TYP (0.5%) groups, F(2, 29) = 2.670, p = .08. Finally, Affect Rating showed a tendency for lower ratings (less animation in affective expressions) in the DD group, F(2, 29) = 2.602, p = .09. (See Table IV.) A central question in this study was whether or not group membership (AUT, DD, TYP) could be predicted correctly from the dependent measures. The nine variables (determined to be potentially useful through the ANOVAs listed above) were used as predictors in a standard discriminant analysis. The resultant individual Wilks's lambda coefficients for each of the nine predictor variables were found to be as follows: Looking at Camera - .81; Object Play Rating = .74; Mouthing Objects = .83; Number of Name Prompts = .82; Affect Rating = .84; Posturing = .82; Social Touch Aversion = .84; Visual Staring/Fixation = .84; and Orientation to Visual Stimuli = .82. The discriminant analysis demonstrated significant results, %2 (18) = 48.35, p < .0001 (Table V). Two functions emerged and the first function accounted for 72% of the variance. Items that loaded more strongly on the first function were: Mouthing (1.20); Social Touch Aversions (0.95); Orientation to Visual Stimuli (-0.81); and Number of Name Prompts (0.56). The second function accounted for the remaining variance (18%). Items loading most strongly on the second function were: Posturing (0.90); Object Play Rating (-0.68); Looking at Camera (-0.43); Visual Object Stereotypy (0.23); and Affect Rating (-0.28). The first function appeared to discriminate the children with AUT from the other two groups. The second function discriminated the TYP children from the DD children, with the values for the AUT group falling between these two groups. Based on these nine predictor variables, the classification analysis correctly predicted 93.75% of the cases. One child from the AUT group was misclassified as TYP; and one child from the DD group was classified as AUT. All TYP children were classified correctly. Since it was important to see how the predictor variables discriminated the two disabled groups specifically (i.e., differential diagnosis), the discriminant analysis was repeated for the AUT and DD pair. Results were also significant, %2 (9) = 23.23, p < .01. Of the nine items, six loaded most highly (above 0.50) on

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Table IV. Rates of Individual Behaviors (Descriptive Statistics) and Group Differences

Baranek

AUT
CATEGORY Item Affective exp. Positive Negative Affect rating Looking Persons Camera Object Gaze aversion Response to name Rate of response No. of prompts/opp Social touch resp. Motor stereotypies Repetitive-legs Rep.-arms/hands Unusual posturing Object stereotypies Twiddle/wave Bang/tap Mouthing Tactile (rubbing) Visual staring/fix. Object play rating Tactile modulation Orients/registers Resp./avers. rating Auditory modulation Orients/registers Resp./avers. rating Visual modulation Orients/registers Resp./avers. rating
a b c

DD

TYP
SD

M
0.48 0.06

SD
0.14 0.10 0.56 0.18 0.19 0.13 0.06 0.35 1.37 0.16 0.10 0.08 0.13 0.02 0.05 0.15 0.06 0.02 0.80 0.29 0.40 0.21 0.17 0.35 0.38

SD

df
2, 29 2, 29 2, 29 2, 2, 2, 2, 29 29 29 29

F
0.98 0.97 2.60 2.32 3.37b 0.24 0.73 0.09 2.89* 2.71 0.91 0.74 3.14* 0.88 1.85 2.83 1.61 2.67a 4.89C
0.34 1.21 1.25 1.36

2.2
0.32 0.58 0.63 0.03 0.68 1.10 0.10 0.06 0.16 0.11 0.05 0.06 0.18 0.03 0.01 2.41 0.80 1.86 0.78

0.40 0.02 1.65 0.38 0.38 0.67 0.03 0.74 0.45 0.02 0.07 0.15 0.14 0.05 0.03 0.09 0.01 0.06 1.55 0.87 2.22 0.63 2.18 0.86 2.38

0.15 0.03 0.71 0.16 0.22 0.15 0.03 0.32 0.51 0.03 0.05 0.14 0.05 0.07 0.02 0.09 0.01 0.10 0.83 0.16 0.56 0.18 0.17 0.14 0.25

0.49 0.05 2.18 0.25 0.60 0.66 0.01 0.71 0.21 0.01 0.03 0.11 0.05 0.08 0.09 0.08 0.01 0.01 2.41 0.88 2.15 0.75 2.28 0.81 2.57

0.19 0.04 0.64 0.06 0.23 0.11 0.02 0.31

17
0.02 0.05 0.08 0.04 0.09 0.09 0.07 0.03 0.01 0.49 0.20 0.57 0.19 0.20 0.16 0.36

2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 29 2, 26 2, 26 2, 27 2, 27 2, 28 2, 28

2.2
0.62 2.33

2.85a 1.19

p < .10. p < .05. p<.01.

the resulting function: Mouthing (1.30), Orientation to Visual Stimuli (-1.06), Social Touch Aversions (1.00), Posturing (-0.84), Number of Name Prompts (0.76), and Affect Rating (0.61). Based on the classification analysis for the AUT and DD pair only, 9 out of 10 DD children and all AUT children were classified correctly, with an overall classification rate of 95%. DISCUSSION Infant Markers of Autism This study confirms that measures of sensory-motor functioning, in addition to indicators of social respon-

siveness, have potential as early markers of autism during infancy. Several sensory-motor deficits were found to be subtle yet salient at 9 through 12 months in children with autism. These findings are consistent with other literature suggesting that in lieu of the more conventional measures used to detect autism in older children (i.e., developmental milestones; higher language functions; DSM-IV "triad"), sensory-perceptual features may be a fruitful avenue to explore in the quest for infant symptomatology (e.g., Gillberg et al., 1990; Wing, 1969). The results also demonstrated that by 9-12 months of age, the pattern of behaviors evident in those children later diagnosed with autism was contrastingly different from the patterns displayed by those with delayed or typ-

Autism During Infancy

Table V. Frequency and Percentage of Subjects Classified Correctly from Discriminant Analysis" Classified as autism Actual Group Membership Autism (= 11) DD/MR (n =10) Typical (n = 11)
a

221
Osterling & Dawson, 1994). This particular behavior (Responsiveness to Name) thus may be particularly useful as a predictor across age groups in young children with autism. Although these findings are congruent with a hypothesis that young children with autism have difficulty orienting to social stimuli (Osterling & Dawson, 1994), they also raise the possibility that children with autism have more general problems with responsiveness (orientation/attention) to all types of sensory stimuli. In fact, the group of infants with autism in this study tended to have attenuated levels of Orientation to Visual Stimuli, a finding previously documented in older children (O'Connor & Hermelin, 1967). Additionally, other sensory-motor markers found useful in this study (e.g., Mouthing Objects) do not appear to be attributable to deficits in social responsiveness per se, while others (e.g., Social Touch Aversions, Name Prompts) seemed to cross the social/nonsocial distinction. One interpretation of these findings may be some symptoms of autism during infancy reflect more pervasive deficits in sensory attention or arousal modulation mechanisms that subserve both categories of behavior (social and nonsocial). Such limited capacities in arousal modulation and information processing have been implicated previously (Dawson & Lewy, 1989; Ornitz, et al., 1977). Further study is needed to determine whether or not deficits in sensory processing (e.g., orientation to nonsocial stimuli or touch aversions) may serve as precursors to difficulties in other, more socially directed behaviors (e.g., joint attention, social withdrawal) that are known to be problematic in children with autism after 12 months of age (Baron-Cohen et al., 1996; Lord, 1995; Sigman et al., 1986). Alternately, more research is also needed to determine whether unusual sensory responses in infancy may be a function of limited social awareness.

Classified as DD/MR
n % n

Classified as typical
%

10 1 0

90.9 10 0

0 9 0

0 90 0

1 0 11

9.1 0 100

Total percentage of "grouped" cases correctly classified: 93.75%.

ical development on a combination of nine variables. See Table VI for a summary of these contrasting patterns and the individual behaviors comprising those patterns. These nine variables predicted group membership at high rates (93.75%) and thus, may be helpful in future research of early assessment/differential diagnosis. It appears premature, however, to use these items as a screening tool until they can be cross-validated in future retrospective as well as prospective studies. Furthermore, this research suggests that aspects of sensory-motor functioning should be used to augment but not replace measures of social responsiveness (e.g., joint attention, showing, social interest), which have been proven to be valid and critical for detection of autism in young children after the first year of life (Baron-Cohen et al., 1996; Lord, 1995; Osterling & Dawson, 1994). This study confirms previous research that children with autism show delays/deficits in their ability to respond to attention-getting strategies (e.g., calling child's name) used by parents of children across various age groups (Adrien el al., 1993; Lord, 1995;

Table VI. Patterns Differentiating Autism, DD and Typical Subjects at 9-12 Months of Agea Infant Symptoms Function 1: Autism symptoms Poor visual orientation/attention (nonsocial) Prompted/delayed response to name Excessive mouthing of objects Social touch aversions Function 2: DD/MR symptoms Stereotyped quality to object play Unusual posturing of body parts Diminished looking at camera Visual staring/fixation on objects Less animated affective expressions Autism profile High DD profile
Low

Typical profile
Low

Moderately low

High

Low

" Autism Group: More vulnerable to deficits on Function 1 than Function 2 behaviors; DD group: More vulnerable to deficits on Function 2 than 1 ; Typical group: Low vulnerabilities on both.

222
Less clear is why some of the social measures investigated in this study were not useful to discriminate the groups. Contrary to expectations, the children with autism in this study had frequencies of positive and negative affect that were comparable to the other two groups. The finding that the DD group had less animation in affective expressions, however, is consistent with other studies of children with Down syndrome (BrooksGunn & Lewis, 1982). In contrast to findings by Osterling and Dawson (1994), Looking at Persons was not found to be a significant indicator of autism during infancy, even though the situations studied were similar (i.e., videos of family events). One caveat is that eye contact is difficult to judge accurately from video since it is sometimes difficult to see all persons simultaneously, and this difficulty may have contributed to discrepant findings. Perhaps, some types of social deficits may be dependent upon developmental progressions before they become apparent in autism (i.e., after 12 months of age). It is also possible that Looking at Persons in isolation of contextual variables is not consistently or specifically deficient in children with autism. Studies with older autistic children have documented that the amount of looking does not necessarily differentiate children with autism from other groups during structured social interactions (Dawson et al., 1990; Sigman et al., 1986). Alternately, it is possible that group differences in looking behaviors may have been overshadowed by the overly social nature of children with Down syndrome that were predominant in the DD group. For example, children with Down syndrome have demonstrated a preference for social stimuli (i.e., faces) (Kasari, Mundy, Yirmiya, & Sigman, 1990) and a greater number of jointattention behaviors as compared to developmentally matched typical peers (Franco & Wishart, 1995; Lewy & Dawson, 1992). Caution must be taken in generalizing the findings from the present study beyond those children with mental retardation specifically associated with Down syndrome. In contrast to Lord's (1995) study of preschoolers, overall measures of stereotypies (which are considered as a critical feature of autism in conventional diagnosis) were not useful as predictors of autism at 9-12 months of age in the present study. Perhaps, stereotypies may also be dependent on developmental changes that afford more advanced perceptual-motor abilities. This interpretation is consistent with evidence that stereotypies intensify and become more obvious from approximately 2-5 years of age (Lord, 1995; Losche, 1990). On the other hand, most simple repetitive movements are so universal during infancy (Thelen, 1981) that atypical manifestations are difficult to differentiate at this early

Baranek stage. One stereotypy, Mouthing Objects, however, did discriminate the children with autism in this study. Thus, there may be a window of opportunity for the usefulness of particular measures; and, it would be important to trace whether such an early behavioral manifestation of stereotypy (i.e., mouthing) is a precursor of later-evolving forms within the same general class. However, it is important to reiterate that the children with DD were identified at a similarly high rate to the group with autism in this study. Although some of the variables (e.g., affect, visual fixation) originally were included in an effort to identify autism specifically, they were actually found to reflect better those with general developmental disabilities. Compensatory Techniques By Caregivers: Clues to Earlier Assessment? The early markers of autism (both sensory-motor and social) revealed in this study were evident on video prior to the age that parents in the study began to suspect problems. This finding is consistent with reports suggesting that a parent's awareness of symptoms depends on the child's developmental stage and the degree to which symptoms deviate from normal development (Lord, 1995; Stone & Hogan, 1993). However, caregivers in this video study were additionally found to use compensatory strategies in an effort to engage their children more successfully in social interactions and playeven though they were not cognizant of the child's subtle deficits. These results echo similar findings with other age groups (e.g., Adrien et al., 1992) and suggest that caregivers act to maximize their children's success during social interactions. It is significant to note that the children with autism did respond when given time and appropriate structure; however, repeated prompting was necessary to bring about the desired response. Parents seemed to be increasing the saliency or meaning of a given stimulus through repetitive cuinga finding that is consistent with the notion that sensory-attentional mechanisms may be disrupted in infants with autism. Thus, the present study demonstrates that parent's compensatory behaviors may provide a reflection of autistic symptoms during infancy, and a means by which to develop useful measures for earlier identification and intervention. Retrospective Video Analysis: Strengths, Limitations and Future Research This study validates previous findings that retrospective video analysis is an effective tool with which to study young children with autism (e.g., Adrien et al.,

Autism During Infancy 1993; Losche, 1990; Osterling & Dawson, 1994). This method provides a window into these earliest manifestations of autistic symptomatology within a naturalistic paradigm; however, it is not without significant constraints and challenges which include the extraordinary amounts of time, technical support needed, and expenses incurred. These are often the things that are in short supply for clinicians and early interventionists, who might be the very persons interested in using alternative methods for early diagnosis. Furthermore, video samples may also be a narrow representation of children's behaviors. That is, parents preselect the situations that favor pleasant situations and special achievements and avoid videotaping children during uneventful, unpredictable, or adverse conditionsa process that may obscure certain symptoms. Other limitations of this study include the rater's potential awareness of distinguishing features of Down syndrome that may have influenced their perceptions during coding, and the relatively small sample since it was difficult to collect large numbers of families with good video records of their children's early development. Likewise, sampling a range of situations in 10 minutes provided a cross-section of age and behavior but did not allow for the detailed analyses of infrequent or contextspecific situations. For example, some behaviors such as affective responses may need to be measured within specific social contexts or perhaps in tandem with other social responses (e.g., smiling while looking at person) in order to evidence atypicalities at this age. Further research is needed to determine the effects of various contexts on the specific behaviors of interest in this study and to compare results to other diagnostic groups that have less distinguishing features. REFERENCES

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ACKNOWLEDGMENTS I extend my gratitude to the families that participated in this study and organizations that provided assistance, especially Lutheran General Developmental Pediatrics, University of Chicago Department of Child Psychiatry, Waisman Center, Autism Society of Illinois, and the Ameritech Corporation Visual Communications Department. Special thanks to Laura Sherpetis, Priti Gandhi, Eden Opsahl, Teresa Moran, and Paul Frellick for their technical contributions, and to Marji Getz and Margaret Creedon for their helpful suggestions. Partial funding for this project was received from NICHD Grant 27184, the AOTA and APA Dissertation Awards. I am most grateful to Gershon Berkson and Cathy Lord for their expertise, mentorship, and tremendous support throughout this 4-year project.

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