Signs of autism in the early years: what to notice and when to seek advice

In Spain, it can take years to put a name to these signs. Dr Mara Parellada, from Hospital Gregorio Marañón, estimates that up to seven years may pass between the first concerns and a confirmed diagnosis. That is why it helps to recognise the signs early: the sooner they are understood, the sooner support can begin.

The first year

Some early signs involve social communication and shared attention: the way a child shifts attention between a person and an object, responds when called or uses gestures to share interest.

A reduced or absent response to their name, limited use of gestures such as pointing to show something, and persistent differences in eye contact may justify seeking advice, especially when they occur together. None of these signs identifies autism on its own; there may be other explanations, including hearing difficulties.

Sleep problems are common among autistic children, but they also occur in many non-autistic children. Sleeping very little or waking frequently should therefore not be presented as a specific sign of autism.

From one to three years

Language may appear later, develop unevenly or include echolalia, meaning the repetition of words or phrases heard elsewhere. In play, a child may show a prolonged interest in parts of objects, arranging them or repeating the same action. These behaviours also occur outside autism; the full pattern and its effect on daily life matter.

Repetitive movements or sounds may become visible at this stage, including flapping, rocking or humming. For some people they support regulation, express emotion or provide sensory input; their function cannot be inferred from observation alone. There may also be particularly strong or reduced responses to light, noise, textures, clothing, food or touch.

From three to six years

As the child spends more time with other children, social differences may become more apparent. They may approach other children but not know how to join a game that has already started; prefer to play in their own way; or find pretend play difficult, particularly games that involve assigning roles and imagining situations. The need for things to remain the same may also become stronger: the same routine, the same routes and intense distress in response to small changes or transitions from one activity to another.

This is also the age when very intense interests often appear: a subject that absorbs the child's attention — a video game, a series, animals or drawing — and about which they build up deep knowledge. It is important to challenge one common assumption here: these are not simply "boys' interests". Autistic girls have equally intense interests, but they may be less noticeable because they fit more closely with what is expected of girls. This is one of the reasons why girls are often diagnosed later.

One sign on its own is not enough

No single item on this list confirms autism. Language delay, solitary play and sleep problems have several possible causes. Seek advice when several differences persist, affect communication or participation, or concern the family. Loss of words, gestures or other skills the child previously used needs prompt assessment.

What happens in the health system

In Spain, the first screening usually takes place during routine child health checks in primary care. The paediatrician observes the child's development using tools such as the Haizea-Llevant scale and, when warning signs appear, may use a specific screening questionnaire, the M-CHAT-R/F, which has been validated for children aged between 16 and 30 months. It is not a diagnostic test. It is used to decide whether the child should be referred for a more detailed assessment in paediatric neurology or child and adolescent mental health services.

Diagnosis follows a more complete assessment. Spain does not publish a regular national waiting-time statistic, and access to services varies between autonomous regions.

What a family can do

Recording what is observed, when it happens, how often and in which settings gives the paediatrician concrete information. It may also help to bring examples from nursery or, when appropriate and respectful, short recordings of everyday situations. A record does not confirm a diagnosis or guarantee a faster referral.

Specific needs can be addressed while an assessment is pending: hearing and language can be checked, painful noise can be reduced, visual information can be provided or an activity adapted. These measures should be chosen according to what has been observed and do not replace a diagnostic assessment.