This document summarizes research on early indicators of autism from fetal life through infancy. Three key findings are: 1) Studies of infant siblings found differences in cry acoustics at 6 months, with later-diagnosed infants having higher pitch and more dysphonated cries. 2) Research examining fetal responses to stimuli found elevated movement and heart rate in some high-risk fetuses who were later diagnosed with autism or PDD-NOS. 3) A prospective study of fetal siblings is ongoing, finding elevated heart rate across stimulus conditions in fetuses at highest risk for autism. This research aims to detect early signs of aut

1. Indicatori di Rischio dell’ Autismo: dalla vita
fetale all’infanzia
Stephen J. Sheinkopf, Ph.D.
Assistant Professor (Research)
Psychiatry & Human Behavior and Pediatrics
Center for the Study of Children at Risk
Alpert Medical School, Brown University
Women & Infants Hospital

2. Early Diagnosis Lord et al., 2006
Autism or
Autism at 2 PDD @ 9
years
• Symptoms evident (99%)
by 12 – 18 months
Autism or
PDD at 2
• Stable diagnoses years
PDD @ 9
(86%)
made by 24 – 36
months Kleinman et al., 2008
• But stability of Autism or
Autism at 2 PDD @ 4 - 6
diagnosis varies by years
(75%)
study
Early diagnosis improved, but refinements needed

3. Infant Signs of Autism
Approaches Significant findings
1. Retrospective smiling
parent interviews eye contact
2. Home videotapes social responses
3. Infant sibling Imitation
studies joint attention
social engagement
Some subtle differences reported in 4 to 6 month-
olds, but most robust differences by ~ 12 months

4. Some considerations
How do social deficits
emerge during
infancy?
Can differences be
detected in early
infancy? sensitivity
Can differences be
detected when
compared to variability
in typical development
(specificity)?
Figure from Ozonoff et al., JAACAP, 2010
Research needs to solve a Signal-to-Noise challenge

5. Current Approaches & Findings
Fetal & Early Infant Periods
Strategies Measurements
1. Prospective cases 1. Cry/vocal
2. Infant Siblings acoustics
2. Neurobehavioral
indicators
Fetal Newborn Infancy

6. STUDY 1:
Atypical cry acoustics in 6-month
old infants at-risk for Autism
Collaboration between Brown Medical
School (Sheinkopf & Lester) &
University of Pittsburgh (Iverson)
Examined pain and non-pain cries in
high & low risk infants

7. Participants High Risk (HR) Low Risk (LR)
n = 21 n = 18
Inclusion Older sibling with ASD, Older sibling with typical
Criteria confirmed by ADOS development
Male : Female 6 : 15 8 : 10
Race/Ethnicity
-White 19 17
-White Hispanic 2 0
-Asian-American 0 1
Maternal Age, 35.0 (4.8) 33.0 (5.1)
mean (sd)
Maternal Age,
mean (sd) 36.3 (3.6) 34.3 (4.1)

8. Data collection methods
Vocal recordings made in homes at 6
months (+/- 2 weeks)
Recorded to digital audio-video files
(audio recording with lapel microphone)
Cry episodes identified on videotape
Samples with adequate recording quality
were selected for analysis

9. Coding & Analysis of Cries
Infants with observable cry episodes:
17 HR & 11 LR babies
Videos coded to identify potential causes of cry
Classified as pain or non-pain related
Acoustic analysis of cries
System used in prior cry research
Samples were filtered (5 kHz), digitized (10 kHz),
and separated by utterance
Analysis within 25ms blocks
Computed the log magnitude spectrum for each
block (Fast Fourier Transform)
Results in a range of acoustic features

10. Variables produced by acoustic analysis
Pitch (F0) Average pitch of cry (Hz)
Variability of Pitch Range of F0 across the cry episode
Phonation % of 25-ms blocks with voiced or resonant sound
Hyperphonation % of 25-ms blocks with F0 > 1,000 Hz.
Utterance Duration Average time of utterances (seconds)
Average Energy/Amplitude: Loudness of cry (mean dB)
Variability of Energy/Amplitude: Range of cry amplitude
First Formant (F1) First resonant frequency (Hz)
Second Formant (F2) Second resonant frequency (Hz)

11. Pain Related Cries
Results of Group Comparisons
Pitch (p = .02) Pitch Range (p = .06)
550
160
ASD- ASD-
Risk Risk
140
500
120
450 100
80
400
60
40
350
20
300 0
Pitch (F0) Pitch Range
At-risk sibs (7)
Low risk sibs (5)
Sheinkopf, Iverson & Lester (submitted)

12. Pitch Range
Individual results by
diagnostic outcome
• Diagnostic follow up at 36
months of age
• Evaluations by ADOS
• Three (3) HR children classified
as autistic
• Two (2) of these children had
cry episodes that could be
analyzed
• Individual results plotted for
pain and non-pain cries, and by
group

13. Infants with later diagnoses had high pitch
(F0) in comparison to HR & LR groups
ASD Risk Group
600.00 ASD-risk
Low risk
Autistic
550.00 Autistic
Pitch (Hz)
500.00
450.00
400.00
350.00
300.00
Non-Pain Pain

14. Later diagnosed infants had more
dysphonated (turbulent) cries than others
ASD Risk Group
80.00 ASD-risk
Low risk
70.00
Phonation (%)
60.00
50.00
40.00
Autistic
30.00 Autistic
Non-Pain Pain

15. STUDY 2:
Physiologic & Neurobehavioral Responses in
“Fetal Siblings” Samples
Collaboration between Brown Medical School (Sheinkopf
& Salisbury) & Queens University (Kisilevsky)
Recruited pregnant women with older children with
autism, or with family history of autism
Fetal ultrasound in 3rd trimester
Responses to auditory and vibro-
acoustic stimulus (VAS)
Heart rate (doppler) & movement
(actigraphy)
Neurobehavior by videotape
coding

16. Initial Case Examples
Case 1: Infant (girl) at risk for autism (sibling with autism)
Heterogeneous comparison group, including mothers with
depression
FETAL ACTIVITY 27 WEEKS GA FETAL ACTIVITY 32 WEEKS GA
Mean +SD Mean +SD
100 COMP 100 COMP
% TIME ACTIVE (SD)
% TIME ACTIVE (SD)
80 CASE 80 CASE
60 60
40 40
20 20
0 0
BASE VAS POST1 BASE VAS POST1
CONDITION/TIME CONDITION/TIME
Elevated movement (actigraph) at 27 & 32 weeks gestation

17. Case 2:
Infant (girl) later diagnosed with PDD-NOS (and with
family psychiatric history, including a sibling with autism)
FETAL ACTIVITY 26 WEEKS GA FETAL ACTIVITY 36 WEEKS GA
Me an +/- SE Mean +/- SE
COMP COMP
120 CASE
CASE 120
100
100
% TIME ACTIVE (SE)
% T IM E ACT IVE (SE)
80 80
60 60
40 40
20 20
0 0
BASE VAS POST1 POST2 POST3 POST4 BASE VAS POST1 POST2 POST3 POST4
CONDITION/TIM E CONDITION/TIM E
Elevated movement (actigraph) at 26 & 36 weeks gestation

18. Case 2:
Elevated heart rate responses to stimuli at 36 weeks, but
not at 26 weeks
FETAL HEART RATE 26 WEEKS GA FETAL HEART RATE 36 WEEKS
Mean +/- SE Mean +/- SE
170 COMP COMP
170
165 CASE CASE
165
BEATS PER MIN (SE)
BEATS PERMIN (SE))
160 160
155 155
150
150
145 145
140
140
135
135
130
130
BASE VAS POST1 POST2 POST3 POST4
BASE VAS POST1 POST2 POST3 POST4
CONDITION/TIME
CONDITION/TIME

19. Prospective Fetal Sibling Sample:
Ultrasound at 34 – 36 weeks
Stimuli:
(1) VAS
(2) VAS, sound only
(3) Mother’s voice
(4) Stranger’s voice
High risk group: Pregnant mothers with family history of
autism (1st degree relatives and/or older children)
Low risk group: Pregnant mothers with no family history
of autism
In our preliminary work, we segregated the high risk
sample into those with highest risk (probands with clear
diagnoses) and those with relatives with reported but
unconfirmed diagnoses.

20. Prospective Fetal Sibling Sample: Preliminary Findings
Elevated HR across conditions in “highest risk” fetuses

21. Fetal Neurobehavioral
Coding System (FENS)
Coding of movement
quality and other
indicators in 10 sec.
bins
Stress Composite in 3
Risk Groupings at 34 –
36 weeks Gestational
Age
Aggregated across
ultrasound session

22. Collaborators & Funding
Brown University Funding
Barry Lester, PhD Autism Speaks
Amy Salisbury, PhD National Institutes of Health
Cindy Loncar, PhD National Institute on Deafness &
Lynn Andreozzi, PhD Communication Disorders (NIDCD)
Todd Levine, MD National Institute of Mental Health
Harvey Silverman, PhD (NIMH)
University of Pittsburgh
Jana Iverson, PhD
Queens University (Ontario)
Barbara Kisilevsky, PhD