Is Lack of Pointing a Sign of Autism?

Did you know that lack of pointing with your index finger by the age of 18 months is a red flag for possible autism? In this video blog, I’m going to show you how you can keep an eye on this early communication skill in babies and toddlers, and how to work on teaching toddlers—with or without a diagnosis of autism—this important skill of pointing. Hi, I’m Dr. Mary Barbera, autism mom, board-certified behavior analyst, online course creator, and best-selling author of The Verbal Behavior Approach. Each week I provide you with some of my ideas about turning autism around, so if you haven’t subscribed to my YouTube channel, you can do that now. When my son Lucas was diagnosed with autism one day before his third birthday, I started learning the warning signs of autism that everyone seemed to miss. I was really upset that not only didn’t I know about the importance of pointing, but Lucas’s pediatrician and his speech and language pathologist didn’t know that lack of pointing was a red flag for autism. Instead of pointing, Lucas used a lot of what they call hand leading, which I didn’t know about at the time. Hand leading is when a child takes your hand, pulls it, and places it on the item they want. Hand leading and lack of pointing with the index finger are core deficits often associated with early autism. The assessment of pointing is used in many autism screenings and is considered a big red flag. There are two types of pointing, which I found out after Lucas’s diagnosis. The first type is imperative pointing, which means pointing at an item to make a request—such as pointing at a cookie on a shelf when you want a cookie. The second type is declarative pointing, which is even more important. This is when a child points at an object or action to get someone’s attention, such as pointing at an airplane in the sky and then looking at an adult to share that moment. This skill typically develops around 15 to 18 months old, but most children with autism don’t have this type of pointing that early on. Both types of pointing—imperative and declarative—are almost always delayed or absent in young children with autism. Other gestures, like showing an item to a caregiver, reaching to be picked up with both arms, waving, and shaking the head “no,” should all emerge between 9 and 15 months of age in typically developing children. Failure to develop these gestures by 18 months can be a deficit in joint attention and may signal possible autism. Now, I want to stress that this is not a definite sign. A child could point and still have autism. A child might point early, but later regress and lose the skill, like Lucas did with waving. On the flip side, a child might not point and yet never receive an autism diagnosis. So it’s just one of many signs professionals look at when considering autism. The good news is that pointing is a behavior that can be taught, just like any other behavior. You don’t have to wait for a diagnosis, since even children at high risk who aren’t pointing yet can learn how. Over the years, I’ve developed a system to teach pointing, and it’s pretty easy. The first step is teaching a child to use their index finger to actually touch items. For example, touching items in books, on flashcards, or on toys. Here’s a short clip of a former client, Jack, as we worked on teaching him to point to pictures in a book: “Good. Touch the cow. Yay, thank you! Touch Adam. Good—touch momma. What would you like? Movie.” Once pointing to touch items is mastered, we can move on to teaching pointing with the index finger to things like a cookie on the shelf or an airplane in the sky. This involves more steps, but it’s totally doable. To summarize: there are two types of pointing. Imperative pointing is when young children point to request items. Declarative pointing is when toddlers point to get attention, such as pointing at an airplane in the sky. Lack of pointing with the index finger on a regular basis by 15 to 18 months can be an early sign of autism. But pointing can be taught, and learning this skill is often a turning point for progress. Wherever you’re watching this, leave me a comment, give me a thumbs up, and share this video with others who might benefit. For more information on my approach to turning autism around, attend a free workshop at marybarbera.com/workshops. I’ll see you right here next week.