Expert: James Michael Roan - 11/4/2008

Question
QUESTION: Hello James, thanks for your quick response. I do not recall her pointing to objects of interest. The absence of pointing is very worrying. However, she does point to objects (both near and far) when asked.

1. Eye contact:
She gives us eye contacts frequently. When she wants something, when she has done something and looks for reaction from us (e.g. when she has identified a picture when requested, she will look at us with anticipation, waiting to be praised. If we tell her it’s the wrong picture, she will flip to another picture, and looks at us again for approval).

2. Sharing:
She shares food if we ask her. Sometimes she pretends to share, then takes it away last minute, then gives us a cheeky look. She enjoys coloring, and will frequently take a crayon and give it to us, as if she wants us to join her in the coloring. Same for playdough. Not sure if this is considered sharing toys.

3. Joint attention:
She points sometimes, and looks at us sometimes. When she sees things that she recognizes (e.g. animals, vehicles), she will either name the animal, or make the appropriate animal/vehicle sound. She will also frequently complete sentences for us. She also flips the pages herself at the appropriate times.

When we ask her if she wants to be read to, she will go take her bolster, then come and sit beside us or on our lap. She will also take the book to us sometimes, or lead us to the book if the book is too heavy.

When playing (e.g. with playdough), she responds reciprocally. She loves action songs (e.g. If You Are Happy, Insy Winsy spider, London Bridge), and will look at us as if wanting to be praised for doing the actions. She will also take our hands and prompt us to join her in doing the actions.

Is the lack of pointing and expressive language a major cause of worry? She seems to be doing fine in other aspects. We are going to seek professional help on her speech delay next week.

Cheers
Steven

ANSWER: Hi Steven;

It all sounds good to me. She is demonstrating sharing in many other ways. It sounds like it's not too hard to establish joint attention either. She is genuinely interacting with you and demonstrates a desire to do so. After listening to your descriptions of her I would be surprised if I observed her and saw signs of autism.

It's good you are following up with a speech assessment.

Kind regards,
James

---------- FOLLOW-UP ----------

QUESTION: Hello James,

it has been a while since the last communication. During this time, my daughter has been diagnosed with showing some spectrum behaviour, and undergoing occupational therapy (though she shows no sensory and motor skills issues) and speecd therapy. And our 2nd baby also just arrived.

The problem we have in Singapore, is that expertise is limited in Autism research and treatment, and almost all professionals go strictly by the book. While surfing this site, I came across a list of questions. I thought I will attempt to answer them and maybe you can help to provide some feedback?
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Checklist for Autism Spectrum Disorder (Susan Mayes, PhD, Penn State College of Medicine)Check each item that applies to your child now or in the past
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PROBLEMS WITH SOCIAL INTERACTION
(1) Social isolation, withdrawn, aloof, avoids contact with others, or prefers to play alone rather than with peers, parallel play along side but not with peers, difficulty establishing friendships
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Parallel play most times. Shows interest in other kids, but does not really engage.
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(2) Limited reciprocal interaction, limited social smile or eye contact (looks away, looks through people, looks at speaker’s mouth, needs to be prompted to make eye contact, or does not make eye contact when communicating).
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Has good eye contact.
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limited sharing and showing (e.g., does not show a toy to an adult, seek recognition, or share an experience or accomplishment with others)
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No issues with this.
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excessively rigid play with peers (dictates play according to his/her peculiar and repetitive interests and rules)enjoys physical or sensory play with others (e.g., tickling, chasing) but has limited reciprocal social interaction (e.g., does not play social games or games involving turn taking)


(3) Self-absorbed or in own world (e.g., engages in self-stimulating behaviors, talks to self, or fantasizes excessively about things such as movies or cartoons) oblivious to the presence of others or unresponsive to the social overtures of others
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Talks to self, recites scripts from TV programs when bored.
She is aware of presence of others, and reacts accordingly.
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(4) Socially indiscriminate behaviour, inappropriately talks to or hugs strangers invades personal space (gets too close to or touches others) no stranger/separation anxiety when young (not wary of strangers or upset if separated from parents) socially inappropriate, insensitive comments or behaviors (picks nose in public, asks personal questions)
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Has stranger anxiety and separation anxiety. Does not seem to intrude personal spaces of strangers
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(5) Problems with social skills. Does not appropriately initiate or sustain peer interaction though may interact well with adults, poor social reasoning (difficulty understanding social cues/comments, facial expressions, body language) wants to have friends but does not know how to make friends.
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Interacts well with adults. Shows interest in other kids, but does not really engage them.
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PERSEVERATION
(6) Narrow or unusual range of interests and play behaviours. Obsessive preoccupations or extreme fixation on things such as certain movies or TV shows (re-enacts or watches the same movies over and over), computer games, letters, shapes, numbers, counting, objectsor topics (e.g., trains, dinosaurs, NASCAR, maps, planes, electricity, Yu-Gi-Oh, cartoon characters, etc.) unusual attachment to and holding or hoarding objects (e.g., small figures, string, other______)
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re-enacts scenes from programs she has seen. But this is because we let her watch the same programs repeatedly. Seems to get better after we stopped letting her watch the same program. Normal interests in shapes, letters, counting, etc

Shows some attachments to certain toys, though this changes from time to time. Sometimes insists on carrying whole bunch of toys before willing to leave the house.
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(7) Stereotyped and repetitive play repetitive play (e.g., excessively lines up, sorts, spins, or throws objects; opens and closes things repeatedly; plays with the same toys without variation; draws the same pictures repeatedly; other_____)disinterest in toys or lack of normal and varied imaginative play unusual preoccupation with parts of objects (e.g., repetitively spins wheels on a toy)
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Started to line up some small objects (e.g. crayons side by side, toy spoons side by side). Used to repeatedly empty colour pencils from container and putting them back. Does not do this anymore.

Plays with toys normally (plays them as they are meant to be played). Engages in imaginative play (e.g. doctor set with her soft toys, pretend to play musical instruments with simple objects, make birthday cake using trays and cylindrical blocks)
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(8) Upset with change, distressed by change (e.g., change in routine or schedule, parent takes a different car route home from school, furniture or child’s toys are moved, seasonal change in clothing, other______)difficulty with transitions (e.g., from one activity to another)extreme need to finish what he/she starts, idiosyncratic or ritualized patterns (e.g., drinks only from a certain cup, wears only certain clothes, insists that food be arranged a certain way on a plate, other_____)insists that things be in a certain location or a certain way (e.g., doors must be closed, coats zipped, etc.)insists on doing things the same way every time, overly precise and inflexible, upset if someone breaks a “rule,” rigid and literal thinking
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Has some difficulties with transition sometimes. Sometimes she responds to reasoning, other times her attention can be diverted easily. But sometimes she throws tantrums. No other pre-occupations with other points here
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(9) Stereotypies (unusual repetitive movements such as hand flapping when excited, toe walking, bodyrocking, head shaking, body tensing, teeth clenching, teeth grinding while awake, finger movements, facial grimacing, repeatedly running back and forth, twirling or spinning, pacing, playing with saliva, skin picking)
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Toe walks at home sometimes, on cold tiles. Does not do that outside. Some minor head shaking motions while lying down sometimes. Some teeth grinding before, but has since stopped. Likes to walk around the house sometimes when bored, and round the coffee table. This started only recently. Used to play with saliva sometimes when bored, but we have not observed this for sometime already. Sometimes likes to pick the skin on her lips.
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SOMATOSENSORY DISTURBANCE
(10) Excessive atypical craving and love of spinning, tickling, climbing, rocking, swinging, bouncing, jumping
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Enjoys, but never demands for it. No problems if the playing stops abruptly.
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(11) Unresponsive at times to verbal input (not react when name called or spoken to, hearing questioned)
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Sometimes seems to be deaf
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(12) Hypersensitivity. Unusual hypersensitivity to some sounds (e.g., distress or covering ears in response to loud noise,motors, vacuum cleaner, hair dryer, baby crying, sirens, clapping, alarms, toilet flushing, people singing)unusual hypersensitivity to smell, light, or temperature
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No such problems
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(13) Distress with commotion or crowds (uncomfortable/anxious in large groups, theatres, cafeterias, parties)
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Sometimes upset with crowds (parties, concerts). Most times no problems (crowded public places e.g. shopping centers, restaurants). But if distressed, warms up after a while and all will be fine.
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(14) Extreme fascination with spinning or repetitive movements (e.g., revolving fans, Wheel of Fortune, running water), linear patterns (e.g., credits on TV, window blinds), minute details, lights, shiny surfaces
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No such problems
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(15) Abnormal sensory inspection, excessively smells, mouths, chews, licks, or rubs inanimate objects or surfaces repetitively visually scrutinizes objects or finger movements close to eyes, places ears against things that vibrate or hum or presses objects against face to an unusual degree
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No such problems
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(16) Tactile defensiveness or extreme dislike of being touched or hugged, touching certain things or getting hands dirty or stickywater on self or clothes, having face washed, teeth brushed, hair combed, or nails cut, walking in bare feet, clothing that is tight, seams in clothes, or certain textures of clothing
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No such problems
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(17) High tolerance for pain (e.g., does not cry when hurt or does not respond normally to painful stimuli)
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No such problems
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(18) Sleep disturbance (e.g., difficulty falling asleep, waking during the night, waking early in the morning)
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Nothing really out of the ordinary
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(19) Feeding problems, very picky eater, limited food preferences, insists on eating only a few foods, hypersensitivity to textures (e.g., lumps in food)retains food in mouth without swallowing, eats inedible substances, other peculiar eating patterns (e.g., eats only one brand, color, or shape of a food, other____)ATYPICAL COMMUNICATION AND DEVELOPMENT
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No such problems
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(20) Language regression or slowing at approximately 1 to 2 years of age (e.g., speaking a few words at one year but then losing speech or normal early language development and later language is delayed)
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Never really spoke before age 2. After that started speaking in short phrases when communicating her needs. Lack of reciprocal conversation (e.g. does not know how to respond to questions like “do you like xyz), but able to indicate her preferences if we ask her to choose between 2 options.
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(21) Visual-motor skills (e.g., assembling puzzles, building with Legos, operating the VCR) significantly higher than language skills during the preschool years or walking at a much earlier age than talking
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Able to build small puzzles (4 to 6 pieces). No other unusual capabilities.
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(22) Communication impairment, absent or limited communicative speech but gestures to communicate (e.g., pulls an adult by the hand and leads to what wants, hands an object to an adult for assistance, brings a cup to an adult for a drink)communicates verbally with others only when stressed or needing something, difficulty with reciprocal conversational speech (initiating and sustaining conversations, listening and responding to what others say), talks at people, or one-sided conversations on topics of interest to self
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Used to use gestures to communicate her needs before, but this has reduced greatly since she started talking. But when under stress, sometimes tends to revert back to gesturing. Understands and able to execute instructions. Can’t really respond to abstract questions like “how was school?”, “do you like the show?”

Able to tell her mummy to “put down the baby”, or “give baby to so-and-so”, and tell the baby to “go to sleep”. This happens when she sees the mother attending to the newly arrived baby.

Still not able to state own name, age and gender.
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(23) Atypical vocalizations or speech, unusual voice quality or modulation (e.g., high pitch, sing song voice, lack of intonation, etc.)screeches or makes other odd noises (e.g., growls, hums, etc.)unusual repetitive vocalizations and sounds, idiosyncratic jargon as if talking in own language, echolalia (inappropriately mimics what others say, such as repeating instead of answering a question)sporadic speech (says a word or phrase once and rarely or never says it again)excessively recites from movies, cartoons, commercials, etc.uses rote or memorized phrases that are excessive, out of context, or not relevant makes pronoun substitutions (e.g., says “you” when meaning “I”)excessively repetitive speech and questions, idiosyncratic thoughts and speech (makes up words, nonsensical speech, unique views and perceptions)
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Likes to recite from her favourite cartoons. But able to adapt the script to real life situations. Sometimes echolalia, sometimes able to use the correct phrase when prompted (e.g. mummy please help me to do xyz)
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(24) Special abilities that are significantly higher than other abilities, exceptional rote memory (e.g., at an unusually young age, identifies numbers, letters, shapes, logos, and colors; sings or hums tunes; memorizes car routes; counts; recites the alphabet; reads; spells; etc.)phenomenal vocabulary or ability to memorize movies, books, or factual information, remarkable ability to mimic movie or cartoon characters, outstanding visual-mechanical skills (e.g., at an unusually young age, assembles puzzles, matches shapes, operates a computer or VCR, figures out how things work, complex constructions with Legos)remarkable artistic or musical talent, extremely well-developed gross motor skills with delayed development in other areas (in contrast to high-functioning children with autism who often have writing or coordination problems)
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No unusual or remarkable capabilities. Able to recite alphabets, identifies colours and shapes, memorizes children’s songs since 2. Normal development of gross/fine motor skills
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MOOD DISTURBANCE

(25) Overreactivity, irritability, low frustration tolerance, agitation, tantrums, meltdowns, explosiveness, aggression, or self-injurious behavior (distressed by minor events or occurrences most children can tolerate, such as intrusions, activity interruptions, proximity, confinement, performance demands, writing tasks, or when things are not the way the child thinks they should be)
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Not really. But she gets upset when we try to play with her toys while she is playing with them (e.g. when she is doing painting, she gets upset if we also try to paint with her, or when we try to play bubbles with her. Sometimes, she responds to reasoning, sometimes throws tantrums)
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(26) Moodiness and emotional lability (the cause for mood changes may not always apparent, such aslaughter or distress for no apparent reason)
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No such problems
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(27) Difficulty showing and recognizing emotions, emotionally unresponsive in some situations, lack of empathy or emotional reciprocity (e.g., does not respond appropriately or provide comfort when someone is hurt or sad), or misinterprets the emotions or responses of others
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She is still not really able to express emotions. But she knows if we are angry, and reacts accordingly. And if we say some parts hurt, she will go pat and kiss it.
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(28) Unusual fears, such as fear of elevators, steps, toilets, balloons, vacuums, tornadoes, other_____P
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No such problems
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ROBLEMS WITH ATTENTION AND SAFETY

(29) Selective attention, ability to hyperfocus on activities, objects, or topics of interest to self (e.g., lines up toys, spins wheels, watches the same movie, assembles puzzles, builds with Legos, or draws pictures for long periods of time), but is inattentive, impulsive, and fidgety at other times
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Not really. She is able to focus on particular tasks (e.g. drawing, painting, reading, playing with toys), but not excessive. If an activity does not interest her, she will not engage for long. Does not really reacts adversely if she does not get to watch her favourite program
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(30) Limited safety awareness, fearless, or oblivious to danger (e.g., unsafe climbing, wanders about house at night, runs off by self, goes into traffic or water, walks off with strangers)
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Has sense of danger, but sometimes not willing to be held by the hand in public places.
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Answer
Hi Steven;

Congratulations on your new baby!

She may have a subclinical condition of Asperger's syndrome. I have observed children very similar to her. They qualitative appear to have Asperger's syndrome, but when assessed formally, they come under the statistical radar. As a result of higher skills, they almost always adapt well socially at a young age and blend in.

You still want early intervention. It should include adult mediated social play groups with peers where the emphasis is on social language and imitation skills.

Kind regards,
James