Expert: Dr. Sharon A. Mitchell - 12/3/2008

Question
I am the primary caregiver of a 16 month old girl. Over the past few months she has started regressing, she used to wave and clap, and now she doesn't. She doesn't speak any words, and is most content wandering into a room and sitting in it alone. She cries over little things, such as a book on the floor, but doesn't cry when she gets injured or is hungry. Her dr. has recommended she go for an evaluation, but her mother will not take her. What can I do?

Answer
It sounds like you're in a difficult position. You see things in this little girl that concern you. Her doctor concurs that there is something going on that's worthy of investigation.

You suspect that something may be developmentally wrong with this child but her mom may not want to look at or admit to that possibility right now. As parents, we hope against hope that all will be well with our child.

Perhaps mentioning all your concerns would overwhelm this mom right now. She may react defensively or dismiss your concerns because the difficulties you're suggestion seem just too enormous or threatening. She may even become angry because you are saying things she does not want to hear or consider.

Instead, you may find a better reception if you focus in on just one or two things - preferably less threatening aspects of what this little girl is or is not doing.

Your eventual goal is to be as helpful as possible. Ideally through your suggestions, the mother and daughter would visit a health care professional who would either find that this toddler's development is within the normal range or if not, then he or she would take it from there and begin the process of getting the needed help.

As a starting point for you, here are some sights that talk about normal physical developmental milestones for toddlers that you can use to compare with what this little girl does:

http://www.med.umich.edu/1libr/yourchild/devmile.htm

http://parentcenter.babycenter.com/refcap/preschooler/pdevelopment/1496593.html

http://parenting.ivillage.com/tp/tpdevelopment/topics/0,,4rwc,00.html

A general physical is another good place to start. It's not nearly as threatening or frightening to parents as going through an autism assessment. Most doctors do a developmental screen with young children to see if the child is meeting expected developmental milestones at typical times. Also, this child is likely due soon for some immunizations. At such times, the public health nurse or doctor may take notice of the behaviors your describe and begin further investigations on their own.

It would not hurt to ensure that the doctor or nurse take a look at how this child uses her eyes to see if there is any physical reason she turns her head or looks out the corner of her eyes. Some young children with vision difficulties also show these behaviors.

A screen on her hearing would also be useful in ruling out other factors. If she is not talking as much as she should be or she once was, then having her hearing checked is a first step and again, less threatening than the thought of an autism assessment. Has she had ear infections? Upper respiratory infections? Such infections can cause temporary hearing loss which interferes with a child's ability to acquire language.

After checking out her hearing, then a visit to a speech language pathologist/therapist would be helpful. Your public health nurse, doctor or school district can tell you how to get in touch with a Speech Path (SLP.

Children don't all develop at the same time, although there are guidelines for what is typically expected at certain ages. Very briefly, here are some speech and language skills that a child of your cousin's age may have attained, according to http://www.child-autism-parent-cafe.com/child-development.html

By the end of 1.5 years (18 months) many children are able to:

- do simple pretend play ("talk" on a toy phone)
- point to interesting objects
- look at object when you point at it and tell them to "look!"
- use several single words unprompted

By the end of 2 years (24 months) many children are able to:

- use 2- to 4-word phrases
- follow simple instructions
- become more interested in other children
- point to object or picture when named

The Canadian Association of Speech/Language Pathologists has some guidelines for when to seek help regarding a child's speech and language development. Below is a quote from http://www.caslpa.ca/PDF/a%20parent%20guide%20to%20children%27s%20speech.pdf

How many words should my toddler be using?

On average, a child should use at least 200 words by the age of two. As general benchmarks, consider whether your child can:
• Say her first word by her first birthday
• Combine two words, for example “Mommy up” by age two
• Use three-word phrases and short sentences by age three, like “Puppy come here”

When should I visit or speak to a speech-language pathologist?
Seek answers if your child:
• Shows no reaction to sound in the first three months of life
• Is not babbling and making sounds by 10 months
• Doesn’t gesture, show, give or point to get something by 12 months
• Doesn’t understand simple commands like “See your ball? Get your ball!” by 18 months
• Doesn’t pretend play, like feeding a stuffed toy, by 18 months
• Is not using single words by 21 months

Does this sound like this child?

Here's a brief checklist you can look at to see if her speech and language are within what's expected for a 16 month old. http://www.asha.org/public/speech/development/12.htm

At the bottom of the above link are things you and the family can do with her.

Is she pointing? If so, that's a good sign. Many kids with autism do not point or use other sorts of gestures. So, pointing is good.

But while you wait for these appointments, I imagine that you all want to help this little girl.

One thing you might consider is using gestures and signs, if the mother is in agreement. Getting started is not difficult. You begin with the sign or gesture of something meaningful to him. Here are a couple websites that give you signs and explain how to do this with your baby:

http://www.signingbaby.com/main/

http://www.handsfirst.ca/

http://www.mimicbaby.com/

Using signs such as these is a form of augmentative communication. It gives the child a means to express himself and get what she wants is a less frustrating fashion than throwing a fit. Do not fear that using signs will further delay this girl's speech. Rather, it will enhance language development and her communication skills. While signing works well, it's still more work than talking. Kids choose to speak rather than sign once they are able. In the meantime, using signs may give this child some power to control his environment and the adults in it.

Here are some possible indicators of Autism Spectrum Disorders, taken from the About.com website (http://autism.about.com/od/earlysignsofautism/a/redflags.htm):

- Does not babble, point, or make meaningful gestures by age 1
- Does not speak one word by 16 months
- Does not combine two words by 2 years
- Does not respond to name
- Loses language or social skills
- has poor eye contact
- Doesn't seem to know how to play with toys
- Excessively lines up toys or other objects
- Is attached to one particular toy or object
- Doesn't smile
- At times seems to be hearing impaired

In case the possibility of autism is still worrying you and this child's mom, take a look at these free, online checklists:

CHAT - The Checklist for Autism in Toddlers http://depts.washington.edu/dataproj/chat.html

The PDD Assessment Scale/ Screening Questionnaire http://www.childbrain.com/pddassess.html

These are just preliminary screening checklists. A score on them does not rule in or rule out autism. But they can provide you with information to take to your doctor.

Sharon A. Mitchell, B.A., B.Ed., M.A.
http://www.autismsite.ca