Expert: James Michael Roan - 3/19/2008

Question
QUESTION: Hi,
I have a 35 month old son. I apologize if this is a little long. We have some autism concerns, and have had him evaluated by the school district twice, first at 27 month and then at 33 months. Our primary concern was language development - our pediatrician recommended a screening based on our son's diction.

at 27 months our son had well over 50 words (I would guess over 100-150 at that age) and 2 word combinations. Still he was diagnosed to be somewhat speech delayed for his age, but they didn't offer interventions thinking he would "take off" when he went to pre-school. We never saw any sensory issues (or at least never noticed any - I understand they can be subtle) but our son DID have a difficult time transitioning to a 7-4pm daycare. It took 6-8 weeks for him to feel comfortable there (he was usually fine after his nap they said) He ate wonderfully until he started preschool - he rarely eats lunch there (usually just fruits and snacks, with the occasional entree) and has become pickier at home.

He was reevaluated at 33 months, and his expressive and receptive language were found to be at 106 and 98 out of 100 mean, respectively. He sounds on target, except for his pragmatic language. He seldom asked anything except "Where" questions (but would "ask" things like "wanna read it, daddy?") But in the past month he has started to ask more "what" questions about his environment and some "how" questions (Does "How about Pancakes for dinner?" count? :) ).

He has also started to be able to answer "How are you" type questions now, and is starting to be able to tell us somewhat the things he did at school during the day. This developing skill wasn't present at either of the previous evaluations.

Socially, when we are with him and schedule a play date, he loves other kids, will offer them his toys and play/run around with the collaboratively. He is genuinely enthusiastic with other kids, although we are told he doesn't play much with kids at preschool. It seems inconsistent with our experiences.

He is also starting to show interest in potty training which he had shown none prior.

He does have some quirks with his language. His pronouns are becoming more consistent, but he does still mix them sometimes. He answers questions, but when given a choice, like "want milk or juice" he will respond with "OR milk". He will almost always add the "OR" in front of his answer, even if it was the first choice, not the answer choice following "or". This started a couple months ago, and has lingered.

Like I said, we have never really noticed any repetitive behaviors or sensory issues. He has always been very affectionate with us and those he meets. Eye contact is usually good, but on occasion it take a few repeats for him to respond to his name. Doesn't always spontaneously greet or say Bye to others. Sometimes, not consistently.

We are in a LONG wait for a developmental pediatrician, and just wondered (knowing you can't make any diagnosis) if this might be consistent with a child going through a delay in language (questions, some pragmatics) or to what degree this might be PDD-NOS or autism, etc. Would we likely have seen other behaviors other than the language delay that should have clued us in more, by this time?

Thanks so much for you time!

ANSWER: Hi Dad;

What behaviors are you seeing in terms of pragmatic language delay? What does his behavior look like when playing alongside same-aged peers? PDD-NOS is very difficult to diagnose at this age and impossible to do without an observation of him at play with peers.

Kind regards,
James

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

QUESTION: In terms of pragmatics, our concerns were that he did not have the typical questioning of his environment that other kids did. He would never ask "what are you doing?" "What's that for?" "Are you ok?" etc. It was a lot of labeling. This has slowly started to change in the past month. He has started asking us more questions - though still no "why" questions. Overall, he isn't that inquisitive, however. Not the "1000s of questions" that kids are said to ask at his age.

He will say things like "I'm hungry/cold/tired/dirty" etc. He has also started to be able to answer more open questions like "how are you" or "what did you do at school today." (Though for more complex ones, he needs some scaffolding to get there)

When playing along same age peers, at the playground, for example, he met these 2 boys (4 and 2.5) and was running around with them, helping each other climb up ladders, laughing together, he was copying them, and laughing with them. On planned playdates, he will say things like "You sit on the rocketship, Jimmy, and I sit on the truck" (little toys we have) I would characterize it as parallel play most of the time. He does like to join in, like when a bunch of girls were jumping on a bed and were jumping off, he would do the same, very happily taking turns, etc. There is a back and forth nature to his peer play, but how developed, or typical it is, I don't know.

Almost all of our concerns have been language concerns. We have never seen stims or sensory issues - no meltdowns, and very easy-going. We have had some questions about imaginative play, though - he will "talk" through his stuffed animals sometimes, but usually any "conversation" is very short, and usually somewhat similar. Again, I don't know if this is because of his developing interactive speech, or if it is stilted, repetitive symbolic play.

I really want to sincerely thank you for your time and help. We are waiting to have our sign formally diagnosed by a developmental pediatrician, but the wait is so long. Any insights to help our son with whatever it is he might need would help us so much. Again, my sincerest thanks.

Answer
Hi Dad;

There does seem to be a degree of social delay reflected in language and play development, though not significant enough to be considered "classic" autism. It may be just delay or a high functioning form of autism. In either case, the prognosis is pretty good.

Here are some ideas for promoting social language:

Engage your son in any interactive games or activities. When reading a book together ask the who, what, where, why questions then pause for a moment. If he doesn't answer, then you answer for him. Do this for pretend play. Start at his level in an area that interests him and extend his skills slowly to more elaborated pretend play. Language does not develop in a vacuum but interactively. It is a tool for social pleasure and for manipulating others...in a good way such as turn taking, negotiating ideas, and sharing. Any activities that interest him can be used to this end.

Kind regards,
James