Expert: Catherine Ridenour - 4/24/2008

Question
QUESTION: Hi Catherine

My son is almost 27 months old.  He is my fourth child but my only boy so I can only compare him to his elder (8, 7 & 7 years old) sisters who were all advanced in their development.   He has no speech whatsoever (along with some other red flags which I'll explain) and has an appointment next month for a hearing check, then with a paediatrician and speech & language therapist from a referral by my health visitor.  He is quite vocal with noises which are like babble with sing song sounds.

My son is adorable, very easy going and good natured, he laughs a lot, smiles frequently and has excellent eye contact (although I'm not sure what his eye contact would be like with unfamiliar people).  He is very cuddly and shows emotion.  He is unafraid of crowds and loud noises and enjoys interaction with his sisters, although it would be tickling, picking up, chasing, boo, that type of play.   He does understand many basic instructions but wouldn’t understand something like 'pick up the paper and put it in the dustbin' or 'your toy is on the table'.  

He has never pointed, or been able to follow a point, although sometimes he seems to and other times not.  He enjoys songs and being sung to and joins in with 'row the boat' and 'round and round the garden'.  For the latter he can point his finger but will give it me to partake in the action. He plays with a only few toys correctly but not his toy cars, he just fiddles with the wheels.  He brings me things but does not share in play, nor does he imitate often, only very occasionally. He mainly enjoys physically play, such as the park or activity play centre, plus climbing things is his passion!  He does not copy or pretend play.  He met all his other developmental milestones, including the babbling and cooing, which he still does it just hasn't progressed.  He will also make noises in response to me talking to him (if that makes sense) in the appropriate places.

When he wants something he takes my hand (or whoever is with him) and leads us to it and he claps when he is happy about something.  He used to shakes his head when he heard the word 'no' and wave goodbye, but this has stopped. He does spin objects but not obsessively, mainly plates and bowls.  He used to spin balls as a baby but now bounces and throws them. He does like to open and close cupboards and doors. He is not bothered by a change in routine nor does he lines up his toys.

So many people tell me it's because we are comparing him to girls and boys are different, but we are very concerned that he has ASD.  Also, my health visitor has indicated she thinks it is a severe speech delay but we do not want false hope.  So many people tell me he is a late bloomer but my husband and I both think it is more than that.  He does not really attempt to communicate or interact unless he needs/wants something (he will look at me and smile often, and does go to his sisters for chasing games etc).

I have done the m-chat and he scored 96 (or showed mild PDD) but I found it hard to score him on the speech section.  I know you don’t diagnose but I would like to be prepared if you think he could be on the spectrum.  We live in London.


ANSWER: Hi Claire,

I think you are right to be concerned. Even late bloomers should have some single words that have consistent meaning and sound something like the real thing. "Mum, Da, gookie(cookie), up, go" things like that by age two. "Normal" development calls for two word combinations by that age, "go out", "drink milk" (allowing for fuzzy pronunciation.)

I do not think he is hearing impaired though he may have an auditory processing disorder. This means that he hears but his brain is not turning the sounds into meanings. This is addressed with speech therapy, as is most autism, so he may benefit from it either way. He could have both.

Many children on the autistic spectrum like rough and tumble play because it is stimulating. Many have very high thresholds for stimulus, that means it does not reach them until it is strong enough. Others are overly sensitive or have mixed levels for different stimuli. I'm guessing your son is generally hard to engage unless the level is high enough. He will likely benefit from play therapy that includes lots of climbing and exertion. Occupational therapists are the ones who will work with him on this.

It is good that you have screening appointments lined up for him. In the meantime, try not to worry too much. Continue to play and sing.

See if you can get him to sing words back to you. For instance, singsong, "Do you want a cookie?" coach him to sing back, "Yes, I want a cookie". We sing from a different part of the brain than we talk. It may allow him to begin to communicate with sound and that would be a good thing. It may be that he will need to learn some sign language to start the communication process. I would wait to start this until he has had his evaluations. It's best to use the correct signs rather than make them up and have to reteach them.

I will tell you that not granting his wishes until you get some kind of verbal "request" can help. After he leads you to what he wants, work on getting any sound at all, then "d" for drink, then work for "duh", "dink" etc. This is called successive approximation and is used in training both people and animals. (You don't expect a puppy to sit the first time, either.) The reward, of course, is that he gets the glass of juice. Keep it lighthearted, don't make it unpleasant.  The automatic language acquisition "software" is not working for him, so he needs training. The sooner, the better. Use limited choices as well. "Do you want juice or water?" Work for "duce" or "wa". See?

Don't let others make you feel strange for your concern. It is more often the case that parents, especially if it is their first child, don't see the signs and wait too long rather than that someone is overly anxious about a second or later child.

Best wishes,
Catherine

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

QUESTION: Thank you for your answer and perspective on the situation.  It's very interesting that you talk about singing and how the brain works in that respect.  He has always responded actively to song and music, (as a small baby he would instantly stop crying if anyone say Twinkle twinkle little star)perhaps this is why.

I wanted to ask you about why defines someone as High Functioning?  Is it based on IQ and if so how is it assessed in a small child who is non verbal?  Or is is based on other criteria, such as eye contact and other forms of non-verbal communication?

Thanks again for your help.

Answer
Hi again,

Some of the definition of "high-functioning" is based on IQ but some is about the ability to interact. I don't know if that distinction is made in small children. I think most of the HFA people are verbal, but I'm not really sure about that.

To tell you the truth, it's a question I have not asked myself until now. Some of it is a matter of self-definition. Those who can function in regular classrooms with some adaptations, go to college or hold jobs, even if they are "odd", consider themselves HFA.

I think it is a hopeful thing that your son is not rocking in the corner and avoiding all physical contact. He will be much easier to reach with therapy. Time will tell about his ability level. It is hard to test IQ in non-verbal individuals so don't assume the first tests are correct if it comes out low. As he gains ways to express himself, how his mind works will show through.

You are his best advocate. These children flourish when we believe in them.

Catherine