Expert: James Michael Roan - 4/14/2008

Question
QUESTION: Hello, I have a question about my daughter who just turned 21-months a few days ago and has no speech.  She has had no very early signs of autism (i.e. the warning signs for infants). Her babbling has recently increased and has changed in the length, frequency and intonation.  She makes what sounds like enthusiastic comments to us while doing her favorite things.  She shows a full range of emotion, smiles frequently, seems to "get" humor when introduced into play, feeds stuffed animals with a spoon and bottle, has run around with a purse over her shoulder and a bag imitating shopping, has grabbed brooms to sweep floors, puts her toy bears down a toy slide (and laughs hysterically if we do it), plays peek-a-boo (often removes my hands from my face and then puts them back while smiling and making eye contact- or removes my hands and gives me a kiss), imitates clapping, has imitated the hand gesture for "Namaste" after seeing a child on a yoga DVD do this, has imitated this same child's hand gesture from the DVD, picks out specific books she wants to read and runs to us with the book in hand and a big smile, jumps on our laps and initiates reading the book , points to pictures in the book and waits for us to say the names, identifies pictures in books when we say "where's the ----" (she will read with us for 30 minutes or more), waits for certain parts of the book or favorite parts of the book and smiles, turns the pages herself and indicates to us by turning the pages which are her favorite parts to read, pushes buttons on toys to make us laugh or to make us do other silly facial expression and laughs aloud while doing this; runs into the bedroom when my husband is lying down and "presents" herself for attention by smiling, making eye contact, and doing a little dance waiting for acknowledgment, plays hide and seek enthusiastically, makes her needs and desires known constantly by taking our hands-bringing us close to what she wants (only when it is too high for her to reach herrself otherwise she will just go and get it herself)and then puts her arms up and vocalizes to get our attention.  Then, when we pick her up she uses her eye gaze and body to move us closer to whatever it is she wants and then when she is close enough grabs it for herself and smiles; will choose from two objects (like an orange or a banana) by leaning towards it and trying to reach it or grab it clearly indicating her preference, will pick a shirt and socks to wear from her drawer, pretends to drink from an empty cup (she knows it's empty), will follow one-step directions most of the time but sometimes doesn;t seem to want to, can open some doors; puts my keys into the door imitating someone unlocking it, dances with us when we dance, kisses baby doll/strawberry shortcake and pictures of babies; brushes her hair with a brush, tries to brush her teeth, patted her baby nephew's head once when he was crying but has seemed to get used to him crying now, dances and looks at herself in the mirror, engages us by running up to us and putting her arms up for a hug or to be picked up or by smiling and starting to dance, plays a game when it's time to dry her hands off whereby she always runs off in a fake manner laughing and turning around to see if I follow and waiting for me to yell hey come back here, initiates and responds to affection always, cuddles and hugs, seeks comfort, has strong emotional connections to all of her close family, is very expressive emotionally, is very interested in watching other children and always runs up to any child she sees (maybe she will look at them touch their shirts, or hair), plays with toys appropriately, colors with her father (who is an artist) for more than 15 minutes sustained while watching what he is doing with his crayon and vocalizing enthusiastically the whole time, consistently uses facial expressions to convey wants or desires. If I feign sadness she stops immediately and looks at me with a sad and concerned expression (I stop my acting when it looks like she might cry), is very flexible and does not have problems with transitions, and has no stereotypic behaviors.  BUT although she brings books to us as described above all the time, she only brings toys a few times per day (like bringing over a favorite toy and showing it to us while making eye contact and waiting for our response) and although she points to objects of interest in books and bring us toys when asked to do so, she does not point to distant objects to share interest.  However, if she sees a distant object she likes, she will show her interest by using her eye gaze and she will follow our eye gaze and our pointing always.  She makes eye contact with us (maybe not as much as other toddlers but not less than half as much as other toddlers) and shows a preference with this (makes  more eye contact with her grandmom than with me sometimes).  This could also be because my mother reads books to her with her facing my mother so there is more opportunity for joint attention.  She waves Bye-bye but not always.  She gives a high-five when prompted.  She "answers" us when we babble back to her with a similar vocalization.  She says "mmmm" when she eats and sometimes makes an "mmm" sound when she smells a flower or gives a kiss (in other words, imitating what she hears from us).  I had her evaluated for Early Intervention and she qualified based primarily on her expressive speech delay but I was told at the evaluation that because she does not point to objects (like a plane) and her eye contact was inconsistent with the three evaluators ( she does not make as much eye contact with strangers) she has "autism markers".  Everyone one who knows her is shocked, including family who have been mental health workers and teachers.  I have worked with autistic youngsters and never even thought about this in relation to her.  I want her to have all the help she needs.  Maybe I'm splitting hairs, but I'm wondering if any of the other behaviors I have described "count" as joint attention -like the shared book-reading I described above.  Does it have to be specifically pointing?  Does she have to present us with a toy, rather than a book or simply herself for this to count as joint attention?  Is pointing to pictures that interest her in the book repeatedly and waiting for us to say the name of the picture pointing for enjoyment or shared interest?  (It doesn't really feel like pointing as a request to me).  If eye contact varies from person to person is that the same as a deficit for eye contact?  Is a deficit in eye contact an early warning sign for Autism or is inconsistent eye contact enough to be an early warning sign?  I have researched the CHAT and I noticed that pointing is given very high importance and I suppose she would have failed the pointing items.  Just thought I'd check in and sorry this is so long but I wanted to give you a full picture.  I also apologize because I said I had a "question" but it turns out to be several questions! ): Thanks!

ANSWER: Hi Karen;

There is a certain amount of paranoia concerning autism now. Eye contact by itself or pointing by itself are not reliable predictors of autism. Your descriptions of her behavior do not alarm me in any way. You have established joint attention with her.

Take the M-CHAT and score it and we can discuss the results if any risk is noted.

http://www.utmem.edu/pediatrics/general/clinical/m-chat.pdf
http://www.firstsigns.org/downloads/Downloads_archive/m-chat_scoring.PDF

Kind regards,
James

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

QUESTION: Hello, Thanks again!! I completed the MCHAT and there are a few items where I am not sure if she passes or fails.  They are as follows:  # 6: She does not point to ask for something because she leads us by the hand to the area of the floor under the object; puts her arms up to be picked up and then when in our arms she uses her eye gaze and her body to nudge us over thus indicating the direction we are to move in and once she is in within reach of the object she will grab it herself.  If I hold up a banana and an oragne she smiles and reaches for the one she wants but doesn't point at it with her index finger #7:  she uses her finger to point to pictures in books while reading; she has run up to artwork painted on the walls at Gymboree and pointed to the shapes on the wall one by one (she can reach them to touch them- e.g., triangle, circle, square etc)but she has never pointed to something in the distance like an airplane or the moon or a balloon in the air. She will simply gaze at it smiling.  #9:  she brings over books constantly to read but she may only bring an object or a toy 2 times per day;    # 23:  she will check our face before doing something she knows she should not do but has only checked our faces when faced with something new or fearful a few times.  She has very frequently run to me and grabbed me or jumped on my lap or cried and buried her head in our arms when faced with something new or fearful.  Maybe I should add here (don't know if it's relevant) that she is our only child and she has been the only grandchild for two sets of grandparents.  We have anticipated her every want and need to the point where she has never really had to point at anything- she just gazes and her wish is our command.
I don't know if she failed 2 critical items because I wasn't sure how to score the above items (as pass or fail).  Maybe I over-analyze a bit, but any feedback or guidance on how to score her for the above items is most appreciated!  Thanks so much! Karen

ANSWER: Hi Karen;

The pointing questions are designed determine if your daughter is sharing objects or activities in an attempt to "share" with you or others. It is more important that she does this than point to objects requesting them. Don't sweat the "pointing to objects at a distance" either. If you are comfortable that she is "sharing" in other ways, that's what counts. She sounds like she passed #23 in my view. Remember, the M-CHAT is a screener and not a test. It was designed to be a bit over sensitive with the thought it is better to screen more children in who do not have autism than it is to screen some out that do have autism.

Kind regards,
James

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

QUESTION: Thanks again so much for your patience with these questions and your specificity.  Out of curiosity, if a pediatrician or other clinician completed this MCHAT without all of my explanations and she failed numbers 7 and 9 (both critical questions), what would that actually mean: that she is likely to be diagnosed with Autism later and if so, how likely?  What would be anticipated- would she (if she were on a path towards Autism) suddenly start to develop the other markers as well? (I guess I'm not exactly sure what the MCHAT is predicting or what to look for).  Also, her Early Intervention team recommended that she receive therapy once per week to improve her pre-language skills (eye contact, joint attention) based on the info I provided in my original question (inconsistent eye contact with them and my responses to their questions about pointing and of course her lack of speech).  Would it be beneficial to also obtain some type of specific speech/language therapy for her from a Speech Pathologist?  The Early Intervention Team seemed to indicate that speech could not really occur without the "building blocks" training in eye contact and joint attention first.  Thanks again and please let me know if I have surpassed the limit on follow-up questions!  Karen

Answer
Hi Karen;

If she truly failed 7 and 9 only, she would be considered to be at-risk for a "possible" autism spectrum disorder. If only these two items were failed, the risk would be small but we don't know how small. She may develop autism if you begin seeing other signs or she may have a social "delay" that improves with language development and experience around other children. Communication and social development go hand in hand. Adult facilitated social language groups like EI recommends are best. Lots of facilitated play in other environments works well also. Remember, without seeing her it could be just a delay, we don't know that. The good news is that girls with high functioning autism suffer little impairment in language and social development because girls are naturally more social than boys.

My practice centers around children and families so there is no limit to follow-up questions!

Kind regards,
James