Expert: James Michael Roan - 7/16/2008

Question
QUESTION: Hello, I am just writing as a follow-up to prior questions you had answered for me under this heading for my (then) 21-month-old daughter with no speech.  I completed the MCHAT and we discussed it back in 4/08 and she had questionable responses to 6, and 9 and with regard to #7 she was pointing to objects of interest in books and on walls but not at a distance.  I was concerned at the time because EI had said she had a few Autism markers. As an update, she now passes questions 6, and 9 and she does now point to objects in the distance as well.  She is quite a professional "pointer" as she is still not yet speaking.  She also now had several signs such as "eat", "more", "love", "open", sometimes "baby" and "hat" and "please".  She doesn't wave "bye-bye" anymore but still high-fives and will kiss people good-bye.  At this point, she imitates signs and clapping and dancing and all other kinds of functional things such as imitating us cleaning up with brooms or rakes, pretending to put on makeup (esp. lipstick); dressing up in the mirror with hats and belts and scarves; imitates us dancing (her dance is so funny), plays with her dollhouse (putting the baby in the crib with a blanket; feeding the baby (she's been doing this since about 12 months), putting the mommy or daddy up the stairs or in the tub on on the potty; she pretends to dig dirt with her play shovel outside and she continues to absolutely LOVE reading books.  She sits in my car with her hands on the wheel.  A few weeks ago a child was crying in a bookstore and she went over to him and patted him on his back and cheek.  She has also patted her baby cousin on the head when he cries.  Her pediatrician just saw her for her 2-year check and said that her impression is that my daughter is not on the Autism Spectrum but has a speech/language delay.  Her EI Team, although not allowed to make diagnoses, has told me that they also do not see it as a spectrum issue but more of a neurological issue.  Some of the reasons they give include her short attention span (she moves very quickly from one toy or activity to another with the exception of reading books or looking at pictures of the family while I tell her stories about the pictures); sometimes when she is interacting with EI she will interrupt the interaction and run off at a short distance, pause, and then run back; and although she continues to babble with more and more variation, she also makes an "mmmm" sound sometimes when she is running.  However, she also tends to make this sound to express emotions: like "mmmm" with a smile when she sees her favorite person; or "mmm" with a frown when she is tired or frustrated; or "mmm" with urgency to try to get our attention, or "mmm" with gusto when her food arrives at a restaurant.  Other issues include her suddenly stopping what she is doing and looking with both eyes off to the left for 5-10 seconds and then returning to whatever she was doing with her normal smile and enthusiasm.  It is always to the left and it seems she might be either processing information or that her eyes are just doing this without her control. She has no "sensory issues" as defined by a list of criteria provided by EI that would make her qualify for an OT evaluation.  She basically does not have any motor issues either.  She is easily engaged by others and has good eye gaze except sometimes with strangers when she is sensing some type of expectation to perform.  Sometimes when she is running around from activity to activity she does not make eye contact a lot, but other times it is sustained and effortless.  Since she has turned 2, she is also a bit less cooperative with requests such as asking her to identify objects in books (I know she knows them but doesn't automatically follow my directions to point to them like she used to).  She has also been very clingy and attached to me and her father like a magnet since we moved to a new house about 2 weeks ago.  She cried when I tried to separate from her for the first time for speech therapy last week and this week she cried for the entire session even though I stayed with her.  She kept making the sign for open and pointing to the door to leave the speech room and screamed when I did not honor her request.  She has private speech therapy twice per week and EI once per week.  Since she is still non-verbal I am considering something EI provides called the Verbal Behavior Method which they say is appropriate for non-autistic children (even though it is geared towards Autism) if they are non-verbal.  In addition, I noticed she doesn't blow out candles when asked or blow on tissues to make them move.  She will stick out her tongue and touch it or occasionally lick food from her mouth, but won't really stick it out when we do it.  She can drink with a straw, blow raspberries, kiss without really puckering, form consonants, show a wide range of facial expressions,and  smile widely.  I add this because I have been concerned about Apraxia of Speech.  Her Speech Pathologist has her with normal receptive language but expressive language emerging at 9 months.  Although she has higher level functional imitation, she does not tend to imitate facial expressions or all hand gestures (only some).  She is working on turn-taking and imitation in speech therapy.  Since she was born SGA at 4 pounds and 11 ounces although Full-term, I am concerned that she could have some mild neurological problems (which is also what her EI people think).  I am going to schedule a neurological and see if she needs an MRI.  I'm thinking neurologist because not all developmental pediatricians seem to have neurology knowledge/experience.  I know your specialty is Autism and it does not look like she is on the spectrum (which matches your initial impression of my description of her back in 4/08), but do you have any information or feedback on neurological problems for SGA kids, Apraxia of Speech or any other areas you think I should be looking into?  Is an MRI dangerous at this age? Is there a chance she may never speak?  (She was just 2 on 7-6-08).  Thanks so much for all of your prior answers and feedback and sorry this is so long.  Karen

ANSWER: Hi Karen;

I think my last email got lost in ether-space! So here I go again.

She sounds perfectly normal to me. She may have some attention related problems, which are part of the executive functions. There are many similarities in early developing behaviors between autism and exexcutive dysfuntion. They primarily lie in the right front of the brain. That's why so many children with autism are first diagnosed as attention deficit. Email me at: roanpsych@gmail.com  and I'll send you some information on apraxia and executive functioning. If you think she may have attention problems ask the EI psych if they have the Behavior Rating Inventory of Executive Functioning-Preschool Version (BRIEF-P). There's a parent and Teacher form so do both if they have them. If significant problems are reported then you can get an appointment with a developmental or pediatric neuropsychologist. Their information will be more practically useful than that from a neuropsychologist.

I have no idea if an MRI is dangerous at this age.

Kind regards,
Jim

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

QUESTION: Thanks again!!  I'm wondering about the imitation issue: she has functional imitation (imitates our real-life activities all the time) but doesn't imitate our facial or hand gestures consistently (although she has learned the signs I indicated above which certainly involves imitating hand gestures).  She will spontaneously use the sign for "love" which is so sweet and copy the signs she has learned when we do them but she just smiles at us when we make specific funny faces or throw our hands up in the air or something like that.  She used to do "so big" and "Bye'Bye" all the time when it was "new" to her but now she doesn't.  I noticed she gets into doing things when they are new and exciting and then seems to be like "been there , done that".  It doesn't feel like she is losing skills or anything, just not interested in certain things anymore.  Does functional imitation count as imitation or must it be facial gestures as well?  Karen

Answer
Hi Karen;

Imitation is imitation, however, this really is an area that I need to investigate more. Imitation requires several things: attention, memory, motor planning, and motivation. I also requires, of course, processing information quickly. If there is a break in any of those areas, then there is a disruption in the in the production of the imitative behavior. There is also specialization in the visual cortex where peoples faces and objects are processed in different areas of the visual cortex. What I'm saying is that development is not even in most of us with some ares developing faster and further than other areas. Also, if she is not "attending" to faces for whatever reason then imitation will not occur. If this area interests you check out the keywords: "attention, imitation, and neuropsychology" at Amazon or the Guilford Press, or Academic Press.

To put all of this confusing "jibber jabber" in perspective: People have always said I can't dance because I don't have rhythm. But what does that mean really? I suggest it means that I have a poor ability to encode a sequence of motor actions well and to recall those sequences and then a poor ability to carry them out in a fluid manner (motor planning or apraxia issues). I could not play basketball either! Take care.

Kind regards,
Jim