Expert: Jene Aviram - 12/18/2009

Question
QUESTION: Hi Jene:
I have a question for you regarding my 2 year old daughter (almost 27 months) and signs of aspergers/autism.  I’ve read several of your responses and am really impressed with your answers  I tend to worry just by nature – so I’m not sure if I’m being an overly worried parent or there is actually legitimacy to my concerns.
I have a couple of things that I’ve noted that are potentially concerning:
•   Routine oriented – but isn’t upset if we change it.  Really, my husband and I really are routine oriented anyway but for example in the morning, she will always play with this baby stroller and play with her babies after we come downstairs from her bedroom.  If the stroller isn’t there, she is asking and looking for it but at times does do other things if there is something new in the environment.  She does get mad though if she can’t find it.
•   She has ok eye contact, not great but certainly doesn’t avoid eye contact.
•   Lately, she has started “licking” stuff – really only when we are distracted to I believe elicit attention but nevertheless kind of weird.  Maybe once or twice a day.
•   She mixes up pronouns more than other kids I’ve noticed – the most prevalent usually being something like “pick you up” when she wants to be picked up.  However – we have noted improvement lately and she is using “I” more often but still uses you and Avery (her name) 50% of the time.
•   She has pretend play – but mostly focused on being a “mommy” and playing with one of her 15+ dolls and associated stuff.  I attribute much of this to the fact she has a 6 month old brother and basically spends her days imitating things that we do.  She does play with other toys though, in multiple different ways and other pretend play, but plays with dolls the most
•   Socially, she is an “observer”.  She likes being around other kids but is shy in social group settings.  She does, however, interact with kid once she warms up and seems “normal” but still shy.  She is usually one of the shyest kids at play time and such.   I’ve noticed lately she tends to “mother” the younger kids – telling them – “here, you have this toy and sit down and play” or other stuff that she does with her brother.   She used to take a long time (45 minutes) to warm up but now its down to 5-10 minutes (still shy though but willing to participate, etc).
•   At times, with strangers/less familiar, they will say  hi to her and she at times responds something like “andrew is at home sleeping” – if she says anything its always about her brother.
•   When I get home from work, instead of being excited she usually whines, cries, or crawls around like a baby  - for a minute or so.  I’m usually stressed when I get home so I think that’s part of it.
•   Spins around on occasion, but it is either a ring around the rosie game or she imitates our dog that does the “bucking bronco” 
•   Occasionally, when mad, she will “shake” (or flap?) her hands – it seems very controlled to the situation and even more rarely walks on her toes (it seems to me all kids do this – I frequently see this at the groups we go to).
•   When she pushes the stroller, it seems like she will look at the stroller wheels at times to watch them going around (while pushing).  Mostly this is done with her baby stroller. I asked her what she was doing, and she said “looking at the wheels”.  She plays with other toys with wheels appropriately (pushes little trucks around on “roads” and stuff like that) – she isn’t spinning wheels and watching but she tends to look at stroller wheels at times when she is pushing these things around.
•   Talks about a variety of things all day but her brother seems to be her favorite topic.
•   She is not overly affectionate but does hug/kiss, etc.  she understands facial expressions and can tell if a baby is “happy” or “sad”.

On the positive end, she tends to always respond to her name, points to things, shows us things (although doesn’t do this real often – maybe once or twice a day.  I attribute this to the fact that she can speak well and just tells us stuff instead – like “want to show mommy my pjs or something).  She has an extensive vocabulary that is slightly advanced for her age based on the other kids we are around, and good receptive language (understands everything we tell her.  Can follow multiple step directions when she feels like it).  She has hit all of her milestones along the way – wasn’t a really smiley baby and isn’t an overly physical toddler (still can’t jump and walked at 15 months) but is within the normal ranges of development.
Sorry for the long list!  Please let me know if you think there is anything in here of concern.  Oh, and I’ve done the m-chat multiple times through our pediatrician and on my own once a month or so and she has passed each time.
Regards – Heather

ANSWER: Hi Heather,

Thank you for your praise on my responses.  I greatly appreciate your feedback.

While I couldn't possibly make a solid diagnosis over the Internet with such a small description, I can certainly give you my opinion on the concerns you shared.
Basically - I think you have no reason to worry about autism/aspergers :-)

I have yet to find a child on the autism spectrum with the skills your 27 month old daughter has.  She is imitating you, communicating with her peers, explaining herself to you, has advanced language and can follow multiple step directions.  This is all simply wonderful!  It's OK that she tends to be shy and takes her time warming up.  She gets there in the end and that's what counts.  

Some children indulge in lots of pretend play, while others prefer more structured activities such as puzzles and interactive toys.  There is only cause for concern if there is never pretend play, very rigid play (example lining up cars and getting very upset if someone tries to intercept this) or toys are not used for their purpose (for example a child might consistently throw blocks down the stairs rather than build with them).  So I certainly wouldn't worry about this area.   

Regarding the mixing of pronouns - this will probably straighten itself out.  Simply correct her when she makes an error and she'll get it.  All children are creatures of habit, and I don't think her preference for routine is an issue.  I'm certainly not concerned about her reaction when you come home.  Perhaps it's an attention seeking behavior for you to shower her with love.  What a smart kid!

Your daughter does display some sensory defensiveness and these explain the other behaviors.  For example, licking things is a definite sensory issue.  So is flapping hands, walking on toes, spinning etc.  Children with sensory challenges often have a need to "control their world" as it makes them feel more secure.  Because of this, they often insist on routine and might get very upset if things change.  This can certainly account for your child's unhappiness in the morning if her stroller is not where it should be.  Spinning the wheels repetitively and watching them turn is another method of control.  

You can request an OT (occupation therapist) evaluation.  I'm not sure she'll actually qualify for services, unless she displays some other sensory challenges you didn't think to list here.  Overall, it sounds to me like your daughter is just fine.  She is developing at her own rate and she seems right on track.  I know it's hard not to worry (impossible actually) but I don't think you need be concerned.  And although I don't think you need do the MChat again, I'm sure you'll probably do it at least 800 times :-)

If you ever have any more questions, you know where to find me.

I hope this has been of some help

Jene Aviram
http://www.nlconcepts.com


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

QUESTION: Thanks so much for your response!  I really value it.  I have a couple quick follow ups:
-her ped actually referred her to OT for shyness.  I'll bring up the sensory concerns - I'm on the waiting list for the next month or so.
-on the sensory stuff - that makes a lot of sense.  Are there other things that I should be concerned with??  For example, she used to hate walking in grass (has overcome that) but hates having dirty hands (sometimes).  I'm wondereing if the sensory stuff is the root of my concerns and would maybe explain a lot.  She also uses her comfort stuff animal nd "tickles" her feet with it and fumbles around with the ears when she is relaxing and falling asleep.

Thanks again for the fast response.
Heather

ANSWER: Hi Heather,

There are many sensory challenges that kids might have.  I'll try to list some here for you and you can see if you can relate to any of them:

1.  Dirty hands - yes this is a big one.  Kids don't like to get anything on their hands from glue, to dirt and constantly want to wash it off, or avoid touching things at all.
2. Textures - Kids have an aversion to textures, such as slimy things (paint slime) or materials, or on the flip side, they have a need to touch certain things, such as satin, etc.
3.  Sound - Children might hate loud noise.  They might block their ears.  If noises get too loud, they might tune out and look lost in space.  
4.  Voice - children might either talk too loud or too softly for others.
5.  Tags - children might hate tags in clothes.  They might hate wearing certain materials.
6.  Food - they might be very fussy and hate certain textures in their mouth.  They might not want to mix foods on the same plate.  They might even physically gag at some foods.
7.  Smell - children might be very sensitive to smells and hate or love certain smells.
8. Walking barefoot - this is often a problem for kids.  If they are barefoot on one texture, they might not want to switch.  For example, they might be walking on the grass, but when the come to sand they refuse to step on it.
9.  Touch - children with sensory defensiveness might hate certain touch - for example light touch.  They might want to be squeezed.  Or perhaps the reverse - they might hate hard touch and want light touch all the time.
10. They might be distressed by having to brush their teeth, or wash their face.
11.  They might have very high tolerance for pain.  
12.  They might gnaw on things or place inedibles in their mouth.
13.  They might have limited coordination and fall down a lot.  They might not have the reflexes to put out their arms in time to catch a fall.
14.  They may walk on their toes only.
15.  They may not be able to identify which part of their body is not being touched if they're not looking.
16.  They might be a thrill seeker - or the reverse and be afraid of elevators and heights.

There are so many more symptoms.  You can search on sensory defensiveness or sensory integration disorder and you'll probably come up with a whole bunch of sites with valuable information.
I hope this has been of some help.

Jene Aviram
http://www.nlconcepts.com

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

QUESTION: Hi Jene,

I hope you don't mind but you've been so helpful in the past and I wanted to ask you a few other questions.  From the original list I sent back a few months ago, the only concerns that still remain are pronoun reversal (70% accurate, 30% inaccurate roughly between mixing up you and I; she also uses herself in third person at times) and her social slow to warm up (eventually comes around but it takes a bit of time).  Also, we had her seen by an occupational therapist for an hour in August, and she noted no sensory issues and didn't see any autism concerns.  

We were going to leave it at that, but our pediatrician recommended that we also see a child psychologist since they look at "other" things as well.  So we met with who he recommended this week.  In the hour visit, the psychologist thought she maybe had some speech delays (as she did say "you" when we were there in reverse and didn't directly ask one of her questions).  But, she's 2.5 (30 months) and a shy child, so this really didn't surprise me much.  She wanted to do a 2 hour evaluation with her - I'm just so torn.  Yes, I've seen that pronoun reversal is associated with autism, but is it really that big of an issue at 2.5?  I'm told by everyone that comes in contact with her that her verbal skills excel over kids her own age - just last night she said to me, on her own, "Mommy, I want to go to the toy store and play with that cart and the baby with you".  Not something taught, or imitated, just indicating something she wanted to do that we've done in the past that she has enjoyed.  Without pronoun reversal.  
So, I guess my question is, given our few remaining concerns and our uncomfortableness with the child psychologist, should I still have her evaluated in the 2 hour appt?  I don't want to feel like I'm ignoring issues but I don't want a label that is inaccurate either.  I'm really torn - any advise or insight you could provide would be very appreciated.
Thanks,
Heather  

Answer
Hi Heather,

I'm thrilled to hear how well your daughter is doing.  She always had great skills and it sounds like she is doing really nicely.

The best thing you can do is NOT TO WORRY ABOUT A LABEL.  You are not alone in your fears.  Many parents don't want their kids to be labeled.  They feel it will put them in a box and that people will treat them accordingly.  They feel like there is a stigma attached to a diagnosis.  They feel their child will be judged.  They feel their child's progress will be hindered.  They feel people will have low expectations of their child.  They feel it will mark their child's future.  They feel their child's self confidence will be diminished....  The list goes on and on.

Actually, a label helps a child get services.  And that's the most important thing.  I don't think your child is on the spectrum, however for arguments sake, lets say she needs some help.  If you don't seek an evaluation and risk getting a label, your child won't get the help she needs.  And the gap between her and her peers will grow wider. Label or not, people will begin to notice the differences.  On the other hand, lets say she does get a diagnosis.  You don't have to tell that to anyone.  It doesn't go on any record that damages her future.  But now she gets the services she needs.  In time all her issues go away and she doesn't have that label or diagnosis any more.  And nobody is the wiser.  That's a much better option, don't you think?

Lets discuss the child psychologist for a moment.  Think about why you did not like her. If you question her professionalism or ability, then do not go back.  There are many child psychologists and developmental pediatricians.  Just because your pediatrician recommended her doesn't mean she's right for you.  Find another one and make an appointment.  If you like what you see, then schedule a full evaluation.  The fact that your pediatrician recommended you see someone also adds importance to getting an evaluation.  A label does NOT have to stay for life.  But it does get your daughter the services she deserves.  If I were in your shoes, I would undoubtedly get a full evaluation but only with someone that I was comfortable with.

I wish you much luck and success.  I have a feeling that in the end, all will be OK.

Jene Aviram
http://www.nlconcepts.com