Expert: Dr. Sharon A. Mitchell - 7/18/2009

Question
I have an 18 month old child that I am very concerned about.
From 6-12 months she had reoccurring ear infections and was not saying mama or dada. She would laugh and squeal and that was it. Never even so much as heard the word baba. At twleve months the dr pushed for tubes because she thought this was interfering with her communication. Three weeks after the tubes she began to say mama and daddy. Then suddenly stopped. Up until the age of nine months we could not even feed the baby food out of a spoon. She would gag. She has started speech therapy and has been in it for the last three months. Through speech therapy she has said a few words either spontaneously or throught imitation but nothing consistently. She tends to very independent and does not want help from anyone. She has showed no interest in learning sign language and will not allow the therapist to teach her hand over hand sign language. She is beginning developmental therapy. Along with the language delay she has other issues that are concerning me. For the most part she does make eye contact but with in some situations she will make short eye contact and turn her head and look at the floor. She is very selective about what children she will interact with. Sometimes she prefers to play alone most of the time with other children. Recently she has started running in a complete circle when she gets excited. Sometimes she will laugh without any reason. She cannot stand for the palms of her hands to be touched. She does not eat fruit and will not drink milk from a cup. Her eyes are senstive to sunlight. She throws violent tempertantrums. She has started to become really aggressive with me. She will hit me repeatedly when she gets upset. Two days ago she started biting herself and actually left a spot on her arm where she had broken the skin. She is very active and on the go all the time. She does not watch television and unless there is music playing on the tv does not really know it exists. She is able to comphrend most of what you say to her but unable to really express anything. We have an appointment in October with a pediatric development specialist. I talked to her doctor about the possiblilty of autism and she blows me off. In fact at her last appointment, she told me my daughter was too intelligent to be autistic. I knew for a fact this was very untrue. My cousins six year old is autistic and very smart. Could she possibly fit somewhere on the autism spectrum?

Answer
Hi Amanda,

It's difficult to give an opinion without meeting your daughter.

As you are obviously well aware, autism is a spectrum disorder, meaning that the degree to which an individual is affected by autism varies greatly as does his or her intellectual level. Some people with IQ's far above the average have autism or Asperger's. In fact one of the diagnostic criteria for Asperger's is to have intellectual ability at least in the average range.  In case it helps, here are the criteria from the DSM-IV that are used in diagnosing Asperger's:

1. Qualitative impairment in social interaction, as manifested by at least two of the following:
        A. marked impairments in the use of multiple nonverbal       behaviors such as eye-to-eye gaze, facial expression, body posture, and gestures to regulate social interaction
        B. failure to develop peer relationships appropriate to developmental level
        C. a lack of spontaneous seeking to share enjoyment, interest or achievements with other people, (e.g.. by a lack of showing, bringing, or pointing out objects of interest to other people)
       D. lack of social or emotional reciprocity
2. Restricted repetitive & stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
        A. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
        B. apparently inflexible adherence to specific, nonfunctional routines or rituals
       C. stereotyped and repetitive motor mannerisms (e.g. hand or finger flapping or twisting, or complex whole-body movements)
        D. persistent preoccupation with parts of objects
3. The disturbance causes clinically significant impairments in social, occupational, or other important areas of functioning.
4. There is no clinically significant general delay in language (E.G. single words used by age 2 years, communicative phrases used by age 3 years)
5. There is no clinically significant delay in cognitive development or in the development of age-appropriate self help skills, adaptive behavior (other than in social interaction) and curiosity about the environment in childhood.
6. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia."

I don't think that your daughter has Asperger's though; if you look at criteria #4, I'm not sure that applies to her, based on what you said.

But there are kids with diagnoses of Autistic Disorder or PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified) who have no intellectual disability.

You are doing so many things right. It was a good possibility that the recurring ear infections were playing a major part in your little girl's expressive language delay. Since you quickly noticed a difference after the tubes were inserted, this indicates that your daughter has the skills to produce language. When her communication then stopped, did you return to her doctor or ENT? Is there a possibility that the tubes became plugged or fell out? Small children don't necessarily let us know when they are in pain or have ear aches. In fact, if a child has had chronic discomfort she may not realize there is any other way to feel. It must have been disappointing when she stopped talking.

Often small children do take well to sign language; maybe your daughter is not interested right now but will want to learn with the speech therapist later.

Other children take readily to the use of pictures instead of signing. Has that been tried? PECS is one common method. Here's a site that explains more about PECS: http://www.polyxo.com/visualsupport/pecs.html You can find more information on using pictures at sites like www.do2learn.com. Using visuals will certainly not hurt and often enhances both receptive and expressive language.

If you are wondering about the possibility of your daughter having an autism spectrum disorder, you might want to look at these free, online checklists. They are by no means a definitive diagnosis but might supply information that you could take to your physician or specialist. Your SLP might have other suggestions as well.

The PDD Assessment Scale/ Screening Questionnaire - http://www.childbrain.com/pddassess.html

Communication and Symbolic Behavior Scales Developmental Profile -  http://www.brookespublishing.com/store/books/wetherby-csbsdp/checklist.htm

Modified Checklist for Autism in Toddlers - http://www.dbpeds.org/media/mchat.pdf Scoring information is here: http://www.firstsigns.org/downloads/Downloads_archive/m-chat_scoring.PDF

Does your daughter have allergies or food sensitivities? Has she seen an allergist?

Have you been involved with an occupational therapist at all? Sometimes an OT and speech therapist work hand in hand. An OT might be helpful with some of the eating issues, tantrums and aggression.

The Centers for Disease Control has a site that gives the diagnostic criteria for all the conditions that fall under the umbrella heading of Pervasive Developmental Disorders. Here you'll find the criteria for autism, Asperger's and PDD-NOS: http://www.cdc.gov/ncbddd/autism/overview_diagnostic_criteria.htm

The checklists and your thoughts on if your little girl meets any of these diagnostic criteria might be good information to take along on your October appointment with the developmental pediatrician.

Best wishes,

Sharon A. Mitchell, B.A., B.Ed., M.A., Ph.D. Candidate
www.autismsite.ca