Expert: Dr. Sharon A. Mitchell - 12/11/2011

Question
I've been monitoring my 35 month old son's development closely since he was about 18 months of age.  When he was 18 months, I had been looking at video we had taken 6 months earlier and noticed that his speech had not really changed.  To clarify, he had no speech at 18 months and his vocalizations were no more complex than his vocalizations at about 1 year of age.

At that time I began to scrutinize his behaviour.  I noticed a lack of eye contact, a propensity to ignore his name being called though he would turn or respond some of the time.  

My pregnancy and delivery were problem free, his early development was right on track.  Physical milestones met on time, some a touch early.  He was an easy baby and young toddler who rarely (if ever) tantrumed.  He transitioned into daycare at 18 months with no problems.

However, his speech remained far behind and at 20 months after reviewing with my family doctor I began speech therapy with him.  He started with zero words and zero signs.

He now has countless words, his language appears to be normal (pragmatics, pronouns, sentence structure, etc.) but phonetics and articulation still lag behind particularly in the labial sounds (f, v, b, p) and some of the more complex sounds/blends.  He has predictable omissions and substitutions that make him quite intelligible to his caregivers/therapists but not to strangers.  Receptive language is good.  Hearing loss/issues ruled out.

Despite the progress in speech (probable apraxia of speech) I still have concerns about his overall development.

Fine and gross motor skills are normal.  His general disposition is happy/agreeable with a dose of 3 year old stubborness thrown in.

He has a few 'things' that when put together are of concern.  Eye contact is improved but not as consistent as I would expect it to be.  He still will ignore being called, especially if he is involved with a preferred activity.

He does not avoid other children or social situations but is very easy to play by himself, he does not mind being alone.  He will wander away with purpose; if we are out in public or outside in general I must watch him all of the time.  If he wants to go or do something, he will go or do that whether or not you accompany him.  This behaviour was particularly noticeable 5 months ago but has been curbed to a degree partially due to the 'rules' that we discuss when going out (the first rule being "you don't run away").

He plays with toys appropriately but seems more into whatever he is playing with than other toddlers his age.  Today he put his square crackers in a grid and was slightly perturbed that there was an uneven number.  Later he put his Shreddies in a grid.  Both times he called me to show what he had done before eating the snacks.  

His palate is very limited.  As a younger baby (9-15 months) he would eat virtually anything.  Slowly he became more and more picky to the point where he eats mainly bread/bread products, fruit, milk, yoghurt, applesauce, chicken nuggets, pizza, fries, popcorn, the occasional meatball.  His stool is soft and stinky but his bowel movements are regular.

In the last 2 weeks I have noticed that he is keeping one fist clenched most of the time.  He will release the fist if asked but otherwise will keep in clenched even when using it (such as drinking from a cup).  He has always pointed with any finger on his hand, often his middle finger.  I remind him to use his index finger and he will do so willingly.

He plays with other children sometimes, his older brother often (18 months older) and he does seem to be aware of their emotions to a degree.  For instance, if older brother is upset, he will bring a favourite stuffed toy to soothe.  He easily shares toys and food if asked but will sometimes overreact if a toy is taken away by his older brother.

He is a fairly good sleeper but will lie in bed sometimes for well over an hour wide awake after bedtime.

We have engaged local support including caseworkers and a psychologist and have had a pediatrician evaluate him on 2 occasions.  The pediatrician had concerns at this first evaluation (at approximately 22 months of age) but at the follow up 6 months later no longer saw the red flags that appeared on the first visit.  The psychologist was also positive stating no need for ADOS.  Both support continued speech therapy (which we are doing).

Each of the little quirks he has on their own don't bother me.  But when I add them up they do concern me.  He's just a touch 'off' and it is hard to put my finger on it.  He is engaging and fun and sweet, and kids and adults alike are attracted to him.  But he has an air of indifference to certain social norms that I didn't expect to have to teach a child.

I'm not even sure exactly what I'm asking except what would you suggest in a case like this?

Answer
Hello Katie,

I understand you're last sentence. It sounds like you have a nagging worry that you can't quite put your finger on.

First I'd like to say what a lucky child your son is to have parents who are so observant and so proactive. He has already received so much service and has made significant gains.

Here are some of the positivies I se:

- you notice when he was only a year and a half that his expressive language was not developing the way you would have expected

- he has received and benefitted from speech therapy

- his eye contact has improved

- you've ruled out hearing loss

- he has good receptive language (receptive language is usually a weak spot for kids with autism spectrum disorders)

- he has met developmental milestones on time

- even with his continued speech difficulties, his errors are predictable, making him far more intellegible

- good fine and gross motor skills

- good natured and easy

- appropriate play with toys

- he's responding to the rules you create

- he will interact to some degree with other children

- he has awareness of the emotions of others (Theory of Mind)

- he points

- he wants to share with you his accomplishments

- he's engaging

From what you describe, I'd concur with your psychologist and would not do an ADOS at this time.

But, I do see some of the things that are troubling you. The professionals you've consulted likely give creedence to your concerns, partlyl because you have an older child as a comparision and partly because you present your observations so well.

As you know, autism is a spectrum disorder, meaning that there is a wide range of cognitive ability among kids on that spectrum, as well as a wide degree of just how much the autism symtpoms affect the child. There are kids who share some symptoms with their peers on the autism spectrum, but not enough symptoms to warrant a diagnosis. Other kids may show some of the symptoms sometimes but with time and learning, exhibit less of them. There are many children who show some signs who will never be diagnosed.

Here are a couple books that might interest you:

Problem Child of Quirky Kid (http://www.amazon.ca/Problem-Child-Quirky-Kid-Commonsense/dp/1575421216/ref=sr_1)

Quirky Kids (http://www.amazon.ca/Quirky-Kids-Understanding-Helping-Doesnt/dp/0345451430/ref=)

You mention that you're okay with your son's quirks, but I get the sense that you'd like to make sure you're not overlooking anything.

A website I like is called First Signs. They have a video glossary where you can watch clips of a typicallly developing child along with a child with an ASD of comparable age. You must register to watch the videos, but there is no charge and no one will contact you. (https://www.firstsigns.org/asd_video_glossary/asdvg_sources.htm).

The First Signs website has some development milestones important when considering the possibility of an ASD at https://www.firstsigns.org/healthydev/milestones.htm.

Whether or not he actually does have autism, you are already accessing the services that would help him, plus you have on your side team a psychologiss and pediatrician to assist you in monitoring your son's growth. The day care providers are yet another group of impartial observers who can let you know how they see your son alongside his peers.

The niggling fear you have may be related to your son's symbolic play, engagement and relating to others. Something you could do to foster his growth in this area is play with him at home following the ideas of Floortime. This tactic would certainly do no harm if your some does not have anything on the autism spectrum and if he is showing some signs, it would benefit him. Here are a couple books that could help you with this:

Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think (http://www.amazon.ca/Engaging-Autism-Floortime-Approach-Communicate/dp/073821094).

The Learning Tree: Overcoming Learning Disabilities From the Ground Up (http://www.amazon.ca/Learning-Tree-Overcoming-Disabilities-Ground/dp/0738212334/).

It sounds like your little guy has made great strides over the last year or so and will likely continue on this path. It's great that you are continuing with the speech work, especially is apraxia is suspected. You are already doing so many things right for your son. i'd suggest you follow along your current path. Sometimes if there is more to be concerned about this becomes more apparents when the child enters the school system and more group demands are placed on him. For now, you are doing what you can to prepare him for that day.

Best wishes,

Dr. Sharon A. Mitchell