Expert: Lee Wilkinson, PhD - 12/5/2011

Question
My son is a happy 15 month old.  However, he is delayed in gesturing.  He still does not wave, clap or point, despite us doing it non-stop for the past 6 months.  He has no real first word yet, though he babbles a lot and says mama and dada - but don't think it is to us.  He knows who mama and dada are as well as some other labeled items.  He is very independent, rarely asking for help if he is struggling with a toy.  He does smile and laugh from interaction with us and toys.  He likes peek-a-boo games and will come up to request more if we stop.  He knows his name.  He is very happy to see mommy and/or daddy as well as both sets of grandparents.  He does bring me/show me toys sometimes.  He doesn't always follow our gaze or point.  This concerns me as well.

He started army crawling at 9.5 months and real crawling at 11 months and pulling up at 11 months.  He started walking at 14 months and is doing it more, but prefers to crawl and crab crawl.  He was late in imitation skills but is getting better at imitating now - imitating sounds and some actions.  His eye contact is great and always has been --will look you right in the eye and examine what you are doing. His favorite "toy" is anything he can open and close - toy box, trashcan...he can do this for 10-15 minutes straight.  He never liked us taking his hands to clap them...he would get mad and pull them out of our hands.  He is getting a little better with this.  He does do high 5 - on command though.  His receptive language seems ok, but slightly delayed.  He understands some commands but not all. He still sometimes uses his mouth to explore objects.  He doesn't parallel play with other kids, but is not upset to be around them.

He is a very picky eater and always has been.  He won't eat table food -- he will eat cheerios, crackers, kix cereal and anything of the like.  He gags on some food still.  He won't eat cut up cooked carrots, chicken nuggets, etc.  He is still on the bottle and is a challenge to get him to use a sippy cup - though he has gotten better with a straw sippy cup.  
 
My question is, in your experience, can limited to no gesturing at 15 months, late talking, and lack of requesting for help (independence) be something other than ASD?  I have been worried for MONTHS and feel better when he learns something new and continues to develop something new each month, but the lack of gesturing and communication worries me.  Also, his lack of requesting for help and sharing our point or gaze.  

He has been in early intervention since 11 months old for his delayed gesturing and imitation.  An OT is coming out this week from early intervention for the first time.  I also have appointments this month with an external OT and an external speech therapist (he has not been seen by a speech therapist yet).  Next month, I have an appointment with a pediatric neurologist.  I am on a 6 month waiting list for a developmental pediatrician - should be seen in February. Any help/advice from your experience is greatly appreciated from this very worried mother.

Answer
Dear Flo,

Thank you for your question. Although no two children are alike in terms of their development and behavior, we generally consider the “red flags” of autism to include the core problems of social responsiveness or reciprocity, language delay, and insistence on routines and resistance to change. Because autism spectrum disorders (ASD) are “developmental” disorders, we must examine developmental milestones. We would expect the typical 15 month to exchange with you many back-and-forth smiles, sounds, and gestures in a row; use pointing or other “showing” gestures to draw attention to something of interest; use different sounds to get needs met and draw attention to something of interest; and use and understand at least three words, such as “mama,” “dada,” “bottle,” or bye-bye. In many cases, it is the absence of expected behaviors that indicates a red flag.

Children with ASD experience (but not always) delays in speech and communication skills. They often develop spoken language later and are less likely to develop non-verbal communication skills such as pointing, joint attention, or gesturing. It’s especially important to consider what we call “joint attention.”  Children seek to share attention with others spontaneously during the first year of life. Joint attention is an early-developing social-communicative skill in which two people (usually a young child and an adult) use gestures and gaze to share attention with respect to interesting objects or events. Before infants have developed social cognition and language, they communicate and learn new information by following the gaze of others and by using their own eye contact and gestures to show or direct the attention of the people around them. Impairment in joint attention is considered an important “red flag” of autism.

Unfortunately, we have no “absolute” clinical indicators of autism in very young children at the present time. There is wide variability in the course and timing of typical development and personalities of infants and children. A child might present with a delay in language development and be later diagnosed with a receptive or expressive language disorder but not demonstrate the social impairment characteristic of ASD.  Although there is some evidence that the features of autism can be identified very early in life, the most reliable diagnosis is generally made by trained professionals when a child reaches approximately 2 years of age.

If your son is delayed in making general communication with you and others who are around him and reaching and gesturing, then this suggests atypical development and the need to consult with your pediatrician or other health care provider.  Your being proactive is important since there is evidence that early identification and initiation of services is associated with a greater response to intervention and positive changes in language, social, or cognitive outcomes. I always recommend that parents and caregivers take action if they observe “red flags” or risk factors and not take a “wait-and-see” approach. Consultation with a speech/language pathologist with experience in ASD is certainly advisable. I also suggest that parents continue to be vigilant and keep an ongoing record of behavior that appears atypical or concerning. This information can be very useful in any future assessments. I’ve listed several resources that you should find helpful. Best of luck to you and your family.

Lee A. Wilkinson, PhD

First Signs. <http://www.firstsigns.org> American Academy of Pediatrics. Understanding Autism Spectrum Disorders [pamphlet]. Elk Grove Village, IL: American Academy of Pediatrics; 2005. <http://www.pediatrics.org

First Signs. <http://www.firstsigns.org>

National Institute of Child Health and Human Development Autism Site
<http://www.nichd.nih.gov/autism>

Stone, W. L. (2006). Does my child have autism? A parent’s guide to early detection and intervention in autism spectrum disorders. San Francisco, CA: Jossey Bass.