Expert: Dr. Sharon A. Mitchell - 5/6/2011

Question
Hello Dr. Mitchell,

My wife runs a home daycare out of our house.  We also have 2 children (3 1/2 and 21 month old and a 3rd on the way).  This past week, my wife took on a family with a 3 year old boy.  She has a questionnaire that she had them fill out and some of the questions ask about certain milestones.  The parents completed the questionnaire indicating that the child had hit milestones.
The boy has been in our care for this past week and both my wife and I have noticed some issues which raise a few red flags.  For the week that the child has been here, we have only been able to understand 2 words "No" and Mommy".  There is no other communication that we can get out of him.  He does mumble sometimes, but we cannot understand what he is saying.  There is very minimal eye contact as well.  He also has difficulty understanding simple commands like “get in your seat for lunch” or “get your coat or boots”.

He cannot use utensils during lunch time.  He attempts to hold the spoon backwards and tries to eat or will use his hands.  Also, when sitting in his chair at lunch, he will “twitch” or make a quick spastic type movement every now and then.  His hands also appear to “freeze up” every so often while eating.

During craft time, he didn’t appear to know how to hold a paint brush, nor did he appear to have any concept of painting as he ended up painting his shirt and face.

During playtime, he tends to play by himself.  He appears to be shy and doesn’t not really interact with the other children (Three 3 yr olds and 3 approx 1 ½).  He tends to play with simple toys such as playing with a stick or a bubble wand instead of playing with trucks and the sandbox.  He would rather watch the other children play than participate.

When my wife is preparing lunch or snacks, she will put the TV on during that time for the children to watch an educational program.  Most of the children will play with toys rather than watch the TV, but this child immediately sits as close as he can and becomes a zombie to the television.  As soon as the television is turned off, he begins to cry to the point of hyperventilation and says “No no no”.  He also hits his thighs.

The child can go up and down stairs, but he puts both feet onto one stair before moving to the next one.  He is also still in diapers and has no interest at all in potty training according to the parents.

My Wife and I checked out several online guides and checklists in regards to 3 year old milestones, and due to the large amount of “non-accomplished” milestones (red flags) we became concerned about this child’s development.

Some of the issues do seem to reflect symptoms of some sort of ASD, but we both feel that there is definitely some type of issue with this child.  Do you have any feedback or input?

On a side note, my Wife does daily e-mail journals that advise the parents what the child ate, participated in and any questions or concerns that have arisen throughout the day.  

Having the best interest of the child as top priority, my Wife ended up advising the parents, in a non judgmental or insulting way, that she had some concerns about their child due to the observations.  She provided the specific details in regards to each observation relating to specific milestones.  

She also specified that she was no Doctor nor is she diagnosing anything, but she suggested that they might want to advise their physician.  She again stated to them that she is bringing it to their attention because the well being of the child is her # 1 priority.  As a result, the child’s Mother replied stating that she was offended and she does not want the child here anymore.  I feel as if they may be aware that there is a problem, but are in denial.  Any advice or suggestions in regards to telling the parents? (In case we run into this in the future)?

Answer
Lawrence, this little boy landed on his feet when he arrived at your home. He is very lucky to have you and your wife in his life.

From your description, it does sound like this child is experiencing some developmental delays and your wife's advice to seek their physician's opinion is sound. I'm sure she phrased it as diplomatically as she could, but still, such news can be very hard for a parent to hear.

You may be right that the mother is in denial. It's easy to do. When we bring a child into this world, we hope for nothing but the best. We want that child to be healthy in every way, to be bright, successful and happy. Especially, when a child has no outward sign of a disability, it can be hard to think that all might not be well with our little one. Sometimes parents are reassured that all children develop at their own pace and that milestones are only guidelines. Even the term "developmental delay", one used frequently by psychologists and medical people, may be misleading. The word "delay" implies that while a child may be somewhat behind right now, he'll catch up. In actuality, that rarely happens. While all kids grow and mature and develop, the child wiht such a delay likely will not progress at the same pace of his peers and fall farther and farther behind.

This possibility strikes fear in the heart of a parent.

There is a chance that this little guy's mom has some niggling thoughts in the back of her mind that something is not right but to take that thought out and actually look at it can be scary. It's admitting that this may not be just in your imagination and it might be something huge to deal with.

The Canadian Speech Language Hearing Association has a fact sheet on language development in preschoolers http://www.speechandhearing.ca/files/preschool_speech_and_language.pdf

I think you're from Ontario, Canada. The province of Ontario offers many early intervention services to children and their families. Generally there is a qualification requirement and the first step in connecting with these services would be for the mother to discuss her concerns with either her doctor or a public health nurse. But of course, this is a parental decision and all you can do is voice what you are noticing and be supportive.

There may be another worry here. Working is a fact of life for many mothers; childcare is an ongoing concern. Some mothers, with good reason, are afraid that if their child has a disability, it will be even harder to find a competent, willing care provider, or that they will be charged a higher than usual fee for that care.

In sincerely hope that this little boy continues to come to your home. Whether or not he receives any sort of diagnosis, and whether or not his mother wants to recognize that her little guy is developing differently, there is much you can do to help. Just the activities alone that you expose him to in your home will help. The constant exposure, the encouragement to try, the modelling provided by the other children and the unconditional acceptance he (and his mom) will find with you will help enormously.

I wish you all the best,

Dr. Sharon A. Mitchell
www.autismsite.ca