Expert: Dr. Sharon A. Mitchell - 6/27/2011

Question
Hello Dr. mitchell, I am the parent of a lovely and smart 3 1/2 year old boy. Since he was 2 or younger I've had the feeling that he is a bit different. It is very hard for him to look people in the eye, he needs to follow a very structure routine, hates going to big birthdays (something that in Panama  were we live happens two or three times a week), and he crys a lot for things that seem insignificant to other like another kid touching him or getting the wrong color ball or toy. I have struggled very hard because otherwise he seams like any other boy his age, and many times I have doubted myself and felt terrible for comparing him or for thinking there was something wrong. But as time passes it becomes more evident that he is struggling in certain areas and now my husband, his teacher and other close people are noticing what I noticed years ago. He definitively has a speech delay. He talks a lot, but mixes syllables and has difficulty with several letters so it is hard to understand him. He is also doing repetitive mouth movements (although very subtle) and as soon as he starts getting uncomfortable in any situation he will put his hands in his mouth. This actually gets worse when hi is nervous or upset, but he usually puts everything in his mouth. Now that he is getting older I also notice that he sometimes doesn't understand acceptable behavior that I feel sometime kids learn on their own. For example I've notice that he sometimes pushes his teachers to get their attention, but he does it with a smile on his face, he even hit a teacher in the face but he wasn't upset, he was completely happy and appeared like he though there was nothing wrong with that. The same thing happens with other adults. When he actually allows other adults like grandma to play more closely he sometimes punches, hits, licks, bites...and when I tell him "No!...thats not right" He still smiles and I am not sure if he understands if I am playing or being serious. He plays very well with his brother and sister, but other than that he relates very little with any other kids. And many times prefers to stay home to avoid any situation where he will have to interact with other kids. Like I said before, I don't live in the US. I have talked to his doctor and we have done hearing tests, hi is currently having speech therapy, we are going to start some behavior therapy, but I still don't have a diagnosis!!. Is there a test I should be asking for, or anything I can do so I know if my son has Aspergers or something in the Autism spectrum. I still struggle something wondering if he is just a very sensitive child and questioning myself on how I should discipline him if he is just doing tantrums or if this is something he cannot help.
Thanks for your help.

Answer
Hello Beatriz,

Your subject line for this question is diagnosis. While knowing an exact diagnosis can be helpful, it sounds like your main goal is finding out what you can do to help your little boy. Or, more accurately, what MORE you can do, because you are already doing a lot.

He has teachers. You are involving him in social activities with adults. He has opportunities to see other children. You have spoken with his doctor and you're had his hearing tested (one of the first things I would have suggested). He already receives speech therapy and will be starting behavior therapy - all excellent things to do.

If your son had a diagnosis of something on the autism spectrum, those are exactly the things that would be helpful for him, so you are doing what you can to help him.

Having a diagnosis might either put a name to your concerns or it might put them to rest. While a label can help, often people seek a diagnosis so that they can access services; you are already receiving those services.

The one service you have not mentioned that might help is that of an Occupational Therapist. OTs are often helpful in determining what may be behind some behaviors, especially if the child has sensory sensitivities. Some children become easily overwhelmed in crowded, noisy situations or social gatherings where they are unsure what might be expected of them. Kids with tactile sensitivities may be wary of being touched and shy away from such contact. They may act out if someone brushes against them or they may behave in ways to push others away.

Noise sensitivities plague some children, while visual stimuli can bother others. An Occupational Therapist can help you sort this out and assist you in putting strategies in place to help him overcome some of his sensitivities and learn coping methods.

But it is not only people on the autism spectrum who have sensory difficulties. Kids who do not have autism may still have these difficulties.

If you think that sensory issues may be behind some of your son's actions, take a look at this sensory checklist: http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist... It in no way gives any sort of diagnosis but might guide you in thinking about his behaviors in a different light.

The link below goes to a rather lengthy, but thorough article that talks about sensory sensitivities and differing perceptions experienced by people with autism spectrum disorders: http://www.autismtoday.com/articles/different_sensory_experiences.htm

You ask if your little boy may have Asperger's. Without knowing your child, my guess would be no. One of the criteria required for an Asperger's diagnosis is that there be no language delay. since your child has a speech delay, that rules out Asperger's. Likely you wondered about Asperger's because you say that you have a bright little guy. While having average to above intelligence is also part of the diagnostic criteria for Asperger's, being bright does not rule out having autistic disorder or PDD-NOS (Pervasive Developmental Disorder-Not Otherwise Specified).

At this next link you will see the five diagnoses that fall under the umbrella term of autism spectrum disorders. It is likely only the first three that would interest you. http://www.firstsigns.org/screening/DSM4.htm

The First Signs website has an excellent video glossary (http://www.firstsigns.org/asd_video_glossary/asdvg_about.htm). Here you can watch a child with autism alongside a video of a typically developing child of the same age. This might help you see, or not see some of the signs in your son.

At this next link is a free, online checklist you could take. Again, this is not a diagnosis but may provide some information that you could take to your physician and/or other therapists who are working with your son. http://www.childbrain.com/pddassess.html

Are you familiar with the term "social stories"? This approach was started by Carol Gray and is quite effective. It's a strategy you can use at home. At this website are a number of such stories that you can use or adapt to the needs of your family and the situations your son encounters. I'd suggest using these before the next social gathering, etc. http://www.thewatsoninstitute.org/teacher-resources2.jsp?pageId=2161392240601226...

Often behaviors are much more severe when a child does not have a way of communicating his wants and needs. It's great that your little boy is seeing a speech therapist. She should be able to help him devise ways of getting an adult's attention that do not involve hitting or biting or licking. (The licking though may have a sensory basis that an OT could help with).

Using visuals is often a useful strategy. A nice website to learn about visuals is www.do2learn.com.

I've likely thrown quite a bit of information at you at once. If you'd like to read through it and ponder a bit, feel free to contact me again if you have specific questions.

Best wishes,

Dr. Sharon A. Mitchell