Expert: Dr. Sharon A. Mitchell - 2/7/2012

Question
QUESTION: Hello,

Today I went to pick up my youngest from daycare, and the director of the center pulled me aside and said my daughter was showing some signs of Aspergers. She said she has tantrums when transitioning activities, doesn't like messy hands, and lines up her toys. She said she would just observe for the next couple of weeks and let me know what she thinks.

I was so overwhelmed in hearing this, that I as soon as she was down for a nap I read anything I could find on Aspergers. I'm getting confused at what the actual 'symptoms' are, because there seem to be so many, and so many levels on which they can vary...

She does line up her toys at home...she is in love with animals, so mostly her little animal figures. She will occasionally pair them up, or separate the sea creatures from the land creatures, or sometimes just put them all in one random line. Shes fine if I knock over the line, help her line them up, or take one animal from the line. She even lets her older sister help too. And occasionally she'll knock over the line herself. But at school, I'm told she doesn't let anyone near her lines of toys...

At home, she is 'the' messiest baby. She loves to eat 'sauce' #ketchup, ranch, bbq, etc# with her hands, plays with playdough, colors herself with markers #yikes#, plays in the mud, etc. While at school, I was told she gets squeamish about 'textured' crafts like finger painting, etc.

The tantrums. Yes, she has bad ones. Usually when she doesn't get her way #if she wants a toy she cant have, sharing with her sister, leaving a fun place, etc# but never for any 'sensory' reasons. We still wont bring her to a restaurant, because she insists on running around, but I can bring her to the store and shes not too bad.

The only thing that sticks out at me is her clothing. She HATES wearing any/all jeans and shirts with tight short sleeves #which are pretty much all girl shirts.# If I put jeans on her, she throws such a bad tantrum that I always end up giving in and changing her into cotton pants. And she will wear a fitted shirt, so long as it has long sleeves. Just recently she threw the worst tantrum I have ever seen over snow pants, but once she was outside, she was laughing and playing and forgot all about them!

Other than that, she laughs, gives kisses, makes eye contact, plays imaginary games with her sister, says "I love you" and gives hugs, plays with little kids and talks really well. Everyday she tells her teacher "Good morning, sunshine!" and every afternoon she tells me what she did that day. She does love animals and tends to focus on them, but she also likes to color and anything that has to do with Toy Story. She likes to play pretend drive-thru, or set up a picnic with fake food...all the things normal two year olds do.

Do any of these things sound like Aspergers? Could it just be something with her school, like maybe she acts different there? She started there January 16th, 2012 so she could still be transitioning...I'm just so worried and don't even know where to start looking. Thanks for your answer!!

ANSWER: It sounds like it was quite a shock, hearing what day care director said. And yes, it can all seem overwhelming and confusing.

You hit on an important point - that the symptoms can vary. The degree to which the characteristics are evident is important and can mean the difference between a diagnosis and someone who is mainly within the neurotypical range.

First, let's look at the exact diagnostic criteria for Pervasive Developmental Disorders. This is the category under which Asperger's and autism fall in the Diagnostic and Statistical Manual -IV, the book that guides most diagnosing in North America.

Since you mentioned Asperger's, we'll start with that. Here are the criteria:

•Qualitative impairment in social interaction, as manifested by at least two of the following:
    •marked impairment in the use of multiple nonverbal behaviors such as eye-to eye gaze,    facial expression, body postures, and gestures to regulate social interaction
    •failure to develop peer relationships appropriate to developmental level
    •a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
    •lack of social or emotional reciprocity

•Restricted repetitive and stereotyped patterns of behavior, interests and activities, as manifested by at least one of the following:
    •encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity of focus
    •apparently inflexible adherence to specific, nonfunctional routines or rituals
    •stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
    •persistent preoccupation with parts of objects

•The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

•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).

•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.

•Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.


This was taken from the website of the Centers for Disease Control at http://www.cdc.gov/ncbddd/autism/hcp-dsm.html. If you go to that site you can take a look at the criteria for Autistic Disorder (autism) and PDD-NOS. (Kids who get that label present as being on the autism spectrum but may not meet quite all the criteria required for an Autistic Disorder diagnosis).

What can be confusing might be the difference between autism and Asperger's, particularly when you feel that your child is meeting developmental milestones and is bright. For a child to be diagnosed with Asperger's rather than autism, she must have had no delays in gaining language and not have an intellectual disability.

Now, let's look at the descriptions you presented of your little girl. Some of what you say could be attributed to a two year old. For example:

- many two year olds tantrum
- few two years are tidy eaters
- playing with messy substances is fun when you're two!
- two year olds like to have their own way

Although each child is an individual, many kids with autism spectrum disorders have trouble with:

- making eye contact
- giving and/or receiving physical affection
- maintaining joint attention
- sharing enjoyment
- adjusting to new situations
- sensory issues
- pretend play
- inappropriate play with objects

It's interesting that you say your little girl enjoys pretend play. This is a weak area of development for many kids on the autism spectrum.

More worrisome is the degree of her tantrums. You have other children, so likely you've been through the "terrible twos" before. Are the tantrums of your youngest child substantially different from her siblings? Last longer? Seem more intense? More unreasonable?

I'd be concerned that you find it difficult to go to a restaurant with her. Does this differ from your other children at that age? Some of the other concerning things you mention are:

- difficulty transitioning between activities at day care
- her dislike of messy activities at day care, even though she tolerates them at home
- her strong reactions to certain clothing and the sensory sensitivities that implies
- lining up toys rather than playing with them (although the degree is important to consider here)

Think back to when she was a baby. Take a look at this website that tracks developmental stages from about four months to four years and see how this matches with how your little girl's development is progressing: https://www.firstsigns.org/healthydev/milestones.htm.

This same website has an excellent video glossary to look at. Here, you'll see typically developing children of various ages along side others who have an autism spectrum disorder. To watch the videos, you must register, but there is no cost and no one will contact you afterwards. Take a look here: https://www.firstsigns.org/asd_video_glossary/asdvg_about.htm.

If you are still concerned, here is a no cost, online quiz you can take, based on your views of how your child is developing. This is not a definitive test of whether or not your daughter has autism or Asperger's but it might provide you with some additional information: http://www.childbrain.com/pddassess.html.

If Asperger's in particular is your question, take a look at this screener: http://www.aspergersyndrome.org/Articles/The-Australian-Scale-for-Asperger-s-Syn.

After looking at the above websites, if you still wonder about something on the autism spectrum, definitely pursue it. Visit your physician. At the First Signs website there is information on resources and where to look for help in your State. Your day care director may also provide you with some leads.

You wrote that she's only been at this facility a few weeks. Likely, the day care is used to having new children arrive and are well aware that adjustments take time. Were any of these behaviors observed before she went there? Has there ever been a niggling feeling at the back of your mind that someone this little girl is different than your other children were at her age?

Perhaps this extra reading will make you think that none of this applies to your little girl. After all, you know her best. But generally day care directors don't approach a parent with such concerns unless they are fairly sure that something about that child differs significantly from others of her age. Perhaps even if she does not have Asperger's, there is something else that might make things harder for your child.

Since I have never met your daughter, I cannot give you an opinion on whether or not this sounds like Asperger's. I can say though, that there may be cause for conern that something is making parts of her life difficult and it's worth investigating this further.

Best wishes,

Dr. Sharon A. Mitchell
www.autismsite.ca









---------- FOLLOW-UP ----------

QUESTION: Thanks so much for your quick reply...it was full of useful information and resources that I really found to be helpful!

As far as her tantrums, they can get bad but they don't last long. If its an issue with not sharing or not being able to have a toy she wants, a quick trip to the time out spot usually stops it. If that doesn't seem to work, we usually can give her a choice ("you cant take your sisters toy, but you can choose one of these toys" type thing# and shes usually fine with that. In the few times shes had a fit and those two things don't work, we usually leave her be for a few minutes and she always just seems to get over it.
My oldest daughter is 4, and I feel like doing a 'comparison' between the two is hard, because she was such a good toddler. She never really went through the tantrum phase, although that could be attributed to her being the only child for two years. I don't think Casey's #the youngest# tantrums are unbearable or out of the ordinary; she's always been strong willed and stubborn. The fact that the fits can usually be subdued easily has me thinking these are normal.
With the restaurant thing, its not that shes 'bad', its that she wants to go up to everyone and check out what they're doing...which doesn't go over so smooth when other people are trying to eat!
As far behaviors before daycare, the only thing I have observed was the lining up of the animals...but like I said she also likes to group them and play with them. She likes to line up #and stack# the pillar candles too, but calls it a 'city'. As far as the pretend play, thats what her and her sister do 90 percent of the day...so I know thats definitely not a weak area for her!
In reading the warning signs, she meets none of that criteria. She loves to give hugs and kisses, make eye contact, play with kids,laugh at jokes and funny movies and plays really well with her sister. She also shows empathy #if we're reading a book, for instance, and theres a sad part shell say things like "oh, don't cry baby."#
I'm going to continue to watch her development, as the fact that the school said something has me concerned. But really, the criteria for Aspergers dont sound like my child at all.
Again, thank you so much for taking the time to answer my questions! It is MUCH appreciated, and you have eased a lot of my fears!!

Answer
It's good to hear that her tantrums are manageable and within typical limits.

Perhaps you can discuss some of what you've read with the day care director and the reasons why you don't think that Casey fits the criteria for Asperger's. The two of you may then be able to work more closely to ease your daughter's transition into this day care.

All the best to you and your family,

Dr. Sharon A. Mitchell