Expert: Dr. Sharon A. Mitchell - 10/13/2007

Question
I have some concerns about my 4 year old son. I have mentioned them to my family doctor and my husband and neither really took them seriously.

My son is very intelligent. He is loving and extroverted, in general. He doesn't understand personal boundaries and I often have to pull him off of people because he will hug, kiss, crawl on top of, etc. people he doesn't even know that well. He doesn't seem to be aware of how this affects other people, even though some people (preschoolers!) do little to hide their aversion.

Since he was a baby, he flaps his hands excessively. This is especially if he is watching TV or if we are about to do something exciting (like go down a waterslide). As he does it, he opens his mouth as if to scream, but he is silent. He usually jumps us and down at the same time.

I wouldn't call him hyperactive, but he rarely ever sits down, even for TV time.

His speech came early and is excellent. I read that 200-300 words is normal for his age and I'm sure he knows probably twice that many. His grammar is good, vocabulary excellent and he understands concepts like cause and effect, chronological order etc. However, he does not understand the difference between "he" and "she" and "him" and "her" and "his" and "her". That is, he rarely uses a subject pronoun instead of a possessive adjective, for example, but he seems to never get the correct gender. He usually uses the masculine form.

Discipline is very challenging, especially because he will lay on the floor, become immobile and refuse to look at us when we speak.

I live in Canada. If my family doctor doesn't think it's worth looking into, what can I do? I think my doctor is distracted because my son can be very sociable and has shown himself to be very verbal and intelligent (for example, he knows all of the planet names and can explain why we have seasons!).  

Answer
I'm a Canadian as well.

Without meeting your son, it's not possible to give a good opinion. Some of the things you describe could though be characteristic of a child with Asperger's Syndrome. Asperger's fall under the autism spectrum.

Many people (including physicians) still have in their minds a picture of someone with autism who sits in the corner and rocks and is severely mentally handicapped. They are not aware that autism is a spectrum disorder with a wide variation in the severity of the symptoms and well as a range of intellectual abilities.

I presume that since your son is 4 he is not yet in school. Any autistic tendencies may become more noticeable when your lad is surrounded by other children his age. At that point, the school may be able to help you with a possible diagnosis by providing their observations, filling out checklists, doing testing, etc.

It's often wise to pay attention to that little voice that's telling you something is not right. If you continue to investigate further and receive some type of diagnosis for your child, then you have a starting point in learning how to help your boy be the best he can be. If your investigations prove that he's operating within normal, expected bounds for his age, then you can rest easier.

Taking things literally and not understanding social boundaries can be characteristics of autism. Not every child with these tendencies necessarily has autism, though.

There are specific symptoms associated with the various autism spectrum disorders. You can read about them and diagnosis here:

http://www.psychiatry.emory.edu/PROGRAMS/autism/pdd.html

And in more medical detail here:

http://www.nichcy.org/pubs/factshe/fs20txt.htm

Here is a short, free, online checklist your could look at to see if you think your son is showing characteristics of Asperger's Syndrome:

http://www.udel.edu/bkirby/asperger/aspergerscaleAttwood.html

Here's a checklist on characteristics of autism:

http://www.hmc.psu.edu/psychiatryservices/child/outpatient/autism/Revised%20Auti...

These checklists are not definitive and do not mean that your child has or does not have autism. They may provide you with some information that you can take to your doctor, though.

There are 4 year olds who have language delays (including trouble with pronouns, and speaking of themselves in third person.

Within the autism spectrum disorders, kids may have some difficulty with pronoun use, self-recognition and imaginative play. Understanding of pronoun use can be enhanced through modelling, pretend play and through interactions with others, all activities which may not come easily to children with autism.(For example, here is some information: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1467-8624.2004.00819.x?cookie...).

While many young children go through a period in which they confuse some pronouns, most start figuring out our grammar and syntax rules on their own. We may inadvertently contribute to this confusion by the way we talk to toddlers; we often speak of ourselves in the third person ("Mommy is so proud of you" rather than saying "I'm so proud of you").

To get an idea of what is considered normal speech and language development for a 4 year old, take a look at sites like these listed below. Armed with this information, you can then speak to a public health nurse, pediatrician or speech/language specialist.

http://www.asha.org/public/speech/development/child_hear_talk.htm

http://www.comeunity.com/disability/speech/milestones.html

http://www.ldonline.org/article/6313

Most kids with autism spectrum disorders take in information better visually than by listening, even kids who have good verbal skills. Because of this, using visuals to aid in communication and in disciplining is very helpful. You can find more information on the reasons why and how to use visuals at sites like:

http://www.do2learn.com

http://usevisualstrategies.com/pictures.html

You might find visuals especially helpful during those times when you son lays on the floor immobile. He may not be doing that out of defiance but he may be in "overload" mode, upset and unable to process what you are saying. In fact, when kids with autism are in highly aroused states, their ability to understand what is said to them can decrease significantly. That's a time when you should talk less. Actually, speak as little as possible; your talking could even contribute to his distress and escalate the situation further, rather than having a calming effect. Instead, wait and talk later. Or use pictures to get your point across.

Kids with Asperger's, although intelligent and verbal, are similar to kids with autism in that they have trouble making sense of much of their world. When the world in a confusing place, we cling to what is known and can be counted on. Routine is so important to such kids and the more predictable and routine you can make your home, the more comfortable your son will be. No home runs rigidly on schedule, of course, but try to let your child know ahead of time what is going to happen and what will be expected of him.

A daily calendar on the fridge will help. A pictorial representation of how you want him to tidy his room, set the table, wash in the bathroom, etc. can help make life go more smoothly for all concerned. The sites I mention above will explain this and www.do2learn has templates for making your schedules and free pictures to use for those of us who are artistically-challenged.

The suggestions I've given here are often used with kids with autism disorders. They're also used with many other children.

Although you're worried about your son, it's not the actual diagnosis that's important. The key point is to find which strategies best help your child to be the best he can be. And you can do that with out without a formal diagnosis.

If you let me know in which province you live, and you want to continue to pursue the possibility of a diagnosis, I may be able to point to toward resources that will help.

Sharon A. Mitchell, B.A., B.Ed., M.A.
http://www.autismsite.ca