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The Paediatrician is in

Not Talking: A Sign of Autism?

May 24 06:20am

Every month I see a few toddlers who are not talking. Most are boys; all are worrying their parents. Some have autism, and others don't.

There are so many children with autism now, that almost everybody knows somebody who knows somebody who has an autistic child. Parents, daycare providers and teachers are all on the lookout. Ten years ago children with autism were often diagnosed as late as age 4 or 5. These days, it seems that most are diagnosed by 3, if not before.

People are also more aware of related diagnoses on the autism spectrum, including Asperger syndrome and Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS). As the "not otherwise specified" part of its name implies, PDD-NOS does not have a very clear cut definition. Children often qualify for PDD-NOS, even though they don't meet the full definition for autism itself.

All of this awareness -- which is a good thing -- and the open-ended nature of the PDD diagnosis makes more parents feel even more insecure. If something is not quite right with their child developmentally, the possibility of autism looms large.

Fear of autism worried the parents of two little boys I saw recently. I'll call them Jack and Tom. They were both around two years old.

Jack did not speak or use sign language, and did not turn to me when I called his name. When I offered him crayons, he took one, but he wasn't interested in scribbling or in playing give-and-take. He opened and closed the door of my toy car, and spun the wheels again and again, but did not "zoom" it across the floor. Jack's mother said she had a hard time getting him to play with her. "He does sometimes," she said, "when he wants to."

Tom looked very different. "I can ask him to get something from another room," his dad explained, "and he goes right there and gets it." He also could point to lots of pictures in books when his parents asked him to. He only said a very few words. But he did make a sound that seemed to mean "What's that?", and he would point at things with his index finger -- a sign that he expected his parents to look where he was looking. We played catch back and forth with a rolled up paper towel, and Tom could have played all day, giggling.

I think that Jack probably has a condition on the autism spectrum. It will be important for him to have a thorough assessment. He is already in speech therapy, but he will need additional therapies to help him with social interactions, attention and play.

Tom probably has a condition that is sometimes called Specific Expressive Language Delay. In other words, he is a late-talker. In general, late talkers do well. Some of them have difficulty learning to read when they're older, and it's not clear that speech therapy helps late talkers much. On the other hand, it can't hurt. I also encouraged his parents to teach him some sign language, and was pleased to learn that he already knew some signs.

Two toddlers who are not talking. Two very different problems.

36 Comments Report Abuse

1. bearoak - May 24 07:45am

Nicely stated, Bob....one of your best!

David Levine, MD (was an intern at Boston City 1987-8 and work with Yasmin Tyler-Hill at Morehouse in Atlanta)

2. minben05 - May 24 07:58am

I have two young boys, one with with Asperger's, and the other that's just a "late talker". Although my oldest son is doing so well now that his Asperger's is nearly inperceptable (once you get over the stimming when anything around him moves...) the difference from my oldest and youngest at comparable ages was profound. My oldest would never let anyone touch him, he wouldn't make eye contact. He would bang his head on the ground. Everything, including clothing, lights, sounds could overstimulate him. When we had him evaluated for preschool, the idea his language was suffering hadn't even hit us. (And his language was delayed, which is actually somewhat unusual for an AS.)
My youngest son was so much different. He has cooed and babbled since he was small. He loves attention, and even though he gets frustraited when we don't understand him, he enjoys that we even take the time to try. I was shocked when we had him tested and found that he had a significant speech delay. Although I will start in him speech therapy to be on the safe side, I know in my heart that he is developing just fine. I believe that the early intervention programs that my oldest participates in now are what he needed to finally blossom.

I suppose the moral is, just really trust your gut. No one knows your kids like you. If I had listened when everyone played down my complaints with my first son, he would never have gotten the help he needed. If I took all the help that everyone is pushing on my youngest, his life would be a constant therapy session. My goal isn't to produce children that are like everyone expects them to be; my goal is to help my children find the voice that they lack in order to help them both be content in their own situation.

3. amydolaes - May 24 10:55pm

FOR ONCE Dr. Needleman I agree with your column. These are the opinions that help parents: the open ended ones. You presented an example and stated the facts. You allowed the parents to develop an understanding and along the way you learned something too. Now I will be able to talk about your column with ut distain.

4. tehillim1 - May 25 02:02am

Ive worked in the field for almost 20 years with developementally disabled children. Nothing can ready you to tell a family member wh is in denial or just dosent have the facts, that his child is showing symptoms he is on the Autism spectrum. Hiding from you not talking and excessive crying due to the lack of language. How do you break it to them? first of all it is a young couple and the father is very proyective and edgy about his son. PLS HELP

5. tumuch27 - May 25 03:44am

I think the best way to teach a child use use the potty, is to first let them see there direct role models(parents) use it.

Children learn the most from what they see. They will mimic our motions & sounds, ie talking, using the cell phone, walking, drinking from a cup etc...every chance they get.

Introduce the potty to your child gradually. Every once in a while, take them to the bathroom with you. While there, break the task down to the simplest understandable steps that they can comprehend.

When they start to attempt to use the potty, behavior specific praise is of the utmost importance. Tell them" great job using the potty" with a high and exctied voice. Give them hugs or high fives as further reinforcement. This praise in children goes a long way.

Most people crave the approval of others, thus making this a powerful tool. Once they start getting the praise for the completed task, they will repeat the task to ensure they get the same praise.

For toddlers who are having trouble, you have to be extra patient. Remember they learn from what they see.Give them behavior specific praise as they go. Break the steps down even further if at all possible.

6. windsornot - May 26 01:13am

Being the mom of a child who rides the line between both these scenarios, I HIGHLY recommend that if there is a concern with your child's speech and whether he/she is autistic, seek out a developmental pediatrician (not a pediatric neurologist) to help fine-tuned the diagnosis. Your regular pediatrician can see the signs, but they are not fully qualified to make that diagnosis. I have a son who has a condition called apraxia, which is a motor planning condition that affects speech, and which often co-exists with sensory integration disorder, and only recently was he diagnosed with ADHD. When you combine those conditions together, to the average person or MD, it does look like mild autism or Asperger's. It took a trained eye, in this case, our developmental pediatrician, to pick all the symptoms apart and show us it wasn't autism, and how we needed to better approach any therapies or how we did things at home or school. My son is thriving from early intervention, so don't wait for your child to outgrow their condition! Most likely they won't, and do you really want to take that chance? My son is almost 7, and he still needs some help in certain areas, but nothing like he did when he was smaller. Make sure you get the CORRECT diagnosis. Not every child who can't speak is autistic or is a "late talker".

7. windsornot - May 26 01:20am

8. doulos31 - May 26 02:24am

Wow. When I read this, it almost perfectly described my 2 year old twin boys. Neither of them talk very much, but there is a clear difference between the interactive skills of each. There is definitely a distinction between children who only have an expressive speech delay as opposed to children with global delays - in expressive and receptive speech, as well as cognitive and motor delays. Both of my boys receive appropriate therapies, but they clearly have different challenges. Although the doctors and therapists we see understand these distinctions, it is refreshing to see it portrayed this way in the media. It gives more information to parents who may be worried about their child's development, and maybe a little reassurance to others. Always have your child checked by a professional if you have any doubts, but maybe this blog will offer a little extra discernment to concerned parents.

9. m_m_charles - May 26 10:57pm

This topic is very interesting. I am a grandmother who works with preschoolers. I researched the topic of vaccinations and found that some of these vaccines have mercury in them. I have also read that the makers of such vaccines have lowered the amount of mercury due to some cases in children who have contacted Autism after being administered vaccinations.
My question is, How young can a child be diagnosed with Autism?

10. katjenpiz - May 27 02:56am

THANK YOU! My son was diagnosed w/ Specific Expressive Language Delay 5 years ago. My nephew is autistic, anyone in our family can tell you the difference. You would be amazed at how many healthcare & educational professionals can not. You managed to explain the difference very succinctly.