Autism or Something Else?

Michael's parents have started to worry.

Like any toddler his age, Michael loves to walk on his own and explore the world around him.

He laughs when he is tickled, prefers his fingers over a spoon when eating chocolate pudding, and squeals with delight when the family dog licks his face.

But something seems to be wrong. Michael is 18 months old and has yet to speak a word.

He seems to understand some of the simple things that his parents ask him to do, but he is busy and independent. He cannot stand to be interrupted.

He often ignores his parents when they try to talk to or communicate with him. When they have to redirect what he is doing to bring him to dinner, give him a bath, or put him to bed, he screams -- louder and longer than any of their friends' children.

His parents have reason to be worried.

Beyond causing mischief and getting into everything, there are certain things every toddler should be able to do. The ability to use three to five words other than "mommy" and "daddy" is something that Michael should be able to do.

Is this a cause for concern? Perhaps. But the reasons why Michael isn't speaking can range from minor delays, which will correct themselves over time, to major developmental problems that will last his entire life.

A first step in identifying the cause is to survey a more complete set of Michael's behaviors and compare it to what toddlers should and should not be doing.

At 18 months, Michael should:

   respond to his own name

   point to things that he is interested in

   make and sustain good eye contact with others

   follow simple commands

   make faces that express his feelings

   stack blocks and put simple wood puzzles together

He should not:

   sit alone for a long time without seeking someone else's attention

   tantrum constantly

   have highly irregular sleep patterns.

For a complete listing of behaviors a toddler should and should not have, check out the Centers for Disease Control and Prevention Web site "Learn the Signs, Act Early"

John Constantino is an associate professor of psychiatry and pediatrics at the Washington University School of Medicine in St.Louis.

Any child who is not reaching these standards by 18 months deserves a good checkup with a child development specialist, someone who can look at and evaluate whether "abnormal" or unexpected behaviors will pass, or are a sign of something more serious.

That checkup should cover six areas of early childhood development:

   Social development


   Emotion regulation or emotional control

   General intelligence

   Sensorimotor function

   A look at the child's living environment: Does it give enough to allow a child to reach his/her developmental potential?

A child's problem in any one of these tested areas could be mild or very serious -- none are "all-or-nothing" categories -- but if even mild problems exist in more than one area (as is all too frequently the case) they can come together to make things worse.

In sizing up these areas of development, experts in child development -- like developmental pediatricians, child neurologists, child psychiatrists and psychologists -- look for ways in which a given child weaves together his or her own abilities, and ways in which he or she uses strengths to make up for any weaknesses.

Social competence is a central goal of the development of the mind and brain of a toddler. By 18 months, children should be learning to strike a balance between the two fundamental forces of all human social relationships: the capacity for intimacy (attachment) and the longing for autonomy (separation).

All great relationships (at any age) represent a harmonious balance between these two seemingly opposing needs, and typically, young children are driven to master the integration of these primary motivations from a very early age.

Neurodevelopmental delays in any area can interfere with these processes and behaviors in characteristic ways, but there remains considerable controversy over the question of when you can first recognize problems.

Autism is a primary disorder of social development whose earliest signs are usually apparent by 18 months, but may be recognizable even earlier.

Researchers have learned that autistic children don't always prefer to hear the voice of a human being over something inanimate. For example, whereas a nonautistic child usually prefers a human voice to a doorbell, an autistic child might not. Such early preferences might result in abnormalities in the manner in which socially relevant information is normally perceived -- and might even affect a child's motivation to interact with family or friends.

John Constantino is an associate professor of psychiatry and pediatrics at the Washington University School of Medicine in St.Louis.

Ultimately, young children with autism tend not to share attention with others over the things they are interested in or to respond typically to the social overtures of their caregivers.

Once an expert identifies a developmental delay in one or more of these six areas of development, he or she will usually begin with an intervention that tackles a specific area or areas of development, not only to bolster the ones that are lagging, but to increase their abilities in other areas to compensate for those that are weaker.

Although these interventions are becoming increasingly sophisticated, parents can include some parts of these treatments themselves at home, especially when the treatment is put into the context of play time.

For children with autism, spending time rolling a ball back and forth with the child; maintaining his/her focus, attention and interest as long as possible; and building in as much eye contact, communication and expression of emotion as possible may help him or her learn how to react to and give back to another person.

Similarly, playing with action figures, puppets or stuffed animals gives children added experience in forming mental images of thoughts and feelings that are critical to the development of language.

Experts still aren't sure how current treatments affect developmental disorders in the long term, but it appears that children with developmental disorders are faring better now than what would have been predicted in the days before these treatments were commonplace.

More research is needed to answer questions about which treatments work best for which children, and whether or not these treatments are worth the cost. In the meantime, early identification of developmental disorders and early treatment are the best remedies that science has to offer.

John Constantino is an associate professor of psychiatry and pediatrics at the Washington University School of Medicine in St.Louis.