Possible Autism in 2-year old

[confusedofengland]

DS2 is 2.5. He has a 'fairly significant' speech delay, for which he had an assessment in August & has had 3 weekly sessions so far. His final session is next week (he missed the first one as he had a D&V bug).

Today, the SALT asked me if I had heard of the autism spectrum, as there were a couple of things regarding DS that made her think he might be on it.

Firstly, it can be (around 10-20% of the time) difficult to get his attention if he is engrossed in something (playing or if he has noticed eg a clock ticking). He also has a short attention span, he will play a game such as wooden peg puzzle for up to 10 minutes at a time.

Secondly, she said his play skills are delayed. She said he doesn't do enough pretend play such as giving dolly a drink. However, yesterday he put dolly in the swing & pushed her & in the session today he was putting play people down a slide. Over the weeks since his assessment he has also happily done lots of things with dolly, with my encouragement, which SALT said was good

She had previously said that his eye contact was not great but she now says that it seems largely OK.

I have read up about autism in toddlers, and have the following observations about him, which I think may or may not point to autism in his case. I have also done the MCHAT test & he scored at low risk of autism because of not talking, everything else was OK:

Cons:

• He didn't point until just after 2 for demands (used outstretched hand from around 18 months), and until about 2.3 for observation eg seeing an aeroplane & wanting to tell me about it. He now points non-stop, usually with accompanying noises (eg a-a for quack-quack if he sees a duck)
• He likes to open & close doors a lot. If we enter a room, he has to close the door behind us. He likes to play with doors on toy cars etc for about a minute before brumming them along the floor.
• He didn't self-feed until around 18 months (finger foods & spoon foods), but now does both as proficiently as any other child his age.

Pros:

• He has never had any problems with sleeping (slept 11-12 hours plus 1-2 hour nap from around 3 months)
• He has never had any problems eating - he eats anything & everything, all different shapes, textures, tastes etc
• Aside from the usual 'terrible twos' tantrums, which last anything up to 5 minutes & which he can usually be easily distracted from, he has never had anything I would describe as a meltdown.
• He loves to play with other DC & adults alike, nursery have said he plays alongside the other DC, as they would expect for his age.

- He has no problem with a change in routine, loves staying away for the night, going away etc.
-He has empathy - I was crying yesterday (pg & hormonal ) & he came to sit on my lap & smile at me, trying to make me smile.

• He copies what other people do, especially his big brother.
• He is not sensitive to any loud noises etc & is willing to try all sorts of new activities that his brother, 2 years older & v cautious, will not do eg go on bouncy castle.

It also may or may not be of relevance that he was lateish to crawl (12 months 1 week) & to walk (17.5 months), but when he mastered them, he did so very quickly, unlike DS1 who did these things earlier, but took a while to get the hang of them. SALT did mention this in her assessment & also today & say that he may just be a child who takes his time to do things.

The conclusion of today's SALT appointment was that as he is to have a hearing test in November (2 previous tests found glue ear), to start an extra nursery session this week (taking him from 2 mornings to one full day & one morning) & as his big brother has now started school full-time & I am able to do a lot more where DS2 has 100% of my attention, she will see him for a further assessment in December, and another block of sessions in January. She said he has made more progress than most DC she sees in just 1 assessment & 3 sessions & this was encouraging. She also said she didn't know either way about autism, but wanted to mention it in case. This led me to think that he may be borderline (if it is possible to be such a thing) or have a mild form of autism if at all.

I also feel like I'm constantly comparing him to DS1, who is very bright - has been talking since 18 months, sentences at 2, reading since 3, is given work ahead of his age range (Reception year). And more to the point, I feel like others are too, which is not really fair on either of them

Anyway, sorry this is such as long post, it feels like there's a lot to get my head around. I don't know what or how to think or feel & so would really appreciate any experiences or opinions or advice. Thanks

[Goldmandra]

That doesn't particularly paint a picture of Autism to me and I have two children with AS and several friends whose children have varying levels of ASD.

I think pointing includes outstretched hands. It is significant that he realised that you wouldn't know what he was thinking about inless he indicated a direction.

I would sit back and wait to see how he develops, especially if your gut feeling is that he doesn't have any significant problems. If this changes in the future you can ask for assessment because you are forewarned about the possibility.

[SimLondon]

Your toddler sounds very similar to mine, there's nothing in your post that would make me be worried about autism. The m-chat test is a great indicator so if your low risk on there then I think you should be fairly confident.

[confusedofengland]

Thank you both for your replies. I must confess I have had my fears in the past, particularly when he was not talking or pointing by 18 months & because he loves to open & close doors (even more so when tired), and it can be hard to gain his attention if he is engaged in something (but I thought children in general were like this, DS1 can be eg if TV is on), but since he has started pointing at things of interest particularly these had died down somewhat. So it was a shock when SALT brought it up again yesterday. I am sure in my mind that he is very delayed in speech & language & certainly he needs encouragement a lot of the time to pretend play, but I have noticed progress in these areas so was not hugely concerned. I feel overall he comes across as a child maybe 8 months younger.

Also, the eye contact is tricky. The SALT sees that he doesn't make a lot of eye contact when he is demanding something, which can be true. However, he will come over to us, put his hand on our knees & just look at us until we laugh, or if he is doing something 'funny' he will look & make sure he has made eye contact to see that we find him funny (he is a little comedian). I feel this is good, but I don't know?

I also wondered as I did the MCHAT test when he was maybe 19-20 months & wondered if all the questions are still appropriate for a child of his age now (29 months).

As I said to SALT yesterday, I don't want to be in denial, but equally, I don't want to be labelling him with something which may not be the case, especially as there are set to be a lot of positive changes for him over the next few months.

[Goldmandra]

M-chat is appropriate to use up to 30 months so he's still within the right age range, just. You may find it reassuring to complete it again now.

Eye contact is a funny thing. My girls' eye contact is erratic, sometimes very appropriate, sometimes not at all. I think the key is that he is looking for eye contact to share a joke. He is using it as communication whereas lots of children with ASD don't.

Children with Autism don't really seem to present as having an overall, fairly consistent developmental delay. They usually have a spiky profile, i.e. advanced in some things but behind in others without a logical explanation for the difference. So a child may be non-verbal at two years but able to complete puzzles designed for children double their age with ease.

Autism is an overall picture of specific difficulties which have a profound effect on the child's ability to function. So a NT toddler might enjoy shutting doors and explore doors everywhere he goes but a child with Autism may spend an hour opening and shutting one door and it may be impossible to distract him without causing a meltdown. The first child has a deep but unusual interest but the second one has an obsession which prevents him from leading a normal life. Having said that, my DDs are both good at masking their difficulties and weren't diagnosed until the ages of 12 and 7 so their symptoms weren't as disabling as you might imagine as toddlers.

I think you're taking the best approach you can as a parent. You are aware and vigilant and have the information you need should his difficulties have more effect on him as he gets older. Whether he has Autism or not, the SALT input is coming at the right time and will help him.

If there comes a time when you feel he would benefit from an assessment don't be fobbed off. Your concerns should be sufficient reason for him to be referred to CAMHS or a developmental paediatrician so be persistent.

Sorry this has turned into an epic post. I could probably have achieved the same thing by just saying that your instincts are a good guide to listen to them

[madhousequeen]

OP, you seem to be concerned to I would ask to be referred to a developmental paed. If you DS has a developmental disability, then the sooner it is picked up, the better. If your DS is fine and 'only' speech delayed, then you will be hopefully reassured.

the M-Chat is not a diagnostic test, just a screening tool.

FWIW - my DC pointed by two, has no issues with routine and is the best eater you could with for - but is still severely autistic. (the difficulties you mention are common in children with ASD but their absence does not rule out ASD either).

If you are worried, then follow your gut and get it investigated. If your DS does need help then better to get the ball rolling now. The waiting lists are long.

[confusedofengland]

madhousequeen thank you for an alternative viewpoint. As I said above, I had pretty much grown out of my worries as ds had made so much progress recently, it was just this appointment with the salt that made me think again.

It is interesting to hear about your DC. How did their autism present itself at 2?

[confusedofengland]

Also, forgot to mention that he was doing some great pretend playing today, transferring dolly from swing to highchair & feeding her with spoon & bottle (all totally instigated by him). It's as if he wanted to prove the salt wrong

[eatyourveg]

I have two dc with ASD too and like Goldmandra your post didn't shout autism to me. ds2 was diagnosed at 22 months and scored 45 on the CARS.

I think your mention of glue ear could easily be a possible explanation for the lack of speech. A thorough assessment (not just a tympanogram) from the audiology department would be something I would be asking for so that you can see just what he is and isn't hearing.

[confusedofengland]

Thanks eatyourveg I have also wondered if glue ear could explain a couple of things, such as not always responding immediately when you call him. He has had 2 hearing tests with an audiologist, each of about 30 minutes, where they rewarded him when he looked at certain toys if he heard a sound, or if he put monkeys in a pot. After this, they then looked inside his ear with a digital thing which reminded me a little of a thermometer that you use in the ear. Is this the kind of test you mean or is there a more thorough one that can be done?

[madhousequeen]

at 2.5 the main symptoms where
-severe speech and language delay (i.e. not only the talking but also the understanding) which was blamed on glue ear (but grommets did not make any difference)

• tantrums, awful tantrums
• no pretend play - rather repetitive play (e.g. building a tower, crushing it town, building it up again, etc, doing the same puzzles all over again)
• echolalia

there were probably a few others but this were the most noticeable ones.

[eatyourveg]

will pm you after tea

[devilinside]

My son has ASD and has never been big into routine (always happy to go on holiday, stay with relatives etc, and do different activities, . He also slept fine as a baby and ate everything (that has changed as he got older). The main things I noticed
Liked to play on his own
Imaginative play was on his own, little stories with action figures
Watched the same DVD over again
No separation anxiety, happy to go off at toddler groups and do his own thing
Little eye contact (mentioned by others, not noticed by me)
Slow to talk and unresponsive
Liked to rip up books, chew toys, empty shampoo bottles in to the bath, he still does most of these at 7, except ripping books

[PatioDweller]

Have you had his eyes tested? If the late pointing is the only red flag alongside his speech delay it could be a sight issue.

I'm not suggesting he does or doesn't have autism but coming out as low risk on the mchat is good as is the instigating pretend play.

I agree though that if a referral to a devel paed is being offered, then snatch it up. They certainly won't diagnose your child with anything he hasn't got and what they have to say may put your mind at rest.

[Madamecastafiore]

Sorry just wanted to point out that nothing from your post would necessitate a CAMHS referral. Most Trusts do not cover autism under CAMHS at all. Unless there is significant issues I doubt that LD teams would cover either if they are as stretched as ours.

[confusedofengland]

Thanks again Madhouse & devil for giving me an idea of what your DC are/were like symptom-wise.

In both cases there are one or two things that sound familiar (the speech delay of madhouse's DC, although my DS' understanding is not too bad, he can understand instructions & quite a few single words, as tested by SALT. Also playing on his own like Devil's DS, although my DS loves to play with other DC, too, he probably does 50/50 when we are around other DC, but he is happy to play on his own. He is also very friendly to everybody & doesn't really have separation anxiety, but sometimes will make a fuss if I go to leave him with other people. He cried for the first 5 or 6 times of being dropped at nursery, but now sits down happily with his keyworker (who he has known for 6 months) for breakfast)

Thanks again, it is always interesting to hear other people's experiences.

[Goldmandra]

Madame in our county CAMHS' neurodevelopmental team assess children for ASD and present the case to a diagnostic panel.

The diagnostic process varies depending on the county or city you live in.

[PatioDweller]

Confused, when you say he understands quite a few words, do you mean he doesn't understand whole sentence instructions?
I would say the average 18-24mths can understand instructions such as, 'sit on the bed' 'go get your shoes' and 'bring mummy your dummy'
Does your DS understand instructions such as these? These are fairly standard for that age group.
Also wanted to add that I think a 10min attention span is fairly average at his age.

[confusedofengland]

Sorry patio I was a bit unclear. He understands loads of instructions, will do most things I ask of him eg fetch shoes, sit down so we can put your shoes on, go up to brush teeth, show Mummy where the frog is (garden pond!) etc. SALT was initially unsure of his understanding of individual words, so she does an activity with him where she gets him to pick an item out of say 5 or 6. He is better now than he was at the assessment in August, but his understanding of nouns probably isn't as strong as his understanding of instructions.

[PatioDweller]

Oh ok, yes I understand.
As I said earlier, can you get his sight tested?

[confusedofengland]

That might be worth testing, it's not something I'd thought of before tbh. I have quite bad short-sightedness (-5.5 on both eyes plus astigmatism) & have worn glasses since the age of 8 so it could be hereditary. Thanks for the idea.

[confusedofengland]

Well, dh & DC just dropped me at bus station to go for a night out & apparently ds2 was saying mamma all the way home! So cute

[confusedofengland]

Just wanted to ask - has anybody with speech-delayed DC seen any improvement after using fish oil supplements? I asked SALT about it & she said she had had other people ask about it but hoped that DC's speech would improve using their methods. However, she did say if I wanted to try it to go ahead. DS2 does already have a good diet & has fish (usually white fish) once a week or so, but this just may make sure all bases are covered?

[confusedofengland]

Well, we had our final session in this first set of speech therapy on Monday, and it reassured me somewhat. I was able to go in to the SALT with a list of about 10-15 minor developments that I had noticed in DS2 over the week, which was great - things from initiating pretend play to saying Mama, to using duck noises appropriately.

She said that she hoped she hadn't scared me by mentioning autism last week, but she wanted to be honest about everything that crossed her mind. She also said that each child is so different & that if DS were displaying any obvious signs of autism it would have been picked up on by now. I asked her about the door obsession & she said it wasn't unduly worrying at his stage of development, as they are a cause & effect thing which he can control & he does stop after a short while. She said it was also good that he played with the toys immediately he came in the room, rather than going straight for the door (which he stood looking at for a couple of minutes during the session).

It did hit me today how far behind his language is, when we were out with a friend & her DD 14mos. The little girl was using some of the same (& only) words DS2 uses . However, I have also been really impressed lately how well DS is following instructions & how he can walk for up to an hour without running off & waiting when I tell him, so long as he has his toy pushchair to push

[ShoeWhore]

I'm really glad to hear you are getting his ears tested OP as he sounds quite like my ds who had moderate hearing loss for quite a long time as a toddler. Did the audiologist tell you what level of hearing he has at what frequencies in each ear? (We get a little graph for each ear)

By the way 12 mo to crawl and 17.5 mo to walk are considered totally within the normal range. None of my dcs were that quick off the mark with moving either.

I think it's always best to check out any worries tbh (having been fobbed off for a long time about ds and his speech/hearing, I know how annoying it is when people dismiss your concerns) I also know where you are coming from on the comparisons

Hope that your ds continues to make such good progress. (My ds is doing really well now, he's 6 and his speech has come on massively since he started school 2 years ago) You have lots of time to sort out the speech issues, which is great.

[confusedofengland]

Thanks Shoewhore I do find it frustrating that they have seen fluid in his ears on 2 separate occasions - one in the height of summer so not just due to cold etc - and will not do anything about it. They won't even talk to me about levels of hearing. I am aware that this may not be the whole picture, but even if it isn't, it can't be helping! I had a cold recently & blocked ears & it was very frustrating & I had to get people to repeat things a lot, so I imagine he feels like this a lot of the time

I am glad you DS is doing well now, lovely to hear of success stories