The standardized guidelines developed for the diagnosis of autism actually involve two levels of screening for autism. Level one screening, which should be performed for all children seeing a doctor for well-child checkups during their first two years of life.
The second level of screening should be performed if a child is identified in the first level of screening as developmentally delayed. It is common for children on the spectrum to have delayed speech development.
Listen as John Constantino, MD, Washington University pediatric psychiatrist at St. Louis Children’s Hospital, discusses how timely detection and early intervention may mitigate the emotional, social and cognitive deficits of this disability and improve the outcome.
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Evaluation and Treatment of Autism in the Setting of Language Delay in Early Childhood
Featured Speaker:
Learn more about John Constantino, MD
John Constantino, MD
John Constantino, MD is Director of the Division of Child Psychiatry and the new Ittleston Professor of Child Psychiatry. A referral from your pediatrician is required to schedule an appointment. Dr. Constantino is consistently recognized in "The Best Doctors in America" list.Learn more about John Constantino, MD
Transcription:
Evaluation and Treatment of Autism in the Setting of Language Delay in Early Childhood
Melanie Cole (Host): A delay in speech development may be a symptom of many disorders. Being familiar with the factors to look for when taking the history and performing the physical examination allows physicians to make a prompt diagnosis. Timely detection and early intervention may mitigate the emotional, social and cognitive deficits of this disability and improve the outcome. My guest today is Dr. John Constantino. He’s a Washington University pediatric psychiatrist at St. Louis Children’s Hospital. Welcome to the show, Dr. Constantino. Tell us a little bit about autism and how it most commonly presents itself.
Dr. John Constantino (Guest): So, it is very common for autism to present itself within the second year of life of a child and, most often, parents become concerned when their child manifests early delays in language development in comparison to other children. Generally, by the first 18 months of life, at the end of that period, a child should have at least a few words other than “mom” and “dad” at a minimum. By the second birthday, children have lots of vocabulary on average, are speaking, using phrase speech, a simple majority of their language is intelligible and, most often, families recognize that when their child is not doing that, that is when they come to clinical attention. Autism can actually be picked up much earlier than that and we can maybe talk about that at the end but that’s when it most often comes to recognition and families present to a primary care appointment and express that concern.
Melanie: So, how does autism affect language and speech development?
Dr. Constantino: Well, it’s not entirely known how that works. The acquisition of language is a function of several sort of independent strands of early childhood development. So, first language development requires enough cognitive skills--that is your general global intelligence--to be able to put together all of the sounds and the relationships to things that words are supposed to represent that require a certain level of cognitive ability to sort of get in the game of being able to do that. A second area is that you have to be able to actually formulate the words and there are different areas of the brain that are responsible, separate from those areas that contribute to intellectual development that specifically underlie the ability to formulate words, to express language, to understand the auditory cues of spoken words. A child can be perfectly intelligent but not have the ability to do that. Those kinds of deficiencies relate to the group of disorders called “specific language impairments”. Then, the third area developmentally that’s common are the Autism Spectrum Disorders. Autism Spectrum Disorders are principally a deficiency in the social aspects of communication in early development that are manifested both by difficulty in engaging another human being on a turn-taking or one-to-one basis, and deficiencies also in motivation for social engagement that are required to competently develop the ability to communicate interpersonally.
Melanie: Based on parental observations, Dr. Constantino, are there reliable diagnostic procedures for looking into this and confirming this?
Dr. Constantino: Yes, absolutely. So, parents’ reports can help a great deal. They’re not the only factor in establishing a diagnosis in the setting of language delay. The first point that’s important to make is that 20-25 years ago, it used to be considered that a child has one condition or the other that would explain a language impairment. What we know now is that any of these areas of development, whether it’s cognition, whether it’s social communication, or whether it’s the ability to formulate words--the basic ability to formulate language--all of those are quantitative rather than all or nothing. So, it turns out that many children who present with language delay may have different relative contributions in each of these areas. So, a child may not be talking because they have a very low ability in intellect or cognition, or it could be that they only have mild deficits in cognition but they’re coupled with mild autistic deficiencies or problems and that when those two collide, they result in sort of an early roadblock, or at least a hurdle in developing spoken language. As far as parents’ ability to help with the diagnosis, parents are great with providing developmental history. So, indicating to a physician or a clinician what were the earliest warning signs of that child’s condition, and so developmental history is very important. Things that are big red flags that are ascertained in developmental history is whether a child responds to his or her own name, whether or not the child makes eye contact, whether the child has ever been able to point to the things that they’re interested in while looking at that parent as if to ask them at the same time, “Can you help me with this?” to sort of share their intentions. These are elements of developmental history that are capitalized in establishing whether or not a young child has a developmental history that’s consistent with an Autism Spectrum Disorder. But, the other aspects of establishing a diagnosis have to do with the symptom burden that is appreciable by a clinician in the room and differentiating the contribution of autistic liability from that of specific language impairment or cognitive impairment. So, what do I mean by that? Well, you can imagine a young child who is not talking in a room who is understanding everything that everybody is saying, that is trying to communicate, and frustrated that he or she can’t, using gestures, and making great eye contact, and when that child is given a command to do this or that or a two-step command that they are able to complete it without any problem. You know that the language delay in that child is most likely due to a specific impairment in expressive language, because they’re understanding language, they’re interested in what’s going on, they’re trying to communicate, but they can’t and they’re knowledgeable about the context of their situation. If you were to consider a child with autism, a child with autism in that same scenario would not be engaged or interested or making eye contact. That child might understand what’s going on, but might be very much oriented to his or her own agenda and not connected to what’s going on with the rest of the people in the room, and certainly not frustrated by not being able to communicate. In contrast, the child with intellectual disability might be making eye contact and might be kind of interested, but unable to speak and unable to really understand when a verbal prompt is given to them to follow a command. Those children are engaged but they’re not actively trying to communicate and they’re not particularly frustrated with the inability to communicate. And so, it’s those little signs that a clinician uses in order to differentiate between the possibilities. Is what I’m seeing attributable to an autistic impairment, to a cognitive deficiency, or to a very specific language impairment? And, at the same time, to be able to do the appraisal of any concern for much rarer causes of language delay, which would include hearing impairment--it’s very important to rule that out - visual impairment--which can delay the onset and use of language; and to make sure that they’re rounding out an appraisal of all those particular kind of contributing factors to a language delay. One of the other final things that we do in an appraisal of whether cognitive impairment is making a major contribution to a language delay is to ask parents whether children are proficient at simple visual spatial tasks like putting together simple block puzzles or shape puzzles where they have to put a shape into a depressed puzzle platform, because children with autism can do that very easily if they have reasonably preserved intellectual functioning, but children with intellectual or cognitive deficits will have a great deal of difficulty with those kinds of particular tasks and not show a whole lot of interest in them. Children with cognitive deficiencies also tend to engage with toys and objects in a very concrete, simple, unimaginative way; whereas, children with autism with relatively preserved intelligence will explore the toys and objects in the room, sometimes in very unusual ways, but they’re intrigued by them and they’re interacting with them or taking them apart or trying to do sort of more sophisticated behaviors with the toys that are presented in the room. So, you can get a sense that even just watching a young child and thinking about how are they using the play materials? How are they interacting with the people in the room? What does their eye contact look like? Are they trying to be engaged with the other people around them? Are they frustrated not to be able to communicate? You can size up fairly quickly with most young children with a language delay, not only which primary problem you’re dealing with, but is it likely that there is an amalgam of one or two or even three components of the problem that are contributing to that child’s delay?
Melanie: When would you tell a pediatrician it’s time to refer to a specialist?
Dr. Constantino: Well, I think that any time a young child manifests a significant developmental delay in either communication or social behavior or there’s significant concern for cognitive impairment, that it’s a good time to make a referral, particularly for developmental therapies that are available across the U.S. through municipal systems for supporting children with developmental disabilities. So, I think that’s an important aspect of it. Whenever cognitive impairment is suspected, we generally recommend making the referral to a child neurologist or a developmental pediatrician who’s skilled in the appraisal of reversible causes of cognitive impairment. There are close to 60 rare but reversible causes of cognitive deficiency in children but it’s very important to evaluate for those and address them if they are contributing to a child’s condition, because once the window of opportunity to treat them is missed, it’s a lost opportunity, literally, to reverse that condition, and these are quite rare but specialists are well-trained in identifying these and screening for them. There are websites that are available to clinicians to learn about how to conduct those appraisals and which of those conditions are able to be treated.
Melanie: In just the last few minutes, what would you like to tell other pediatricians about recognizing speech and language development delays in autism and on the spectrum? What would you like to tell them about how the condition is treated? What would you like them to know?
Dr. Constantino: Well, it’s increasingly important to recognize when autism is present because the developmental therapies for autism are getting more specific and more effective. So, affording children the opportunity to do more than traditional interventions in early developmental therapy, which were largely restricted to speech therapy and occupational therapy - both of which are good - but there’s now a whole generation of early intensive behavioral interventions that relate to the methods of field of developmental therapy that is encompassed by applied behavior analysis as a principle, and that these types of therapies are becoming more and more widespread and readily available to children. So, looking for opportunities to incorporate them, and certainly by the time these children reach age three, these kinds of interventions can be built into the educational planning that all young children are entitled to as a function of entitlements for early childhood education for children with special needs.
Melanie: Tell us about your team. Why is St. Louis Children’s Hospital so great to work with?
Dr. Constantino: Well, we have a team that is very multi-disciplinary and covering all of the bases, not only of the appraisal and diagnosis and intervention planning for children with autism, but with close ties to specialty services like child neurology in the setting of children who have suspicion for cognitive delays or epilepsy. We have very special expertise in a related field for children, when they reach a little bit older age of following a language delay, again, in the range from age three and up, that is called “augmentative communication”, which is a very specific therapy as a next step for children if they don’t respond to the earliest developmental therapies. This is another way to help them work around or overcome that language gap through use of new technologies that will allow them to have a better opportunity to develop a functional communication that they can use every day.
Melanie: Thank you so much for being with us today, Dr. Constantino. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Evaluation and Treatment of Autism in the Setting of Language Delay in Early Childhood
Melanie Cole (Host): A delay in speech development may be a symptom of many disorders. Being familiar with the factors to look for when taking the history and performing the physical examination allows physicians to make a prompt diagnosis. Timely detection and early intervention may mitigate the emotional, social and cognitive deficits of this disability and improve the outcome. My guest today is Dr. John Constantino. He’s a Washington University pediatric psychiatrist at St. Louis Children’s Hospital. Welcome to the show, Dr. Constantino. Tell us a little bit about autism and how it most commonly presents itself.
Dr. John Constantino (Guest): So, it is very common for autism to present itself within the second year of life of a child and, most often, parents become concerned when their child manifests early delays in language development in comparison to other children. Generally, by the first 18 months of life, at the end of that period, a child should have at least a few words other than “mom” and “dad” at a minimum. By the second birthday, children have lots of vocabulary on average, are speaking, using phrase speech, a simple majority of their language is intelligible and, most often, families recognize that when their child is not doing that, that is when they come to clinical attention. Autism can actually be picked up much earlier than that and we can maybe talk about that at the end but that’s when it most often comes to recognition and families present to a primary care appointment and express that concern.
Melanie: So, how does autism affect language and speech development?
Dr. Constantino: Well, it’s not entirely known how that works. The acquisition of language is a function of several sort of independent strands of early childhood development. So, first language development requires enough cognitive skills--that is your general global intelligence--to be able to put together all of the sounds and the relationships to things that words are supposed to represent that require a certain level of cognitive ability to sort of get in the game of being able to do that. A second area is that you have to be able to actually formulate the words and there are different areas of the brain that are responsible, separate from those areas that contribute to intellectual development that specifically underlie the ability to formulate words, to express language, to understand the auditory cues of spoken words. A child can be perfectly intelligent but not have the ability to do that. Those kinds of deficiencies relate to the group of disorders called “specific language impairments”. Then, the third area developmentally that’s common are the Autism Spectrum Disorders. Autism Spectrum Disorders are principally a deficiency in the social aspects of communication in early development that are manifested both by difficulty in engaging another human being on a turn-taking or one-to-one basis, and deficiencies also in motivation for social engagement that are required to competently develop the ability to communicate interpersonally.
Melanie: Based on parental observations, Dr. Constantino, are there reliable diagnostic procedures for looking into this and confirming this?
Dr. Constantino: Yes, absolutely. So, parents’ reports can help a great deal. They’re not the only factor in establishing a diagnosis in the setting of language delay. The first point that’s important to make is that 20-25 years ago, it used to be considered that a child has one condition or the other that would explain a language impairment. What we know now is that any of these areas of development, whether it’s cognition, whether it’s social communication, or whether it’s the ability to formulate words--the basic ability to formulate language--all of those are quantitative rather than all or nothing. So, it turns out that many children who present with language delay may have different relative contributions in each of these areas. So, a child may not be talking because they have a very low ability in intellect or cognition, or it could be that they only have mild deficits in cognition but they’re coupled with mild autistic deficiencies or problems and that when those two collide, they result in sort of an early roadblock, or at least a hurdle in developing spoken language. As far as parents’ ability to help with the diagnosis, parents are great with providing developmental history. So, indicating to a physician or a clinician what were the earliest warning signs of that child’s condition, and so developmental history is very important. Things that are big red flags that are ascertained in developmental history is whether a child responds to his or her own name, whether or not the child makes eye contact, whether the child has ever been able to point to the things that they’re interested in while looking at that parent as if to ask them at the same time, “Can you help me with this?” to sort of share their intentions. These are elements of developmental history that are capitalized in establishing whether or not a young child has a developmental history that’s consistent with an Autism Spectrum Disorder. But, the other aspects of establishing a diagnosis have to do with the symptom burden that is appreciable by a clinician in the room and differentiating the contribution of autistic liability from that of specific language impairment or cognitive impairment. So, what do I mean by that? Well, you can imagine a young child who is not talking in a room who is understanding everything that everybody is saying, that is trying to communicate, and frustrated that he or she can’t, using gestures, and making great eye contact, and when that child is given a command to do this or that or a two-step command that they are able to complete it without any problem. You know that the language delay in that child is most likely due to a specific impairment in expressive language, because they’re understanding language, they’re interested in what’s going on, they’re trying to communicate, but they can’t and they’re knowledgeable about the context of their situation. If you were to consider a child with autism, a child with autism in that same scenario would not be engaged or interested or making eye contact. That child might understand what’s going on, but might be very much oriented to his or her own agenda and not connected to what’s going on with the rest of the people in the room, and certainly not frustrated by not being able to communicate. In contrast, the child with intellectual disability might be making eye contact and might be kind of interested, but unable to speak and unable to really understand when a verbal prompt is given to them to follow a command. Those children are engaged but they’re not actively trying to communicate and they’re not particularly frustrated with the inability to communicate. And so, it’s those little signs that a clinician uses in order to differentiate between the possibilities. Is what I’m seeing attributable to an autistic impairment, to a cognitive deficiency, or to a very specific language impairment? And, at the same time, to be able to do the appraisal of any concern for much rarer causes of language delay, which would include hearing impairment--it’s very important to rule that out - visual impairment--which can delay the onset and use of language; and to make sure that they’re rounding out an appraisal of all those particular kind of contributing factors to a language delay. One of the other final things that we do in an appraisal of whether cognitive impairment is making a major contribution to a language delay is to ask parents whether children are proficient at simple visual spatial tasks like putting together simple block puzzles or shape puzzles where they have to put a shape into a depressed puzzle platform, because children with autism can do that very easily if they have reasonably preserved intellectual functioning, but children with intellectual or cognitive deficits will have a great deal of difficulty with those kinds of particular tasks and not show a whole lot of interest in them. Children with cognitive deficiencies also tend to engage with toys and objects in a very concrete, simple, unimaginative way; whereas, children with autism with relatively preserved intelligence will explore the toys and objects in the room, sometimes in very unusual ways, but they’re intrigued by them and they’re interacting with them or taking them apart or trying to do sort of more sophisticated behaviors with the toys that are presented in the room. So, you can get a sense that even just watching a young child and thinking about how are they using the play materials? How are they interacting with the people in the room? What does their eye contact look like? Are they trying to be engaged with the other people around them? Are they frustrated not to be able to communicate? You can size up fairly quickly with most young children with a language delay, not only which primary problem you’re dealing with, but is it likely that there is an amalgam of one or two or even three components of the problem that are contributing to that child’s delay?
Melanie: When would you tell a pediatrician it’s time to refer to a specialist?
Dr. Constantino: Well, I think that any time a young child manifests a significant developmental delay in either communication or social behavior or there’s significant concern for cognitive impairment, that it’s a good time to make a referral, particularly for developmental therapies that are available across the U.S. through municipal systems for supporting children with developmental disabilities. So, I think that’s an important aspect of it. Whenever cognitive impairment is suspected, we generally recommend making the referral to a child neurologist or a developmental pediatrician who’s skilled in the appraisal of reversible causes of cognitive impairment. There are close to 60 rare but reversible causes of cognitive deficiency in children but it’s very important to evaluate for those and address them if they are contributing to a child’s condition, because once the window of opportunity to treat them is missed, it’s a lost opportunity, literally, to reverse that condition, and these are quite rare but specialists are well-trained in identifying these and screening for them. There are websites that are available to clinicians to learn about how to conduct those appraisals and which of those conditions are able to be treated.
Melanie: In just the last few minutes, what would you like to tell other pediatricians about recognizing speech and language development delays in autism and on the spectrum? What would you like to tell them about how the condition is treated? What would you like them to know?
Dr. Constantino: Well, it’s increasingly important to recognize when autism is present because the developmental therapies for autism are getting more specific and more effective. So, affording children the opportunity to do more than traditional interventions in early developmental therapy, which were largely restricted to speech therapy and occupational therapy - both of which are good - but there’s now a whole generation of early intensive behavioral interventions that relate to the methods of field of developmental therapy that is encompassed by applied behavior analysis as a principle, and that these types of therapies are becoming more and more widespread and readily available to children. So, looking for opportunities to incorporate them, and certainly by the time these children reach age three, these kinds of interventions can be built into the educational planning that all young children are entitled to as a function of entitlements for early childhood education for children with special needs.
Melanie: Tell us about your team. Why is St. Louis Children’s Hospital so great to work with?
Dr. Constantino: Well, we have a team that is very multi-disciplinary and covering all of the bases, not only of the appraisal and diagnosis and intervention planning for children with autism, but with close ties to specialty services like child neurology in the setting of children who have suspicion for cognitive delays or epilepsy. We have very special expertise in a related field for children, when they reach a little bit older age of following a language delay, again, in the range from age three and up, that is called “augmentative communication”, which is a very specific therapy as a next step for children if they don’t respond to the earliest developmental therapies. This is another way to help them work around or overcome that language gap through use of new technologies that will allow them to have a better opportunity to develop a functional communication that they can use every day.
Melanie: Thank you so much for being with us today, Dr. Constantino. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.