Case 22: A three-year-old who does not talk yet

01The case

The parents of a 3-year-old boy bring him to a child psychiatrist because he is still not talking. They wonder whether he is deaf, since he does not react when they call him, and he seems absorbed in himself. Most of the time he plays with his father's car key. New toys do not interest him, and he can watch the washing machine going round for long stretches.

02Summary

Diagnosis

Childhood autism, in ICD-11 autism spectrum disorder.

What points to it

• Impaired social communication: no speech at 3, no response to his name, little interest in other people. Poor eye contact and few shared emotions usually go with this.
• Restricted, repetitive interests: one object (the key) rather than toys, and fascination with a spinning drum.
• No pleasure in new toys and no pretend play.
• Onset in early childhood.

What else it could be

Hearing must be tested first, by a formal audiology assessment, since deafness also delays speech and stops a child responding to his name. Other causes to consider are a developmental language disorder, global developmental delay or intellectual disability (which often comes with autism), severe neglect or deprivation, and rare genetic syndromes such as fragile X. A loss of words or skills he once had calls for a fuller search for a cause.

Management

• A multidisciplinary assessment: child psychiatrist or paediatrician, speech and language therapist, psychologist, with observation of the child and structured tools such as ADOS. A physical examination, and genetic tests where indicated.
• Information and support for the parents, and a parenting programme for autism.
• Speech and language therapy and a social communication intervention, often delivered through the parents.
• A structured, predictable routine, with visual supports, and help with nursery and school placement.
• No medicine treats autism itself. An antipsychotic such as risperidone is used only short term for severe aggression, and melatonin for sleep when behavioural measures fail.

Outlook

Autism is lifelong, but how a child does varies widely. Useful speech by about age 5 and normal intellectual ability predict a better outcome, and early support for communication helps.