Remember Quentin from my last post (Tattling vs. Telling)? He is a 9-year-old 4th grader who was brought to see my by his parents. They were concerned about social skills deficits that were interfering with Quentin’s ability to make and maintain friendships with his peers. Friends from earlier grades were beginning to exclude or actively reject Quentin, and he had not made any new friends since first grade. After a careful and comprehensive evaluation that included testing, structured interviews, and input from teachers and parents, I made a diagnosis of Asperger Syndrome.
Asperger Syndrome is a developmental disorder at the high-functioning end of the Autism Spectrum. Its cardinal feature is impaired social functioning. Other features may include a restricted range of interests, repetitive behaviors, and delays in motor development. Examples of the social impairment in Asperger Syndrome include avoidance of eye contact, missing nonverbal social cues, misreading the meaning of facial expressions and unusual speech patterns and intonations. Individuals with very mild forms of the syndrome are often described as “quirky.” Quirky is a good descriptor for Quentin who also happens to be very bright and sweet as well as adorable. (For more information about Autism and Asperger Syndrome, click here.)
One of the questions I always ask parents during a child evaluation is When did you first start to suspect that something was wrong? Today’s quote is the response I received from Quentin’s mom:
My husband and I knew something was wrong when Quentin first started preschool, but the pediatrician just kept telling us not to worry.
I hear this story all too often. Parents become concerned that something is amiss about a child’s development or behavior or emotional adjustment, they are reassured by doctors, other parents, teachers, and relatives, and then the parents do not trust their own instincts. The time that passes between parents’ first expressed awareness that something is wrong and a thorough evaluation of the problem is time that could have been devoted to intervention. It is very sad when this happens because it is well documented that early intervention is essential in addressing many childhood disorders.
I do not intend to be critical of pediatricians, most of whom are excellent at recognizing early developmental delays and helping parents obtain the services their children need. I also don’t intend to beat up on parents. I’ve said before and I continue to believe that parents work very hard to do what is best for their children. It is only natural to accept the reassurance from a trusted expert.
The best advice I can give parents, and I often do give this advice to friends, family members, and acquaintances who ask my opinion about their child is this: Trust your instincts. No one knows your child better than you. If you are concerned, follow up on that concern.
This advice is pretty vague, I realize. Fortunately, there are five much more concrete indicators that professional help is needed. If one or more of these apply to a child, it is wise for the parents to seek help and to continue seeking help until they find it.
1. A child is not achieving specific developmental milestones in one or more areas – motor, speech and language, social, emotional, behavioral. Here is a good resource if you are unsure about these milestones. It was the delay in achieving social milestones that Quentin’s parents observed when he entered preschool. They noticed that he was less interested in social play than his peers and that there was an unusual quality to his speech that they did not observe in his classmates.
2. A child is experiencing impairment in functioning in one or more areas: social, academic, emotional, behavioral. For example, Attention Deficit-Hyperactivity Disorder (ADHD) is often first recognized when a child reaches 3rd grade. Before that time, a child might be viewed as more active or less focused than her peers, but in many cases, there is no interference with social or academic functioning until 3rd grade when social interactions become more nuanced and when students are expected to achieve a greater level of independence in their school work. Inability to complete homework, to exercise appropriate levels of self-control, to get along with peers, or to regulate emotional responses are all examples of impairment in functioning.
3. A child is experiencing subjective distress in the form of anxiety or depression. Even children who are developing along a healthy trajectory in all areas and who are functioning well socially, behaviorally, and academically can be in crisis. I often see child clients who are “model citizens.” They do everything they are supposed to do at home and at school, they are well-liked by peers and adults, and they succeed in whatever they try. Yet, they are riddled with worries about failing, about being judged by others, about terrible things happening to them or their loved ones. Or, they feel cranky and sad for no apparent reason. They can’t enjoy life and they would rather sleep than hang out with friends. The cause may be a true psychiatric disorder or it may be a reaction to major stressors in the child’s life such as the death of a loved one, illness or disability, or parental divorce.
4. A child’s behavior is creating worry and tension in the household. Sometimes, a child whose development is fully on course, who is doing fine socially and well enough academically, and who seems perfectly content with his life engages in behavior that causes worry for family members or strife in the household. This is often the result of acting out behaviors such as violating curfew, experimentation with drugs and/or alcohol, lying (see Lying, Type 2 for more on this), and petty criminal behavior such as stealing from a classmate.
5. A school-aged child or adolescent appears to have trouble distinguishing fantasy from reality. While it is very rare, it is possible for children and adolescents to suffer from psychotic disorders in which they hear voices or see things that are not real (hallucinations) or hold firmly to unusual beliefs that are not grounded in reality (delusions). Virtually always, these children are first identified because they experience significant distress, but on rare occasions, they simply incorporate the psychotic experiences into their understanding of the world.
Because Quentin’s difficulties were very subtle, many smart and well-meaning experts, including the pediatrician and his teachers in preschool through 3rd grade, had missed them. It was not until the 4th grade teacher was flummoxed by Quentin’s behavior on the playground that someone besides his parents recognized that something was not quite right for this otherwise sweet and successful little boy. When I confirmed the parents’ suspicion that Quentin meets the diagnostic criteria for Asperger Syndrome, they were relieved. Having identified the problem, they could now turn their energy toward putting together the right combination of interventions to help their little boy. At the moment, Quentin is waiting to begin speech and language therapy through his school district, he is attending a social skills training group, and his parents are working with me to learn strategies to help him be more flexible and to support his efforts to make and maintain friendships.
Having laid out the five specific indicators that a parent should seek professional help – from a pediatrician, a child psychiatrist or psychologist, a developmental specialist, etc. – I still would say that the best advice I can give is to trust your gut. If you seek help from a competent, well-trained expert who gives you plenty of time to share your concerns and completes a thorough evaluation only to conclude that everything is okay, what harm has been done? It will be well worth the investment of time, energy, and money to have your worries put to rest. And, if a problem does exist, then you will have taken the first step toward addressing it.
[Names and potentially identifying information have been changed to protect privacy.]