Question
I have two patients, twins age 2, that have not been diagnosed with any specific disorder. They present the following behaviors:
high pitched variegated babbling
fixation on objects (holding objects in hand and not releasing, gazing at obje
Answer
First of all, the characteristics of your clients' language and social behavior warrant a very thorough neurological assessment. Although many children may not achieve communicative developmental milestones by the age of 24 months, such as 2-word phrases, there are specific symptoms in the behavior of your clients that may constitute a pattern seen in children with Autistic Spectrum Disorder (ASD). Some of the symptoms that you are describing have been identified by a group of Canadian researchers in 6 to 12 month old infants as predictors for diagnosing autism at 24 months. These are:
reduced social interaction
lack or reduced ability to imitate,
atypical eye contact
lack of interest in other people
delayed language abilities
irritability or over or under reactions to activity or features of the environment
playing with toys in an unusual way.
Your current goals for the twins are developmentally appropriate for toddlers with overall language delay and show your knowledge of socio-cognitive and linguistic developmental milestones. However, your little clients show specific behaviors that may not allow them to achieve these goals because they do not seem to have required precursors. Namely, they don't seem to have an appropriate eye contact which is a cornerstone for attention to language and social interactions. Therefore, you may start by getting them to attend to you first even if it will be for a minute in the beginning. Some of the things that can be done in therapy:
hold a toy that they seem to like at their (and your) eye level and manipulate it: if the toy is mechanical, you may get a response if it stops
move the toy away where they can see it and provide signs or sound combinations for requesting it
try child-directed (milieu) therapy - follow their initiative and narrate their actions, as well as providing some signs and/or sound combinations for labeling, requesting, rejecting, etc.
if they are engaged in their own play you may want to "interrupt" it, i.e., stop the mechanical toy, prevent a toy from moving forward, remove an important part that is needed to complete a favorite activity. Provide signs or sound combinations for request: you may have a tantrum in the beginning, but if you are consistent and reward a child for completing the task, you may see a better compliance.
I would also suggest minimal visual stimulation in the therapy room: provide only the item/items that you are using at any given segment of the therapy.
Dr. Elena Zaretsky, Ph.D., CCC-SLP, is an Assistant Professor in the Department of Communication Disorders at UMass, Amherst. She is part of the team of professors in that department who received a four-year DOE grant to better educate and train graduate students to work with children with Autism Spectrum Disorders (ASD). Her other interest include language learning disabilities and reading acquisition, as well as issues in bilingualism.
Elena Zaretsky, Ph.D,CCC-SLP
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