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Does my 4-year-old have an autism spectrum disorder?
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Does my 4-year-old have an autism spectrum disorder?

We have a 4-year-old son. We're concerned about his development and recently we've taken the step to seek specialized help.
If you have a few moments, I would very much appreciate any insights you may have.

Where do I begin? I guess I'll just write down observations I can think of... My son walks, jumps and runs normally and can climb any of the constructions in play yards, is not very handy at ball games but where he has a lot of trouble is with his fine motor skills.
Without help he doesn't hold his pencil right and it takes effort to draw even a basic circle. Same thing for cutting, pasting etc. On the other hand he likes playing with playdoh and lego, with which he can make basic constructions comparable to his peers. When he dresses himself in the morning, often he puts his pants or sweater on backwards or his shoes on the wrong feet.
At first we thought it was just an attention problem, but now we're sure it's more than that.
He talks a lot about pirates and spiderman, but his interest doesn't seem obsessive to us (so far?). He doesn't seek to know everything about pirates (he'll change our bath tub or his bed into a pirate boat for example), nor does he protest if we interrupt him from watching a pirate video or his pretend play . He often doesn't use toys the way they're intended (he makes an imaginary pool with train tracks for example). When he's excited, he'll sometimes flap his hands.

Our son has difficulty making friends at school. More often than not, we find him playing alone in the school yard when we pick him up or drop him off.
On the other hand, he likes to play with his nephew who has the same age and he asks us for playdates with him.
He also likes to crawl in his little 18-month old sister's bed in the morning and play with her, we love hearing them laughing it out loud and having fun.
According to his teacher, he has great difficulty following instructions in group activities, except for singing which he likes (because this is something he's as good at as his classmates?).

He's doesn't offer any resistance at all against going to crowded places, on the contrary. Once we're in a busy store he continues to behave normally, shows interest and doesn't seem to be bothered by loud noise or people bumping into him.
If we offer him the choice between staying at home with one parent or joining the other parent on an unexpected trip to an unfamiliar place, he wants to come on the trip.

He'll pick out the smallest and biggest item of 5, but when asked he can't order them from small to big (whereas his peers can). When we ask him to count oranges, he manages to do so up to three but when presented with more he just replies something like "five, seven eight, fifteen" and starts to look away and act silly. He'll put beads on a string, but not in the sequence asked (he'll make his own game out of it). When he took a verbal intelligence test he scored well above average, but on a more universal test he scored as a 3-year old except for solving puzzles. The attention problem was an important factor though. What else? Oh, he speaks fluently and looks you in the eyes, at least when we he focuses. He also doesn't seem to take descriptions or expressions literally when they're not intended as such.

We haven't seen any preference for rule-bound behavior, he tosses his jacket wherever when he comes in and he has no habits of putting things in a certain location or doing things in a certain order (at least that we know of or have seen).

I've read a lot about the different possibilities of dx like ADHD, DCD, ASD, ... but I find myself asking questions like whether the social problems are a consequence of feeling inadequate, i.e. being in an environment the whole day where he wants to but physically can't do the same things his peers can (and his peers have started remarking on it), or is it because he really has trouble with social cues, or ...?

He's a really sweet little boy and we want to help him in the best way we can. It's hard to wait for the diagnosis which we hope to have in a few months...

What do you think of all this? Does it sound like PDD-NOS, Asperger's, ... based on your experiences ?

Thanks a lot for any comments!!
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I'm just a parent of a 7+ year old on the spectrum, and to be honest your son doesn't strike me as obviously being on the spectrum compared to some other posts.  I'm not saying he isn't having difficulties, as he sounds like he is, and he may have some autistic traits, but he sounds like he is doing too well in all the areas.  
Has his speech been assessed by a Speech and Language Therapist with experience of autistic spectrum disorders and speech disorders?  You say his expressive speech is fine.  But has his receptive speech been assessed.  There can be a big difference.  My son is age appropriate for expressive speech.  However he is also echolalic (google that to see what it is), and that brings his expressive speech score higher (unrealistically so).  But he has problems understanding what other people are saying so following instructions is difficult, listening to the teacher in class is difficult etc.
Children on the spectrum also tend to have Semantic Pragmatic Speech Disorder - google that to see what it is.
The SALT should also assess his auditory memory retrieval skills as well as Auditory Processing.
Has/does your son every repeat things you have said back to you or does he repeat TV/DVD dialogue?  
The fact that he makes an imaginery pool with train tracks is a good sign.  My son can also do this type of thing so it does show some imagination.  Autistic children can tend to play with bits of toys rather than the whole toy in the purpose for which it was intended.  So they might spin the wheel of a car.  Or may remove a piece from a toy and play with just that piece.  Using objects to represent other objects is good.  Is your son able to go along with make believe play or does he tend to want to re-enact something he has already seen on TV or in films?
It is hard sometimes to find the root cause.  You really need professionals to assess him and they should be experienced indiagnosing ASDs etc.  As you say a child may not be able to join in because of auditory processing disorder, for example.  However some speech disorders usually accompany ASDs.
If you want to see the clinical criterias for any disorder google DSM IV for Autistic Spectrum Disorder, for example.  
Would you say that your son uses language to socialise and chat with you, or does he only use it to get his needs met eg. mum I want a drink/TV on/where's my toy etc etc.  Or would he say 'today at school Billy saiddid xxx ', for example.
I think the SALT should give you alot of insight as long as they are a good one.
Also google Executive Function Disorder to see if that sounds relevant.
He doesn't sound like he has a need for routines or rituals or having his expectations met.  He also doesn't sound like he has problems with transitions.  You also don't mention anything about tantrums, emotional outbursts, getting upset/angry etc.  These are typical behaviours of being on the spectrum because they get easily overwhelmed and cannot control their emotions like we do.
I would make it very clear to professionals that you want to know why he is having difficulties with social interaction.  Does he try to join in but fail, and if so why.  Does he show a lack of interest in his peers?  
My son recently started a new school and kept telling me that he wanted to make friends and play.  But he doesn't know how to.  He doesn't know what to say, how to join in, or how to adapt his play.  His school have inroduced a system where he chooses what he wants to play prior to playtime (out of a choice of two things).  Then he chooses who he wants to play that with (out of a choice of two children).  This has helped him enormously because he knows what he will be doing and with whom.  Previously he would go out into the playground and just walk up and down on his own.  The school also have dinnertime clubs such as lego, drum club, IT that he goes to.
See what the SALT says, and if you aren't happy get a private report done by a professional with experience of ASDs and speech disorders as well as knowledge of Educational Law.
Also get him doing lots of physical things such as climbing/crawling, swimming, trampoling etc which are all good for brain development.
You could try to find a private Play Therapist who has experience of children with ASDs for her to do some sessions with him to see how he interacts with them.
Does he mispronounce words that you would expect him to know at his age eg. nap for map, glubs for gloves etc.
Does he ever appear deaf or cover his ears at certain sounds.  Is he okay with haircuts and nail cutting?
At 4 it is not too unusual for a child not to have one to one correspondence with numbers up to 5.  That means that the child doesn't actually understand the amount the number represents, so when they see 3 or 5 they cannot bring to mind how many items that would mean and which one is the biggest.  My son still cannot do this at 7+ but he can order numbers.  But that isn't the same thing.  My son can remember things immediately so putting numbers 0-20 is easy.  But the numbers don't mean much to him yet.
You've mentioned some fine motor skill difficulties.  These should be assessed by an Occupational Therapist.  It might be down to something like dyspraxia (however you say his gross motor co-ordination is okay, apart from ball throwing).
Or it could be down to motor planning issues.  This is how the brain plans the movement needed to complete a task.
Do you have Dyslexia or Dyscalculia in the family, or other developmental difficulties?

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My daughter (who does not have an ASD) has visual perception problems.  When she was that age she could not make a circle, etc.  She ***** at puzzles and cannot do anything more than 12 pieces without it taking forever.  They tend to bloom later in those areas - and though she has trouble writing she is an excellent student - especially in English and math.  At 9, she still colors like a three year old.  So don't assume ASD - there is so much in the media that everyone assumes that their child has it.

You are not describing most of the 4 year old behavior of the children I know who were later diagnosed with Aspergers.  Most of us are in tears as our child has been thrown out of preschool or we can't even go out on a simple outing without our children.  You don't mention massive breakdowns or total refusal to do things on a schedule, etc.  

IF you are going to have him tested I suggest go to an Occupational Therapist.  The problems you are describing seem more of an OT issue.  
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Children with ADHD also have a lot of trouble with handwriting.  He may have some executive dysfunction issues - they also have trouble making friends.  In fact, our doctors still can't decide if he has a really bad case of ADHD with an unspecified mood disorder or Aspergers.  Don't assume the worse.
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Thanks all very much for sharing your experiences! My son in the end has been diagnosed with ASD. When I read the DSM IV criteria myself on the Internet, I just didn't see some of them in my child until the child psychiatrist pointed them out to me. My son for example builds rockets with boxes, makes saturn out of a circle of train tracks with a ball inside of it, etc. and I thought these were examples of a vivid imagination. But what I didn't see is that my boy doesn't make up story play with his cars, dinosaurs, knights etc. like other 4 year olds do and that's what counts. The good news is he's only 4, so with some effort on our part we can teach him coping mechanisms that can become second nature to him.
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Yes, alot of their 'play' when examined is actually reconstructing or replaying something they have already seen.  But imagination to some degree can develop with time.
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I'm not surprised of your son's diagnoses.  Just because he did not display some of the stereotypical behaviours of children with ASD people easily discount a diagnoses.  Some of the repetitive behaviours canbe subtle and difficult to see and we don't all have sensory intergration difficulties to any extreme.  I would say my imagination always appeared normal, however I was immitating/mimmicking play etc from TV shows/other children.  Hated tea parties with my sister, there was never any actual consumables. My favourite task as a child was buliding 'Rat' traps out of chicken wire and setting up a mechanism to activate the entry door closure once they had bitten the apple core.

I was leaning towards Non verbal Learning Disorder which is considered to be on the autism spectrum in countries other then the USA.
Here is a link to many Autism Spectrum Disorders and their criteria;
http://www.pediatricneurology.com/autism.htm#Non-Verbal%20Learning%20Disabilities%20(NVLDs)
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When reading your description of your son it sounded like my son at that age, who is now 11 and only got diagnosed at the age of 9. We actually, like you, suspected sth like Asperger's because of an article we read in the Sunday papers, but everytime I went into the research myself, like you, I thought the descriptions just did not seem to fit. Professionals did not take us seriously, maybe because we couldn't put it quite so scientifically. Lucky you persisted, you see parents have a lot of intuition about their kids even if we are missing sometimes the way to explain it to others. My son was in therapy from the age of 4 for one thing and another, but it was always looked at as an isolated problem. It frustrated us no end, finally, when he was nine, a new psychiatrist diagnosed him and was very surprised that I started coming across all giggly. I was so relieved!! We still have a long way to go as will you have, but how brill you found it!!! Good luck!
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During the tests, my son was never able to concentrate past a certain point in the intelligence tests and started to rub his eyes, look around him, slouch and give silly answers. He also often responded immediately with a wrong answer (to get it done with I guess), and only after we could get him to focus again he gave the right answer. The result was an average measured intelligence, not enough for an Asperger's dx according to the evaluating psychiatrist. Another psychiatrist stopped her (verbal) based test in the middle, saying the test results would not be representative, as she saw evidence that he understood a lot more than came out of the test due to focus and concentration problems. She said it was therefore too early to assess his possibilities. That's why they diagnosed him ASD for now without further specification.

Kai939, I'm lucky to live in a country with an excellent health care and school system. Children go to kindergarten school here from age 2.5, so the teacher spotted pretty easily that my son was struggling in some areas compared to his peers. We knew this from age 3 already but decided to give it some time to see how things evolved. The next level was the local center for individual scholar help which referred us to the specialized center for developmental disorders. ANY treatment he needs will be completely free for the next 3 years and that includes physiotherapy and individual help for the teacher and my child at school to teach him things in a way he understands.
My wife and I were considering moving to the US but now we're not so sure as it sounds ideal for healthy young people without problems and that's not us anymore.
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if he is on the specturm he maybe like me an outgrow alot of it, i have always been able to look people in the eyes, i played some group sports, but tennis and softball were not easy for me, i was able to function in preschool, infact , most of my teachers did not even know i had a learning disiblity, there is such a wide range of symptoms, and some people have more than others, for me, the only time i am affected by the aspergers is when i am stressed out, or learning something extremly difficult, so if by chance your 4 yr old does have aspers or another ld, do not panic, most children, including myself do get better with time, and for me, i ourgrew most of it on my own, and i have also watched my son outgrow and change most of his aspie behavior, the , most difficult thing i have had to do is stop comparing my son and myself to other people, when i look at how well, this group of children are doing in math, i start worring about my son being so far behind, i have to remember that some people just take a long time to get math computations, and thats ok, i know that reading books like homeschooling a ld child, even if you are not homeschooling willl help, because ultimantly we are responsible for our childrens education and it is our responsibility to find out what learning principals will work for them, and these books help out with this
you can also check out a site called superduperpublications..com
this site has alot of resources for testing, and skill building, its a bit expensive, but i enjoyed using this site when i son was younger
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