Generally, children are 3 to 4 years old before they exhibit enough symptoms for parents to seek a diagnosis. There is no set pattern of symptoms and signs in children with PDDNOS. It is important to realize that a very wide range of diversity is seen in children with PDDNOS. All the items of behavior described in this section are common in these children, but a single child seldom shows all the features at one time. In other words, all children with PDDNOS do not have the same degree or intensity of the disorder. PDDNOS can be mild, with the child exhibiting a few symptoms while in the school or neighborhood environment. Other children may have a more severe form of PDDNOS and have difficulties in all areas of their lives. Because of the possibility that PDDNOS and Autistic Disorder are on a continuum, many clinical features described in the following section are very similar to those being described in the literature for Autistic Disorder.
Deficits in Social Behavior
Some infants with PDDNOS tend to avoid eye contact and demonstrate little interest in the human voice. They do not usually put up their arms to be picked up in the way that typical children do. They may seem indifferent to affection and seldom show facial responsiveness. As a result, parents often think the child is deaf. In children with fewer delays, lack of social responsiveness may not be obvious until well into the second or third year of life.
In early childhood, children with PDDNOS may continue to show a lack of eye contact, but they may enjoy a tickle or may passively accept physical contact. They do not develop typical attachment behavior, and there may seem to be a failure to bond. Generally, they do not follow their parents about the house. The majority do not show normal separation or stranger anxiety. These children may approach a stranger almost as readily as they do their parents. Many such children show a lack of interest in being with or playing with other children. They may even actively avoid other children.
In middle childhood, such children may develop a greater awareness or attachment to parents and other familiar adults. However, social difficulties continue. They still have problems with group games and forming peer relationships. Some of the children with less severe PDDNOS may become involved in other children's games.
As these children grow older, they may become affectionate and friendly with their parents and siblings. However, they still have difficulty understanding the complexity of social relationships. Some individuals with less severe impairments may have a desire for friendships. But a lack of response to other people's interests and emotions, as well as a lack of understanding of humor, often results in these youngsters saying or doing things that can slow the development of friendships.
Impairment in Nonverbal Communication
In early childhood, children with PDDNOS may develop the concrete gesture of pulling adults by the hand to the object that is wanted. They often do this without the typical accompanying facial expression. They seldom nod or shake their heads to substitute for or to accompany speech. Children with PDDNOS generally do not participate in games that involve imitation. They are less likely than typical children to copy their parents' activity.
In middle and late childhood, such children may not frequently use gestures, even when they understand other people's gestures fairly well. Some children do develop imitative play, but this tends to be repetitive.
Generally, children with PDDNOS are able to show joy, fear, or anger, but they may only show the extreme of emotions. They often do not use facial expressions that ordinarily show subtle emotion.
Impairment in Understanding Speech
Comprehension of speech in children with PDDNOS is impaired to varying degrees, depending on where the child is within the wide spectrum of PDDNOS. Individuals with PDDNOS who also have mental retardation may never develop more than a limited understanding of speech. Children who have less severe impairments may follow simple instructions if given in an immediate context or with the aid of gestures (e.g., telling the child to "put your glass on the counter," while pointing to the counter). When impairment is mild, only the comprehension of subtle or abstract meanings may be affected. Humor, sarcasm, and common sayings (e.g., "it's raining cats and dogs") can be confusing for individuals with the most mild PDDNOS.
Impairment in Speech Development
Many infants with PDDNOS do not babble, or may begin to babble in their first year but then stop. When the child develops speech, he or she often exhibits abnormalities. Echolalia (seemingly meaningless repetition of words or phrases) may be the only kind of speech some children acquire. Though echolalic speech might be produced quite accurately, the child may have limited comprehension of the meaning. In the past, it was thought that echolalia had no real function. More recent studies have found that echolalia can serve several functions, such as self-stimulation (when a child says words or phrases repeatedly without a communicative purpose--just because it feels good); as a step between a child being nonverbal and verbal; or as a way to communicate (Prizant & Rydell, 1993). Other children develop the appropriate use of phrases copied from others. This is often accompanied by pronoun reversal in the early stages of language development. For instance, when the child is asked "How are you?" he or she may answer "You are fine."
The actual production of speech may be impaired. The child's speech may be like that of a robot, characterized by a monotonous, flat delivery with little change in pitch, change of emphasis, or emotional expression.
Problems of pronunciation are common in young children with PDDNOS, but these often diminish as the child gets older. There may be a striking contrast between clearly enunciated echolalic speech and poorly pronounced spontaneous speech. Some children have a chanting or singsong speech, with odd prolongation of sounds, syllables, and words. A question-like intonation may be used for statements. Odd breathing rhythms may produce staccato speech in some children.
Abnormal grammar is frequently present in the spontaneous speech of verbal children with PDDNOS. As a result:
- -- phrases may be telegraphic (brief and monotone) and distorted;
- -- words of similar sound or related meaning may be muddled;
- -- some objects may be labeled by their use;
- -- new words may be coined; and
- -- prepositions, conjunctions, and pronouns may be dropped from phrases or used incorrectly.
When children with PDDNOS do develop functional speech, they may not use it in ordinary ways. Such children tend to rely on repetitive phrases. Their speech does not usually convey imagination, abstraction, or subtle emotion. They generally have difficulty talking about anything outside of the immediate context. They may talk excessively about their special interests, and they may talk about the same pieces of information whenever the same subject is raised. The most able persons can exchange concrete pieces of information that interest them, but once the conversation departs from this level, they can become lost and may withdraw from social contact. Ordinary to-and-fro conversational chatter is lacking. Thus, they give the impression of talking "at" someone, rather than "with" someone.
Unusual Patterns of Behavior
The unusual responses of children with PDDNOS to the environment take several forms.
Resistance to change. Many children are upset by changes in the familiar environment. Even a minor change of everyday routine may lead to tantrums. Some children line up toys or objects and become very distressed if these are disturbed. Efforts to teach new activities may be resisted.
Ritualistic or compulsive behaviors. Ritualistic or compulsive behaviors usually involve rigid routines (e.g., insistence on eating particular foods) or repetitive acts, such as hand flapping or finger mannerisms (e.g., twisting, flicking movements of hands and fingers carried out near the face). Some children develop preoccupations; they may spend a great deal of time memorizing weather information, state capitals, or birth dates of family members.
Abnormal attachments and behaviors. Some children develop intense attachments to odd objects, such as pipe cleaners, batteries, or film canisters. Some children may have a preoccupation with certain features of favored objects, such as their texture, taste, smell, or shape.
Unusual responses to sensory experiences. Many children may seem underresponsive or overresponsive to sensory stimuli. Thus, they may be suspected of being deaf or visually impaired. It is common for such young children to be referred for hearing and vision tests. Some children avoid gentle physical contact, yet react with pleasure to rough-and-tumble games. Some children carry food preferences to extremes, with favored foods eaten to excess. Some children limit their diet to a small selection, while others are hearty eaters who do not seem to know when they are full.
Disturbance of Movement
The typical motor milestones (e.g., throwing, catching, kicking) may be delayed but are often within the normal range. Young children with PDDNOS usually have difficulty with imitation skills, such as clapping hands. Many such children are very overactive, yet tend to become less overactive in adolescence. Children with PDDNOS may exhibit characteristics such as grimacing, hand flapping or twisting, toe walking, lunging, jumping, darting or pacing, body rocking and swaying, or head rolling or banging. In some cases the behaviors appear only from time to time; in other cases they are present continuously.
Intelligence and Cognitive Deficits
Generally, children with PDDNOS do very well on tests requiring manipulative or visual skills or immediate memory, while they do poorly on tasks demanding symbolic or abstract thought and sequential logic. The process of learning and thinking in these children is impaired, most particularly in the capacity for imitation, comprehension of spoken words and gestures, flexibility, inventiveness, learning and applying rules, and using acquired information. Yet, a small number of children with PDDNOS show excellent rote memories and special skills in music, mechanics, mathematics, and reading.
Because many children with PDDNOS are either without functional speech or otherwise untestable, some people question the validity of testing their intelligence. Moreover, it has been observed that a number of these children show major improvements in other developmental areas during the follow-up period without a change in their tested IQ. Follow-up studies have also shown that retardation present at the time of initial diagnosis tends to persist. Those children with a low IQ show more severely impaired social development. They are more likely to display unusual social responses, such as touching or smelling people, ritualistic behavior, or self-injury.
The emotional expression of some children with PDDNOS may be flattened, excessive, or inappropriate to the situation. For no obvious reason, they may scream or sob inconsolably one time, yet giggle and laugh hysterically another time. Real dangers, such as moving vehicles or heights, may be ignored, yet the same child might seem frightened of a harmless object, such as a particular stuffed animal.
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