PETER E. TANGUAY, M.D., F.A.C.P., is the Spafford Ackerly Endowed Professor (Emeritus) of Child and Adolescent Psychiatry in the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Louisville. He is the author of many articles in leading journals on the subject of autism, and has presented lectures and workshops in the United States, Europe, and Japan. From 1975 to 1985 he was Director of the NIMH-funded Child Psychiatry Clinical Research Center at UCLA.

His research has focused on autism and Asperger's Disorder. It is based upon an understanding of social communication and incorporates interviews designed to assess core deficits in the condition. One goal of the work has been to develop practical ways in which teachers and clinicians can become expert in the diagnosis, understanding, and treatment of persons within the autism spectrum.

Dr. Tanguay's recent publications include an invited ten year review of Pervasive Developmental Disorder in the Journal of the American Academy of Child and Adolescent Psychiatry. In 1998 he won the Rieger Award of the American Academy of Child and Adolescent Psychiatry, as author of the most significant paper published by a child psychiatrist in the Journal of the American Academy of Child and Adolescent Psychiatry in 1997-98.

Between 1990 and 1997 Dr. Tanguay was a Director of the American Board of Psychiatry and Neurology. Currently he is Associate editor of the Child PRITE - the Psychiatric Resident-in-Training Examination. He is a Member of the Group for the Advancement of Psychiatry and a Fellow of the American College of Psychiatrists. He was an expert consultant on the film RAIN MAN which starred Dustin Hoffman.

Thank you Dr. Tanguay for participating in this very special interview.

Autism is a very complex developmental disability that typically appears during the first three years of life. It is four times more prevalent in boys than girls and may occur in as many as two to six in 1,000. We have invited Dr. Peter Tanguay here to take questions and discuss this neurological disorder, giving us some very respected information and direction. Thank you, Dr. Tanguay, for sharing your time and expertise with StorkNet.

Patti: I have a 15 year old nephew with autism. Can it be genetic? What are some early warning signs to look for? (Continued below this part of Dr. Tanguay's reply)

Peter Tanguay, M.D.: Although the factors which cause autism are not known in any detail, the scientific evidence, based on twin and family studies, suggest that genetic factors play an important role. There have been many individual studies (with small numbers of affected persons) which have studied specific regions of one or other chromosome in an attempt to identify abnormalities, or which have looked at specific genes (such as genes responsible in serotonin production), but so far none have found much of consequence. There have been two large multi-center studies involving hundreds of families. Although each study came up with "chromosomes of interest" which might contain abnormal genes implicated in autism, the findings have not been strong enough to say for certain that this is so. The most provocative conclusion has been that statistical analysis of the results indicates that "at least ten genes may be involved". One of the major problems of genetic studies is that our technology is not up to efficiently investigating multi-gene disorders. Such technology will certainly be developed in the next decade, which should help advance our understanding of the genetics of autism.

There are also instances where "secondary autism" has been seen in certain known genetic abnormalities. Twenty percent of persons with tuberous sclerosis have autistic symptoms, as do 3-5% of persons with Fragile-X syndrome. Also have an autism picture. The former has been attributed to the result of the growth of tubers in the brain, while the latter may implicate widespread brain abnormalities in Fragile-X.

What we need to understand is that we are really talking of abnormalities of "social communication" when we speak of autism. It is possible that studying the dependence of the development of various aspects of social communication on brain function, and on the genetic underpinnings of this development, will begin to unravel the mystery.

The earliest symptoms of autism have been well defined in the Checklist for Autism in Toddlers (CHAT), a short screening examination developed by Simon Baron-Cohen and his colleagues for use in well-baby examination at 18 months of age. The link above is a copy of the salient questions and observations. Though targeted for evaluation of 18-month olds, the signs and symptoms could be useful in younger children. The problem is that the elements of social communication, like language, develop at different rates across groups of children. Not using words by eighteen months of age may be worrisome in a child, yet most of the children in this group will go one to develop normal language by 30 months of age. The same might be said for social communication, but we do not have a good understanding of the spread of ages in development of social communication in large groups of children.

Also, I am lost in the department of discipline, he doesn't listen to me no matter what I do, and he is a master at tuning me out. He doesn't care about time outs, and doesn't find it a punishment. At preschool the teachers just let him sit by himself and do puzzles and math and he doesn't have to integrate more than he wants to but in grade school this won't be the case. He will get obsessive about the VCR or dvd player and play with the buttons, and he has broken many things. But he will not listen when we tell him to stop. Also regarding potty training, he will go to the bathroom on the toilet only if he is at home and naked. This is fine at home as he doesn't like wearing clothes so we usually don't push it, but he is four and we need to train him. At preschool he uses a diaper.

Thanks for any advice, I also wanted to add that he sees a speech therapist once a week and a special Ed teacher once a week and we are getting him into a regional center program here in California.

Peter Tanguay, M.D.: In the past decade or so developmental psychologists have realized that beginning at two or three years of age, children begin to learn to two parallel capacities of processing information. One, which has been termed "folk psychology" or "intuitive psychology" involves understanding such things as human motivation, and the numerous (and largely non-verbal) social signs and signals which people use in communicating with each other. Over the years people acquire detailed understanding of such matters, to the point at which, without even thinking about it, they can size-up a social encounter and generate the expected and appropriate social response. The second capacity, termed "folk physics" or "intuitive physics" encompasses understanding of the world through factual knowledge, often mediated by verbal information. Your son's ability to count and to identify patterns within numeric arrays would seem to be an example of "intuitive physics." Although most people develop good intuitive psychology and intuitive physics, occasionally some people may develop the second one well, while handicapped in the first. People with a "high functioning" form of autism, which may also be called Asperger's Disorder, may show such patterns of handicaps and skills.

That he "tunes you out" is an indication of his inborn lack of any propensity to note and respond to social signals, or perhaps to even understand that you have a mind that is different from his. He may not realize at all that you can feel joy if he pays attention to you, or engages in social behaviors such as looking at you, hugging, or using social gestures. Other children are programmed to do this naturally. It is good that he is seeing a speech therapist and a special Ed teacher. While there is no harm in doing math games with him, it would be useful if you and his therapists used things he enjoys doing to expand his range of social behaviors. Talk to the parents of autistic children in your community; find out what specific therapeutic approaches exist for enhancing children's social communication. The regional center staff should also know this and can guide you in finding therapies for your son as he grows older.

Tracy: My son is 3 years old and diagnosed in the lower end of severe ASD. He was born very premature and followed in a neurodevelopmental clinic from birth so we were lucky to get an early diagnosis. He currently attends a specialized preschool half days, 4 days per week. He receives speech, occupational, and physical therapies one time per week, 4 hours per week with a behavioral specialist, and 25 hours per week with therapeutic staff support to help implement ABA. We've made a ton of progress with this, however, communication continues to be a huge hurdle. He cannot communicate even his basic needs. We've tried sign language, and different picture programs along with his speech to help, but he doesn't seem to really get it. Although he does have some words, he mostly just babbles them with no true meaning. I've read many books and have attended a National Autism Conference, but I haven't found "the key" for my son yet. Do you have any suggestions or ideas? Also: What therapies or treatment options do you recommend or encourage? Do you believe there is any credence in biological treatments for Autism? Can you recommend any good books? Thank You. Tracy.

Peter Tanguay, M.D.: Tracy, you are doing ALL the right things: ABA, speech, occupational and physical therapy, and behavioral training. You are a member of Autism Society of America, you go to their conferences - you are doing it all! There is no good scientific evidence that any of the diets or biological therapies you hear about (including psychoactive medications) improve one's social communication or language or intellectual skills. Anecdotal evidence of the effectiveness of these treatments is not enough. Attached is an editorial that appeared recently in the Journal of the American Academy of Child and Adolescent Psychiatry on the subject. As for books, I am sure you know the literature better than I do. I was recently doing a workshop and when I came outside at the break and found that the organizers had a long table covered with books on autism. I counted 80 books! Much is being written. Here is a short list of books I have been recommending to participants at my workshops. I am sure that there are many others which are good.

Judy: Dr. Tanguay, What would be something that we should notice and be aware of, as new parents, thinking our son may be autistic? Is it obvious or are they little signs that become bigger as time goes on? Thank you. Judy

Peter Tanguay, M.D.: Hi Judy. See my recommendations about the CHAT as described above. I hope this helps.

Claire: Is autism always the same or are there different kinds, different degrees, or different symptoms? Does it last a lifetime?

Peter Tanguay, M.D.: Our best clinical understanding of autism is that it is an inborn disorder in the development of social communication, to which may be added deficiencies in language, motor, and intellectual development. Here is an extract from a clinical report that I give to parents:

In 1943, Leo Kanner first described the disorder we know as autism, and in 1944, Hans Asperger described persons who appeared to have similar problems but to a milder degree. In the current diagnostic manual, the Diagnostic and Statistical Manual, Version IV (DSM-IV), there is a category of disorder called Pervasive Developmental Disorder, under which autism and Asperger's Disorder are listed. The main difference between the latter two disorders is that persons with Asperger's Disorder have had normal language skills present since early childhood.

In the past fifteen years, many clinicians have come to see that Pervasive Developmental Disorder appears to describe a spectrum of handicaps in which the impairments range from profound to mild. Categorical systems such as DSM-IV, which include a couple of well-defined disorders with specific handicaps, inadequately capture a spectrum disorder. It leaves out persons with milder but quite handicapping conditions. The latter is unfortunate since services are often available only to those persons meeting the criteria for the more severe disorders of autism and Asperger's Disorder.

Like many other experts, we have suggested that the concept of social communication can be useful for better understanding individuals within the category of Pervasive Developmental Disorder. DSM-IV is still the only official diagnostic system, and it is likely not to be updated for another dozen years, but we feel it is important to describe the clinical handicaps of the spectrum disorder now and in terms that can lead to a better understanding of their symptoms and of what interventions may be effective.

Social communication refers to specific behaviors in which complex cognitive and emotional information is communicated through facial expression, emotional gesture, the prosodic melody of speech, and through knowledge of the social rules of communication (pragmatics). The latter include what has been called a "theory of mind", i.e., knowledge that others have thoughts and feelings different from our own that can be ascertained and used to enhance our interpersonal relationships.

Research in the past twenty-five years has revealed that children come into the world behaviorally programmed to begin to look at complex stimuli (such as faces) and to interact with their caregivers in ways that allow them to learn which facial, gestural, and tone of voice cues are salient. They use this information to construct a nonverbal understanding of how one interacts with others. By 18 months of age children possess an extensive repertory of social communication skills and knowledge, even though, at this age, they are only beginning to learn spoken language. Children who are not driven to interact with others will fail to develop normal social communication skills, and will be diagnosed as autistic. Around three or four years of age children begin to develop two new and diverging sets of skills, which have been called "folk psychology" and "folk physics". Folk psychology is understanding that a person's behavior is driven by inner motives, while folk physics denotes an interest in learning about how things work, about facts, and about inanimate objects. Young children learn how to guess the motives of others by reading their nonverbal cues within the social context. This ability has also been called "mind-reading", and its absence "mind-blindness." Most children develop equal skills as mind-reading and understanding the world of objects, but occasionally one may see good folk physic skills in the absence of the ability to mind- read.

Some persons may mistakenly think that a child with autism will always have little or no language, or have a profound lack of social interaction, or engaging in stereotypical behaviors such as hand flapping, twirling, or turning on and off light switches. Some autistic children may have such problems, but others have normal intelligence and language, and only mild or moderate deficits in social communication skills. Despite their good intelligence and normal speech, however, such children can still be quite handicapped in dealing with others.

In the past several years, I and my colleagues have been studying how best the various degrees of autism spectrum disorder could be characterized in terms of social communication handicaps. Two recently available interviews lend themselves well for identifying social communication problems in children, as well as identifying other types of common symptoms of autism. The interviews are the Autism Diagnostic Interview (ADI) and the Autism Diagnostic Observation Schedule (ADOS). Our current investigations suggest that the spectrum of social communication problems can be described within four domains:

Norma: Dear Dr., I read recently that exposure to metals and other substances/chemicals might be a cause of autism. The article included mercury in tuna. What are your thoughts? Thank you.

Peter Tanguay, M.D.: There is no reliable evidence that heavy metals in our foods or in the air we breathe causes autism, but heavy metal ingestion (particularly lead) can cause decreased intellectual development. Heavy metal poisoning (from ingestion of large amounts) can produce many abnormalities in brain and somatic functioning.

Mandy: What are some signs to look for in a toddler? I've read a few that my son matches but I'm not sure if it's because he's a toddler or if it's due to autism, such as walking on his toes, not looking me in the eye, etc.

Peter Tanguay, M.D.: See my note on the CHAT. Walking on the toes is pretty non-specific; my oldest grandson did it as a toddler, and he still occasionally does at 8 years of age. Otherwise he is quite typical of children in general. When he realizes that it may look "odd" to others I expect he will concentrate on not doing it.

Alison: We have a six year old with Autism. Has anything ever been linked genetically to the male side? Say what the father may have done in his past to contribute to the disorder. We hear about vaccines, pitocin and head size but no one says much as far as factors from the father. We had him tested genetically and it wasn't found to be. Thank you for your time.

Peter Tanguay, M.D.: See my answer to the first question above. Head size abnormalities have been reliably observed to be abnormal in autism. There is a recent article by Courchesne in the AMA Journal on this: he reports abnormally small heads at birth followed by abnormally rapid head circumference growth in the first year of life, leading to large head circumference by the second year of life. This finding needs to be replicated before we can believe it, but it is very interesting. Neither vaccines or pitocin have been reliably linked to development of autism. There are some three or four large studies of the effects of MMR vaccine in millions of children, and they have not at all supported the notion that MMR vaccine caused autism. As one author stated, "If it causes autism it does so at rates that are too small to be statistically identified." See link.

Are the genetic factors inherited from the father than the mother? Interesting question, now that we are seeing that genes may have quite different effects depending which parent passed on the gene. No one has studied this in autism since we have no specific autism genes to study at this time. Negative results on genetic testing can be important to rule of Fragile-X, but beyond this a negative results means very little since we have not yet identified which genes to look at.

Siobhan: Hello, Dr. Tanguay. My son is four years old. We have had extensive diagnosis for him and he was labeled high functioning autistic. He has some speech but uses it mainly for communicating his needs "I want juice," "turn light on" etc. And not for pleasure. He is very advanced in certain areas, especially math. He can count to an unlimited number just like an adult, he can add, and I notice that he makes interesting advanced patterns on his equations, such as 30, 60, 90, 120, 150... obviously adding by thirty. He is completely obsessed with math, and has developed his own math sign language, which is very complex and goes over 100.

I have heard that we should not indulge, and actually discourage these obsessions, yet I just can't agree with that -- we spend a lot of time on math because he really enjoys it. How do you feel about this? Also, I am lost in the department of discipline, he doesn't listen to me no matter what I do, and he is a master at tuning me out. He doesn't care about time outs, and doesn't find it a punishment. At preschool the teachers just let him sit by himself and do puzzles and math and he doesn't have to integrate more than he wants, but in grade school this won't be the case. He will get obsessive about the VCR or DVD player and play with the buttons, and he has broken many things. But he will not listen when we tell him to stop. Also regarding potty training, he will go to the bathroom on the toilet only if he is at home and naked. This is fine at home, as he doesn't like wearing clothes, so we usually don't push it, but he is four and we need to train him. At preschool he uses a diaper.

Thanks for any advice, I also wanted to add that he sees a speech therapist once a week and a special Ed teacher once a week, and we are getting him into a regional center program here in California.

Peter Tanguay, M.D.: Siobhan, please read the references which I have already sent to StorkNet on the subject of autism. (links in answers above) Your son appears to be quite good at what had been called "intuitive physics" but not too good at "intuitive Psychology." The former (the name is not a good choice) pertains to being interested in and learning factual knowledge, including, in his case, mathematics. The latter is the ability to learn about what motivates others, and to develop a body of knowledge about social expectations and responses, which people can call upon automatically and quickly as needed. Children become more and more skilled in intuitive psychology as they grow older, and quite adapt at it by eight or nine years of age. I advise you to continue working with the speech pathologist, special Ed teachers, and others who can provide social coaching.

In the past few years therapists have been experimenting with "social coaching groups" in which children practice such skills as "starting a conversation with others", "talking at lunch", "asking directions", "meeting others for the first time" etc. What is important is that the persons with autism have an ACTIVE learning experience (rather than simply being told what to do, or watching others engage socially), in which they try things out and practice. Some groups use older normal children as well as therapists as social coaches, and use videotape as part of the process. Arranging for other children to come and play with your son at home is another ploy: but the play has to thought out in advance and taught to him, and the play with the friend has to be closely coached and supervised. I don't know what is available in your community. Ask other parents in your local autism society what they have found. Although your son may wish to spend all his time on math, he also needs to spend as much or more time in social coaching situations. Also: rules should be established about his experimenting with and using the VCR, DVD etc.

Amy: Thanks so much for doing this -- I am full of questions, actually. At the risk of overloading you, here are a handful of them:

1. Growing up I'd never heard of a single case of autism, now suddenly it seems like there is an autistic kid on every block. Are the rates of autism really rising as rapidly as they seem? What do you think of the claims that this is just the new fad illness, or that we are over-diagnosing what should just be considered a "different" type of personality?

Peter Tanguay, M.D.: This is a question which many have asked in the past year. The opinion of most experts is that this is mainly an ascertainment increase, especially driven by our understanding autism as a spectrum disorder, with mild, moderate, and severe cases. There is no doubt that the prevalence rate of autism as one in 250 is correct. The recent (and ongoing) studies by the Center for Communicative Diseases are very well done and have established these figures as definitive. If autism is actually rising then no one has any idea why this might be.

2. If the number of cases are truly rising the way they seem to be, then what is your best guess as to why?

Peter Tanguay, M.D.: I have no idea why. Over the past 10 years various environmental causes ranging from soil contamination to the MMR vaccine have been touted, but none have stood up to careful follow-up study.

3. Do you know of any links between the rise of autism and the rise of ADD/ADHD? It just seems odd that they are both suddenly so prevalent.

Peter Tanguay, M.D.: I have been quite interested in seeing the rise in ADHD. I think it is entirely iatrogenic, i.e. caused by physicians and psychologists willingness to call everything ADHD. There are persons with ADHD, but not at all to the extent that it is being diagnosed. I know this from the numerous persons I have seen in teaching and practice who have been mislabeled. Even worse is the over-use of medication - or rather overuse with those who do not have ADHD, and under-use with some who do, as recent studies suggest. Although a recent book by Diane Kennedy argues for a link between ADHD and autism, I am not convinced this is so. There is a book Running on Ritalin by a San Francisco pediatrician that I have found useful in understanding the over-diagnosis of ADHD. Everyone wants a simple answer and a quick fix! I look at my boisterous grandchildren and think how some physicians would immediately want to label ADHD. There are other children who are under-socialized and who are labeled ADHD. Medication will not teach them better behavior.

4. Are there any early warning signs of autism? What sort of behaviors should we consider to be red-flags? Do the symptoms begin gradually, making it hard to spot, or do they hit all at once?

Peter Tanguay, M.D.: See the article on the CHAT that I sent. This is still the best check-list for autism in the second year of life. The symptoms may only seen as the child fails to achieve certain social and language skills. Theoretically it is possible to spot these symptoms at six months of age, but since most people are not looking for them at that time they are usually missed. Some parents report a more abrupt onset in the last second year - this is hard to study retrospectively, however.

5. Bottom-line: how do I know if my child is normal but "different" (quiet/introverted/a late bloomer/an "odd duck") or if he has a mild form of autism? Where do you draw the line?

Peter Tanguay, M.D.: We have not studied where one should label a person as definitely handicapped or as merely "different." Jon Constantino at Washington University in St. Louis has told me about his studies of "social reciprocity" in typical children. He found that it was distributed at a bell-shape normal curve. So the question is: is this person merely at the left-hand side of the curve, or might he have genetic abnormalities leading to more handicapping social communication lags. This needs to be studied and we, as a society, need to decide, for service availability, what is normal versus abnormal. We have done this for mental retardation and I expect we will do it for autism.

6. Finally: I've heard that a lot of parents are putting their autistic kids on wheat-free, dairy-free diets with good results. What is your opinion on possible dietary links?

Peter Tanguay, M.D.: There is no hard scientific evidence to support this.

Amy: Thanks again for taking the time - with so many of my friends' kids being diagnosed, and with an "odd duck" of my own, it is a topic of great interest! Amy

Peter Tanguay, M.D.: You are welcome and best of luck.

Margaret: Is it true that they still think there is a link to autism and vaccinations? If so, is there any way that I can make my child's immunizations schedule any safer? I have heard that having them done separately, or at later ages is better. I am a nurse and have concerns about not getting my children vaccinated as I know how deadly some of the diseases can be also.

Peter Tanguay, M.D.: There is no scientific evidence that MMR vaccine causes autism. Several large studies have addressed this, and, as one concluded, "if there is a link it is too rare to be measured statistically. The same goes for the mercury preservative that was used in MMR vaccines. See link

Margaret: Also, is there any correlation to the fact of genetics playing a role in autism. My husband's nephew is autistic and now that I have a baby boy, I'm terrified of the disorder.

Peter Tanguay, M.D.: There is plenty of good evidence that genetics plays some role in autism. Careful studies have not been able to identify where the genetic abnormalities reside, or what is their nature. One large multicenter study concluded that at least 10 genes may be involved. So much for any easy answer!

JB: I live in Europe and have a dear friend whose 8 year-old son is autistic. He currently is in school 2 hours a week and in a specialized day center part-time. He does not communicate with language and has had problems recently with cataracts. I would like to know what you could tell us about the causes of autism. My question is perhaps frivolous given all that parents have to deal with every day, but I am saddened to see my friend additionally burdened by people who think that Thibault is autistic because she didn't "bond" with him while he was an infant. Is there any truth to the supposed link between aluminum and autism?

Peter Tanguay, M.D.: I have been a consultant to groups in Europe. Only in France, Italy, Switzerland is autism "still caused by bad mothers." It is very unfortunate that psychiatrists think this way. Blame old-fashioned psychoanalysis for this situation. Until the parents rise up in revolt and shout "The emperor has no clothes" this may continue. This is what the parents did in the U.S. in the 1960s. It was not necessary for them to do so in England since the "bad mother" hypothesis never really took root there.

StorkNet: Several readers posted questions to our guest asking if there is a relationship between the MMR vaccine and autism. Dr. Tanguay explains that he has answered this (above in this interview) with a "no." He goes on to say,

"A cautionary tale: In 1970 in England there was a claim that was widely circulated that the mumps vaccine could cause terrible brain damage, as it certainly could in perhaps 2 in a million children. By 1972 the mumps vaccination rate dropped from 90% to 30%. Ten years later there was a mumps epidemic that killed 70 children. These deaths would all have been preventable with vaccination."

Dora: Is it possible to spot a baby as having autism when a woman is still pregnant. If so, in what way?

Peter Tanguay, M.D.: No, not with our current technology.

Yvette: My son was just diagnosed with Asperger's Syndrome at the age of 10. He had a previous diagnosis of ADHD at the age of five. The main recommendation from the doctor was to begin a Social Skills Training group. She gave me a name and number to call but I have some concerns. When I called my insurance company they didn't have any listing for this person. I have no idea what this costs or whether it can be paid by insurance. Do you have any experience with Social Skills Training and what I can expect?

Peter Tanguay, M.D.: Social skills training is essential - see my answers above. But the person who does it better know what they are doing or it may not work very well. Will your insurance pay? Probably not - they will say it is an educational rather than a medical treatment.

Wenzday: My son is going through the diagnostic process right now. Friday is the big day when I guess they make their decision. Regardless, my son is going to be in the spectrum. He will be four in January and has improved so drastically over the past year. My question is... Is it likely that he will continue to make such improvements and since he is VERY social and I gather that's an uncommon thing for an autistic child, do you think he could suddenly withdraw?!

Peter Tanguay, M.D.: It's always hard to prognosticate - but it sounds like he is in the group who are more likely to continue moving ahead. Will he regress - not that I have ever seen. In fact, if he begins to regress severely I would be concerned that there is some other abnormality than autism.

Ashley: I have a friend with an autistic son. He had testing done recently and they found that he had severe mercury poisoning. He is taking very strong medication to get it out of his system.

Peter Tanguay, M.D.: I strongly suggest getting another reputable lab to do the testing and see if it is true. Chelation therapy is expensive and not needed if the person does not really have heavy-metal poisoning.

Ashley: My question is this- if the symptoms of mercury poisoning are the same as the symptoms of autism....is there a chance that he is not autistic?

Peter Tanguay, M.D.: The chance is more likely that he does not have mercury poisoning. Severe mercury poisoning in this country is very rare - unless you work in mercury factory and inhale the fumes.

Jayme: My son, who is five, doesn't talk yet. He hardly recognizes his name. Does he have autism? The doctors say that it's not likely and that he's just shy.

Peter Tanguay, M.D.: Your son should a comprehensive screening by a competent speech and language person, or knowledgeable professional immediately. Not to speak by age five must be investigated now.

mcaren: My three-year-old son has PDD NOS, and has just started on ritalin for hyperactivity. Should I be seeing improvement right away?

Peter Tanguay, M.D.: I assume that he has hyperactivity, and if this is so, Ritalin could be helpful within a day or two. If it isn't then he may need a trial of another ADHD medication. Ritalin will not help his language or social handicaps.

Erica: My son was born seven weeks early. His weight, length and head circumference were all in the fifth percentile at birth. Between three and six months, his head grew to the 90th percentile. We were sent for a CT to rule out hydrocephalus, and it came back just fine. Now at 15 months old, his head is in the 95th percentile, and his height and weight are still in the 10th. I have read that rapid head growth can be a marker for autism, and am worried about my son. He is globally delayed, but making great progress with therapy. I've also read that some autistic babies will develop skills normally for awhile, then lose those skills as their autism becomes evident.

Basically, I'm asking, is my son at a higher risk due to his head size? And if so, what should I watch for in order to get a diagnosis that would enable him to get the help he'd need faster? Any advice or reassurance you could give would be appreciated! Thanks for your time!

Peter Tanguay, M.D.: Erica, see Eric Courchesne's recent article in the Journal of the American Medical Association. He answers your question in the article. Unfortunately I do not have a copy of the article to send by email. Any university medical library will have a copy. Here is what my workshop slide says: Evidence of Brain Overgrowth in the First Year of Life in Autism (2003), Courchesne, E et al., JAMA, 290:337-344. "The clinical onset of autism is preceded by two phases of brain growth abnormality: a reduced head size at birth and a sudden and excessive increase in head size between 1 and 2 months and 6 and 14 months. Abnormally accelerated rate of growth may serve as an early warning signal of risk for autism."

StorkNet: Dr. Tanguay, thank you very much for your time and expertise. You have given our readers some valuable information and direction. We appreciate that you have stopped by to share your knowledge and support here at StorkNet and please know that you are welcome back any time!