An Interview with Dr. Louis Pellegrino : What are Developmental Delays and When Should Parents be Concerned?

Jun 27, 2012 by

Michael F.Shaughnessy

1) Dr. Pellegrino, you are a developmental pediatrician. What are the most common developmental delays that you encounter?

Speech and language delays are probably the most common developmental delays I encounter, especially in younger children. They may occur in isolation, but language difficulties are also a part of other, broader developmental problems.

2) Let’s start with verbal delays: a 2-year-old who does not even say “mama” or “dada.” What are the first steps that a parent should take?

The first step should be to have the child’s hearing tested by an experienced audiologist. Although most instances of speech delay are not due to hearing loss (they usually have a developmental basis), it is easy to miss a significant hearing problem. Most parents of a child with significant hearing loss are convinced that their child hears normally, until testing proves otherwise.

The second step, which should really occur concurrently with the first, is to involve the child in early intervention services, which would typically include speech therapy. Although a 2-year-old may not be able to engage in what we think of as traditional speech therapy, the creative speech-language pathologist will find multiple ways to encourage language use and will be able to serve as a consultant to parents in their efforts to help their child.

3) What about strange or idiosyncratic behavior? When is a psychiatrist typically called in?

Child psychiatrists are experts at recognizing and treating behavioral disorders, and necessarily must also be experts in the typical and atypical variations of child development. Unusual or idiosyncratic behaviors are actually the province of pediatricians, psychiatrists, and neurologists alike, and there is great overlap in the types of problems each of these types of specialists would evaluate and diagnose. For example, doctors from all three specialties are typically involved in diagnosing autism. Child psychiatrists are particularly expert at evaluating and diagnosing children who demonstrate unusual thought processes (such as psychotic thinking), and are often consulted when children have depression, anxiety, obsessive-compulsive difficulties and severely disruptive or aggressive behavior.

4) You and I know about the increase in children being diagnosed with autism. What are some signs that parents should be alert to?

Children typically begin to show an interest in the people around them beginning in early infancy, so parents should be concerned if this interest is lacking. Lack of eye contact, poor imitative responses, and an absence of pretend play are also red flags. Many children with autism do not respond consistently to their name when called, don’t point to things when they want them, and generally show little interest in communication. If they speak, they may use language in unusual ways, such as repeating things verbatim from favorite TV shows.

Many children with autism demonstrate unusual, repetitive behaviors (such as hand flapping) or unusual, obsessive interests, and many are bound by rigid routines that cannot be varied without creating great distress for the child. The bottom line is that any parent who has concerns about their child’s social development – even if these concerns only amount to a “gut feeling” – should trust themselves and their instincts and act on them.

5) Now, what about kids who don’t respond when called or spoken to? Is it usually an inner ear infection? Otitis media or otitis externa? Hearing loss?

Maybe none of these. Most often, children who don’t respond when called are simply not paying attention, although as mentioned above, children with autism also don’t respond when called, and of course children will sometimes refuse to respond out of a sense of control or defiance. What we think of as an “ear infection” is usually an infection of the middle ear, or otitis media, and can cause transient, usually mild hearing loss that should normalize when the infection clears. Persistent middle ear fluid (often present for days or weeks after an infection) can also cause generally mild, transient hearing difficulties.

Swimmer’s ear,” or otitis externa, is an inflammation of the ear canal, and does not typically cause hearing loss. Inner ear infections are very rare, and generally cause dizziness rather than hearing loss. The most concerning type of hearing loss, sensorineural hearing loss (or “nerve deafness”) is not usually caused by infection (although infections during fetal development can cause this). It often has a genetic basis, and may be present at birth or become progressively worse during childhood. It is this type of hearing problem that should be ruled out when a child does not respond when called.

6) If a child doesn’t “play well with others” and lacks social skills, when should parents be concerned?

Most children begin to show an interest in other children from infancy, and will initiate contact with other children as early as a year of age. By 2 years of age, most children engage in “parallel play,” or play in the company of other children, and by 3 years of age, most children engage in interactive play (playing together, also called associative play). Parents should be concerned if their child does not show this progression, or entirely lacks any interest in other children.

7) Many Head Start facilities have developmental screenings. Are these adequate, and what are they comprised of?

All screening tests have their uses and limitations. Some screening tests are well standardized and have a proven track record of identifying developmental problems, but even the best screening tests aren’t perfect, and will occasionally fail to identify a child with a developmental problem or misidentify a typically developing child as having a problem. Many Head Start programs (and primary care doctors) use very good standardized screening tests such as the Ages & Stages Questionnaires (ASQ). Children who “fail” screening tests should be referred to a developmental specialist for further assessment.

8) Dr. Pellegrino, I seem to hear about more and more kids being diagnosed with amblyopia, or lazy eye. What are the signs and symptoms, and what is the typical treatment?

Amblyopia is a condition that develops for several reasons. Whenever a child has a strong preference for looking at things with one eye over the other, the child’s brain becomes accustomed to not using the less favored eye, and over time, permanent visual loss will result. Some children have amblyopia as a consequence of eye muscle weakness that causes one eye to turn in or out (this is called strabismus), resulting in a preference to use the “good” eye. Other children may have one eye that is very farsighted or nearsighted compared to the other, and this discrepancy also results in a preference to use the eye that has better sight. Treatment usually involves efforts to correct the discrepancy and strategies to force the brain to use the weaker eye. Glasses (corrective lenses) can help correct differences in vision and may also improve mild cases of strabismus. Severe strabismus may require surgical correction. In many cases, “patching” is tried. This involves covering the “strong” eye with a patch to force the brain to look at things with the “weak” eye. The younger a child is when treated (preferably in the preschool years or earlier), the greater the likelihood that the intervention will succeed.

9) With gross and fine motor coordination, what should parents be looking out for?

Parents should be alert for obvious delays (for example, not walking by 15 months of age) and should also be concerned when their child seems excessively awkward with motor skills generally. A particular concern is the child who shows a preference for using one side of the body at any age, or the child who shows an obvious hand preference prior to 18 months. These asymmetries may be a sign of a neurological problem such as cerebral palsy.

10) Is the average teacher adequately trained to evaluate and observe children for developmental delays?

Teachers, especially experienced teachers, are often highly sensitive to differences in development among children. After parents, they are often among the first to recognize when a child has a developmental problem.

11) Tell us about your book and where interested parents can get a copy.

My book, The Common Sense Guide to Your Child’s Special Needs: When to Worry, When to Wait, What to Do (Brookes Publishing, 2012), was written with parents in mind, and is especially meant to help parents who are struggling to understand the nature of their child’s developmental problem and who want to learn about the sensory and medical problems that are sometimes associated with developmental disabilities. The chapters in Section I, Understanding Your Child, are devoted to specific areas of concern, such as delayed speech, difficulties with walking and other motor skills, delays in developing daily living skills, and difficulties with social skills, learning, or behavior. The chapters in Section II, Special Children, Special Needs, are devoted to describing sensory and medical problems associated with development problems and specific disability conditions. Special sidebars are used throughout the book to highlight key concepts, define confusing technical terms, and expand on particular areas of interest. My intention was that the book should be always readable, frequently useful, and at least occasionally entertaining.

12) What have I neglected to ask?

Perhaps this: What should parents do when they have a concern about their child’s development, but a doctor or teacher or other professional has dismissed their concern? In my experience, parents are most sensitive to their children and are often the first to recognize a developmental problem. In instances where parents find themselves at odds with a professional, I would advise them to trust their own instincts, and respectfully but assertively advocate for their child’s needs.

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