Developmental consultation

Developmental Consultation

"It was a pleasure to see" Leo Vance, 5 yo, Senior Kindergarten at Oakridge Public School, accompanied by his mother, Sarah Vance.

Leo is a boy of many strengths including his affectionate nature, strong visual memory, and enthusiasm for puzzles.

Reason for Consultation

• Evaluation of speech/language delay, impaired social communication, and repetitive behaviours.

History of Presenting Concerns

• Parents report limited conversational speech, inconsistent eye contact, difficulty with peer interactions, and distress with transitions. Frequent hand-flapping when excited and rigid adherence to routines.
• Concerns first noted at 18 mos due to delayed speech; social and behavioural differences became more pronounced upon starting JK at age 4.

Developmental History

• Uncomplicated pregnancy, SVD at 39+2 wks, BW 3.4 kg.
• Gross motor: sat at 6 mos, walked at 13 mos. Fine motor: pincer grasp at 10 mos, currently holds pencil with immature tripod grasp, buttons large buttons. Speech/language: first words at 24 mos, 2-word phrases at 3.5 yrs. Expressive: uses 3-4 word sentences, frequent delayed echolalia (scripts from cartoons). Receptive: follows 1-step familiar commands, struggles with multi-step directions. Gestures: points to request, rarely points to share interest, no sign language used. Play/Interests: parallel play, lines up toy cars by colour, intense interest in train schedules. Repetitive behaviours/tics: hand-flapping, spinning wheels, no vocal tics. Academics: knows alphabet, counts to 50, recognizes basic shapes. Social skills: prefers solitary play, limited joint attention, difficulty reading social cues. Adaptive: toilet trained for urine during day at 4.5 yrs, wears pull-ups overnight, requires assistance with dressing.
• No history of developmental regression.

Reports reviewed: Vanderbilt Assessment Scales (Teacher: elevated inattention, social withdrawal), Preschool Language Scales-5 (PLS-5: Auditory Comprehension 5th percentile, Expressive Communication 3rd percentile), IEP from Oakridge Public School noting communication exceptionality.

Vision and Hearing: Formally assessed at 04/11/2025; audiometry normal bilaterally, optometry exam normal. No parental concerns.

Dental health: Regular dental visits every 6 mos; no caries, brushes with parental assistance.

Sleep behaviour: Difficulty settling (takes > 1 hr), wakes 1-2x/night, total sleep ~8.5 hrs. No snoring or apneic pauses. Takes melatonin 3 mg PO QHS.

Eating behaviour: Marked food selectivity; prefers crunchy, beige foods (crackers, chicken nuggets). Refuses most fruits/vegetables. Drinks 500 mL 2% milk daily. History of mild iron deficiency. No choking or dysphagia.

Medical History

• Recurrent acute otitis media in infancy (resolved, no tubes). No surgeries, hospitalisations, seizures, head injuries, or IV fluid requirements.
• Maternal prenatal vitamins taken, no teratogenic exposures. Born at 39+2 wks, APGARs 8 and 9, no resuscitation required, unremarkable neonatal course, no NICU admission.
• Ferrous sulfate 30 mg PO OD, melatonin 3 mg PO QHS.
• NKDA.

Family History

• Mother: hypothyroidism. Father: hypertension.
• Maternal uncle with ASD; older brother (8 yo) has ADHD.

Social History

• Lives in a detached home with both parents and 8 yo brother. Supportive family environment, English spoken at home.
• Attends SK full-time with shared EA support. Struggles with classroom transitions and group circle time; excels in independent puzzle/matching tasks.

Physical Examination

• Alert, active, limited eye contact. Wt 19.2 kg (55th percentile), Ht 110 cm (50th percentile), HC 51.5 cm (60th percentile). HR 92 bpm, BP 96/60 mmHg. Nondysmorphic. ENT clear. CVS: S1/S2 normal, no murmurs. Resp: clear bilaterally. Abd: soft, non-tender. Neuro: CN II-XII grossly intact, normal tone/bulk/power, DTRs 2+ symmetrically, gait normal (occasional toe-walking observed). Skin: no neurocutaneous stigmata.
• ADOS-2 Module 2 administered: Communication and Social Interaction scores above autism spectrum cutoff.

Assessment

• Leo is a 5 yo boy who has many strengths including strong visual-spatial skills and an affectionate temperament, and has difficulties in social communication, expressive/receptive language, and behavioural flexibility.
• Autism Spectrum Disorder (ASD), Level 2 (requiring substantial support), with accompanying language impairment. Differential includes Global Developmental Delay (GDD) and ADHD.

Plan

• Refer to Ontario Autism Program (OAP) for core clinical services (ABA/IBI). Refer to occupational therapy for sensory processing and fine motor skills. RTC in 6 mos for developmental follow-up.
• Recommend continued speech-language pathology (SLP) therapy focusing on functional communication and pragmatic language. School team to update IEP with ASD identification.
• Advised parents to utilize visual schedules at home to aid transitions, limit milk intake to < 400 mL/day to improve appetite for iron-rich foods, and continue melatonin 3 mg PO QHS with consistent bedtime routine. Provided Autism Canada resources.