James Coplan

Early Language Development in Children Exposed to or Infected With Human Immunodeficiency Virus

Objectives. To compare language development in infants and young children with human immunodeficiency virus (HIV) infection to language development in children who had been exposed to HIV but were uninfected, and (among subjects with HIV infection) to compare language development with cognitive and neurologic status. Design. Prospective evaluation of language development in infected and in exposed but uninfected infants and young children. Setting. Pediatric Infectious Disease Clinic, State University of New York–Health Science Center at Syracuse. Subjects. Nine infants and young children infected with HIV and 69 seropositive but uninfected infants and children, age 6 weeks to 45 months. Results. Mean Early Language Milestone Scale, 2nd edition (ELM-2) Global Language scores were significantly lower for subjects with HIV infection, compared with uninfected subjects (89.3 vs 96.2, Mann–Whitney U test). The proportion of subjects scoring >2 SD below the mean on the ELM-2 on at least one occasion also was significantly greater for subjects with HIV infection, compared with uninfected subjects (4 of 9 infected subjects, but only 5 of 69 uninfected subjects; Fishers exact test). Seven of the 9 subjects with HIV infection manifested deterioration of language function. Four manifested unremitting deterioration; only 1 of these 4 demonstrated unequivocal abnormality on neurologic examination. Three subjects with HIV infection and language deterioration showed improvement in language almost immediately after the initiation of antiretroviral drug treatment. Magnetic resonance imaging or computed tomography of the brain were performed in 6 of 7 infected subjects with language deterioration, and findings were normal in all 6. ELM-2 Global Language scaled scores showed good agreement with the Bayley Mental Developmental Index or the McCarthy Global Cognitive Index (r = 0.70). Language deterioration, or improvement in language after initiation of drug therapy, coincided with or preceded changes in global cognitive function, at times by intervals of up to 12 months. Conclusions. Language deterioration occurs commonly in infants and young children with HIV infection, is seen frequently in the absence of abnormalities on neurologic examination or central nervous system imaging, and may precede evidence of deterioration in global cognitive ability. Periodic assessment of language development should be added to the developmental monitoring of infants and young children with HIV infection as a means of monitoring disease progression and the efficacy of drug treatment.

Modeling Clinical Outcome of Children With Autistic Spectrum Disorders

Objectives. Autistic spectrum disorders (ASD) have variable developmental outcomes, for reasons that are not entirely clear. The objective of this study was to test the clinical observation that initial developmental parameters (degree of atypicality and level of intelligence) are a major predictor of outcome in children with ASD and to develop a statistical method for modeling outcome on the basis of these parameters. Methods. A retrospective chart review was conducted of a child development program at a tertiary center for the evaluation of children with developmental disabilities. All children who had ASD, were seen by J.C. between July 1997 and December 2002, met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for autism or pervasive developmental disorder (referred to hereafter as ASD), had undergone at least 1 administration of the Childhood Autism Rating Scale (CARS), and had at least 1 determination of developmental quotient (DQ) or IQ (N = 91) were studied. The sample was 92.3% male and 80.2% white. Methods. The DSM-IV was used to confirm that each patient met criteria for a diagnosis of autism or pervasive developmental disorder. The CARS was used to quantify the severity of expression of ASD. Age at evaluation, CARS score, and DQ or IQ at each visit were extracted from the medical record. The 2 independent sample t test or the Mann-Whitney test was used for comparing CARS and age between 2 groups: first recorded DQ or IQ <0.70 (n = 58) versus first recorded DQ or IQ ≥0.70 (n = 33). Associations among CARS score, IQ or DQ, and age were examined using Pearson or Spearman correlation. A mixed-effect model was used for expressing the multivariate model. Length of follow-up (period) was calculated by subtracting age in months at initial evaluation from age in months at each follow-up evaluation. Therefore, at first evaluation, period = 0. Period was considered as a random effect because collection of repeated information from patients was not uniform. The predictive relationships among CARS, age at first evaluation, period, and DQ or IQ group (<0.70 and ≥0.70) were examined using a mixed-effects model. Variables that were expressed as percentage change between first and last measurements were analyzed using the t test or the Mann-Whitney test. Socioeconomic status was assessed using Hollingshead criteria. Results. All patients met DSM-IV criteria for ASD. Mean age at initial evaluation was 46.2 months (SD: 23.7; range: 20.0–167.3 months). Mean CARS score at initial evaluation was 36.1 (SD: 6.3; range: 21.5–48). Mean DQ or IQ at initial evaluation was 0.65 (SD: 0.20; range: 0.16–1.10). There was no significant difference in socioeconomic status between DQ/IQ groups. CARS scores among children with an initial DQ or IQ <0.70 showed no significant decrement with time. In contrast, CARS scores among children with an initial DQ or IQ ≥0.70 showed a significant decrement with time, which could be modeled by the formula CARS = 37.93 − [(0.12 × age in months at first visit) + (0.23 × period)]. The predicted CARS scores generated by this model correlated with the observed values (r = 0.71) and explained 50% of the variability in the CARS scores for this group. Conclusions. These data provide preliminary validation of a statistical model for clinical outcome of ASD on the basis of 3 parameters: age, degree of atypicality, and level of intelligence. This model, if replicated in a prospective, population-based sample that is controlled for treatment modalities, will enhance our ability to offer a prognosis for the child with ASD and will provide a benchmark against which to judge the putative benefits of various treatments for ASD. Our model may also be useful in etiologic and epidemiologic studies of ASD, because different causes of ASD are likely to follow different developmental trajectories along these 3 parameters.

The high-functioning autistic experience: birth to preteen years.

A retrospective chart review of 15 children with high-functioning autism was conducted for the years 1981 through 1992. The purpose of the study was to describe the experience of children with high-functioning autism from infancy through preadolescence. Chart data included clinic staff records, parent letters, academic program records, service records, and comments from the children themselves. The findings of this study support the proposition that children with autism who have an IQ above 70 follow a varied but improving course over time. All 15 children met the DSM-III-R criteria for autism when first evaluated. By middle elementary school, however, none of the children in this study met the DSM-III-R criteria for autism, although they continued to have various language disturbances, social skill deficits, and unique behavioral qualities.

Expressive language delay in a toddler.

CASE Shelly is a 20-month-old white female whose parents thought she was in excellent general health when she came to her pediatrician for a health supervision visit. A developmental survey consisting of focused questions revealed that Shelly spoke only occasionally with a vocabulary limited to five words. Although motor and social skills were age-appropriate, verbal expressions typically consisted of nonintelligable utterances and frequent pointing to objects. She occasionally chatters “as if she had her own language.” Shelly reportedly responds to directions appropriately, and she appears to hear normal human voices, music, and a telephone ring. Shelly has been in home day care since 10 months of age when her mother returned to work. With four other toddlers, she is cared for by a Spanish-speaking caretaker; her parents speak English at home. She is the only child in her family; her parents remarked that they each had a sibling whose early language acquisition was delayed but as adults did not seem language impaired. Shelly’s prenatal course was complicated by premature contractions treated from 30 weeks gestation with terbutaline. She was delivered at term by a spontaneous vaginal delivery without complications. Apgar scores were 8 at 1 minute and 9 at 5 minutes. On physical examination, Shelly appeared robust. Social and visual engagement occurred easily with her mother and the examiner. Growth parameters were at the 50th percentile. The examination was normal, including her tympanic membranes (normal appearance and compliance), palate, pharynx, facial structure, and neurological assessment. Gross and fine motor skills were documented at the 20to 24month level. She responded to commands given by her mother and the examiner. She was able to point to pictures of objects on request and correctly pointed to three body parts. When asked to “go get your shoes and sit down,” she completed the task after the second request. Throughout the interview and examination, Shelly did not say any specific words. However, she pointed to a toy and doll she wanted during a play situation.

Three Pitfalls in the Early Diagnosis of Mental Retardation

Correspondence to: James Coplan, M.D., Department of Pediatrics, State University of New York, Upstate Medical Center, 750 E. Adams Street, Syracuse, NY 13210. Received for publication July, 1981; revised August, 1981; and accepted September, 1981. Editors’ Note: This brief clinical editorial, written from the point of view of a consultant in the field of developmental disabilities, is aimed at raising the clinician’s index of suspicion for the diagnosis of mental retardation at an early age. One reviewer of the article felt that the counterpoint of each of the author’s three pitfalls needed to be considered: one, dull appearance does not rule out normality; two, delayed motor milestones do not equate with retardation; three, there may not be a lot to gain by intensive early evaluation for possible borderline retardation. The practicing clinician

Evaluation of the child with deafness or delayed speech

Key diagnostic features of deafness and partial hearing loss are reviewed, with respect to etiology, detection of hearing loss, language development, and management.