A two-year-old boy with language regression and unusual social interactions.

CASE Jimmy, a 2 1/2-year-old boy, was seen for the first time by a new pediatrician after a recent family move. His mother made the appointment for a health supervision visit although she had concerns about his language and social skills. She stated that he spoke primarily with unintelligible sounds and often communicated by pointing with his finger. He spoke only 10 words that were clear enough to be understood. Jimmy's mother said that he could hear, but she was not sure whether he understood everything she said. Although he played at home with his 4-year-old brother, he typically played by himself when he was in the presence of other children. Jimmy's mother was asked if he had had a 2-year-old visit to a pediatrician and what the assessment was at that time. She said that his delayed development was discussed with the pediatrician, but she was reassured that he would progress during the following year. An uncomplicated full-term gestation was followed by a vaginal delivery without perinatal problems. Jimmy was a "calm" baby who was breastfed for the first 6 months of life. He sat at 7 months, pulled himself up to stand with support at approximately 9 months, and walked at 13 months. Transitions were always difficult for Jimmy; he screamed and was difficult to settle whenever cared for by someone other than his parents. He typically resists physical contact when children or adults approach him. His mother recalled that language emerged early. He acquired a significant number of words between 12 and 15 months of age. Jimmy apparently recognized letters when his parents were teaching the older sibling. At 15 months, Jimmy's language output regressed dramatically, and by 18 months, he no longer used words to communicate. Since then, he has spoken fewer than 10 single words. He mostly babbles and uses repetitions of the same sounds. The pediatrician inquired into family structure and life events at the time Jimmy lost language milestones. He was told that, at this time, the father, an engineer, changed his position in the company and began to travel extensively. Jimmy's mother thought that the absence of his father might be related to the language regression. She also noted that Jimmy seemed to have a stronger attachment for his father: "Jimmy has always been attracted to his father, and his brother seems to prefer me." The parents' marriage was strong and free of any major disharmony. During the interview, the pediatrician noted that Jimmy played persistently with his set of small trains, repetitiously lining them up in order. He was not interested in other toys that were on the floor next to him. He ran around the trains, mostly on his toes, while making unintelligible sounds. He looked away when the pediatrician called his name and became agitated when his mother attempted to redirect his attention to the examination. The pediatrician, 4 years in practice after his residency, had never seen a child with Jimmy's pattern of development. That Jimmy's development was unusual in two domains was apparent to his pediatrician from the preceding information and brief observations. He asked himself what the next steps should be.