“It is crucial to act on signs (...) instead of taking a ‘wait-and-see’ approach.” – Melanie Penner

Signs are not always obvious. Many children who seem to be developing without issue actually harbor hidden difficulties that only trained professionals can identify. The earlier these challenges are recognized, ...

Photo: @copyright Signs are not always obvious. Many children who seem to be developing without issue actually harbor hidden difficulties that only trained professionals can identify.

The earlier these challenges are recognized, the greater the chances the child will receive the support they need. To better understand this topic, we spoke with Dr. Melanie Penner, a developmental pediatrician and senior clinician scientist at Holland Bloorview Kids Rehabilitation Hospital in Toronto—one of Canada’s leading children’s diagnostic and treatment centres. Dr. Penner also leads the ECHO Autism program, which trains family doctors across Ontario to diagnose autism, thereby reducing wait times that can exceed a year at specialized centres.

In this interview, the specialist explains that warning signs go far beyond whether a child walks, talks, reads, or writes at the right age; they involve more subtle details, such as eye contact, gestures, or how they share interests with those around them. Dr. Penner also explains how to practically distinguish a “simple” language delay from signs of autism or attention-deficit/hyperactivity disorder (ADHD). This conversation also sheds light on why so many diagnoses are only made once children reach school age, and how the referral process currently works in Ontario.

For parents who do not yet have a diagnosis but feel that something might not be right, Dr. Penner’s message is clear: there is no need to wait. Free supports with no waitlists, such as SmartStart Hubs and preschool speech and language services, are available in every region across the province. Milénio Stadium: What are the early signs that parents should watch for, even when a child seems to be developing “normally”?

Melanie Penner. (DR) Melanie Penner: Many parents focus on whether their child does things, such as walk and talk, by the expected ages.

These are important reasons to seek out professional input if parents feel that their child is not meeting these milestones. However, some signs that a child is developing differently may be more subtle, such as their non-verbal communication (using eye contact, gestures, pointing, and facial expressions to communicate), sharing what they enjoy with parents and other children, and challenges with some parts of the sensory environment, such as certain fabrics or noises. In my clinic, I think beyond what a child should be doing by a particular age and ask questions like, “how much support does this child require to participate in daily activities at home, at daycare, at school, and in their community?

Does the child experience a lot of distress throughout their day? How hard is the parent working to allow their child to participate, and to minimize their child’s distress?” MS: In practice, how do you distinguish a language delay from a sign of something broader, such as ASD or ADHD?

MP: This is a question I frequently hear in my clinic! Many autistic children have delayed language, and some go on to have lifelong challenges with spoken communication.

In the case of autism, we also see broader challenges with how the child communicates beyond just their use of words. A child with a language delay who is not autistic will often use their non-verbal communication (eye contact, gestures, pointing, and facial expressions) to make sure that they are understood, whereas an autistic child is likely to also struggle with using non-verbal communication. Attention-deficit/hyperactivity disorder (ADHD) generally is not diagnosed until age four at the very earliest.

Language delay is not as common in ADHD as it is in autism. Notably, many children with ADHD have co-occurring learning challenges, which can include their language development and reading. If parents have concerns that their child with ADHD also has a learning challenge, they should ask the child’s school psychologist for an assessment.

MS: Why are so many children only diagnosed later in life, once they reach school age? MP: There are many factors that impact when a child receives a diagnosis. Academic and social demands increase with age, and some children are able to do well in preschool may experience more challenges as they enter their school years.

Sometimes, parents are worried about their child being identified with a developmental diagnosis and may avoid or delay the assessment. Unfortunately, this means that the child can miss out on important therapy opportunities that are most effective in the early years. Over the years, I have heard from many families that their doctor did not believe them when they mentioned that they saw something different about their child’s development.

For both families and professionals, it is important to act on signs that the child is developing differently, instead of taking a ‘wait-and-see’ approach. Finally, we know that wait times for developmental assessment can be long, which makes it even more important to act when a developmental condition is suspected. MS: What is the referral and diagnosis process in Ontario, and what are the current wait times?

MP: The first point of contact for parents looking to discuss their child’s development is their primary care provider (a family doctor or nurse practitioner). That clinician can either do an assessment themselves or refer to someone who can.

In Ontario, many different types of clinicians can diagnose autism (physicians, psychology professionals, nurse practitioners). Your child may be able to be seen by a clinician in the community for a diagnostic assessment, which can sometimes have a shorter wait time than a larger centre, where wait times are often a year or more. At Holland Bloorview, Canada’s hospital for kids with disabilities and developmental differences, I lead a program called ECHO Autism ( https://hollandbloorview.ca/services/programs-services/echo-autism ) where we train and support clinicians in the community to provide autism care so that children don’t need to wait many months to see a specialist.

Other conditions such as ADHD are very commonly diagnosed by a physician in the community. MS: What advice would you give to parents who are concerned about their child’s development but do not yet have a formal diagnosis? MP: There are so many ways to support your child’s development!

In Ontario, a great starting point is the Smart Start Hubs – each region has a hub that is the main intake point for families looking for developmental supports for their child. Preschool speech and language services are available in each region of Ontario and don’t require a diagnosis, and there are many similar services across Canada. I find that children also learn very effectively from other children, and enrolling your child in a daycare or going to a community-based group, such as EarlyON, is a great way to provide them with these opportunities.

At home, parents can do little things like building more language into their day (reading, singing, describing things on walks) and doing pretend play or other activities together. MB/MS The content on the Milénio Stadium website is automatically translated using Google Translate.