JANIE, 2½

Nonverbal; acts startled when other children come near her.

When Janie's mother phoned to make an appointment, she didn't hold back. "We're desperate," she said. "My husband and I honestly don't know what to do." A reputable pediatric neurologist had diagnosed their 2½-year-old daughter with both pervasive developmental disorder and a phobic aversion to being touched. Now the mother sat in my office crying because, in addition to the medical diagnoses, the preschool psychologist had informed her that Janie had autism and would never speak normally. "My husband isn't helping matters," she said, dabbing her eyes. "He says to stop worrying, that Janie will get by on her looks." I glanced at the child, whose round face was dominated by large, dark eyes and surrounded by a halo of softly waving hair. She was indeed pretty, but no child is pretty enough to be taught that looks are enough to get her through life.

I asked the mother if Janie had friends, and she replied that she had been making up excuses when other parents invited Janie over to play. "I can't bear to see her jump every time someone comes near her," she said. "It's easier if we just play together at home." This was good: Not all parents have the patience to play with their atypical kids. On the other hand, it is important for kids on the spectrum to play with other kids, especially neurotypical kids, so they can develop awareness of how human interactions work. I ushered the mother into the waiting room and joined Janie on the floor.

First impression: inconsistent responses; unintelligible speech. As we started playing with various toys and puzzles, Janie's responses followed no discernible pattern. I handed her a wooden puzzle, the kind with pieces that fit into matching recessed areas and have little pegs to make the pieces easy to manipulate. This one had different colored circles in increasing sizes. Janie would remove circles in no particular order, willy-nilly, sometimes replacing them in random slots and other times dropping them on the floor. When I asked her repeatedly which was the biggest circle, she looked at me blankly. I brought out a set of colorful plastic rings that sat on a spindled base from largest to smallest, dumped off the rings, and invited Janie to replace them on the spindle. She dropped the biggest one on first, then added the second-smallest ring, saw it didn't belong there, removed it, and replaced it with the second-biggest one. But when it was time to add the smallest one at the top, she walked away. During her second attempt, she put the second smallest ring on the spindle too early and was astute enough to remove it, but was unable to place it correctly when its time had come. It was as if she could see each ring individually but neither the relationship between them nor how they formed a tapering tower.

I pressed on. When I placed a shape-sorting toy in her lap, she just looked at it. Later, I saw her staring at a colorful ball. "Janie, what do you want? Do you want the ball?" I kept asking. She brought her lips together and mumbled something that sounded like "buh," sat, and waited. Next I placed a toy xylophone in front of her and handed her the mallet, which she used to hit the bars from left to right, largest to smallest, lowest pitch to highest, over and over again. She never altered the order in which she struck the bars; it was always the same. I tried placing my hand over hers and directing it toward the opposite end of the instrument but she resisted; she only wanted to strike the bars from left to right.

Then something struck me: when I touched Janie's hand she didn't flinch, but continued to play with my hand atop hers. In fact, we had touched numerous times as I handed her things, but not once had she seemed to notice the contact, let alone been disturbed by it. This was odd for someone who had been diagnosed with a phobic aversion to being touched. Janie seemed comfortable with me in my office; was there something about the day care environment or the other children that made her anxious? I decided to find out.

Janie at day care. With the blessing of Janie's mother and day care teacher, I settled into a small chair at the back of the playroom. Children were milling about, including Janie's younger brother. Everyone was occupied except Janie, who stood off to the side looking disoriented. She watched the other children playing but held herself apart. She sometimes followed the teacher's instructions, as when she invited the kids to converge at a table for snack. I asked Janie if I might have one of her goldfish crackers six or seven times before she responded and gave me one. Later, I asked if I might play with a stuffed pony she wasn't using but she didn't respond. She mimed pouring herself a...