The language and culture of delay

Case: Satish is a 3 1/2-year-old boy you are seeing in your primary care office for a "sick visit" due to parental concerns about his language development. He is the only child of a couple who immigrated to the United States from India shortly before his birth. He received early intervention services for speech and language delays for a few months before he attained 2 years of age. However, services were discontinued when the family moved back to India for a year. After the family returned to the United States, they lived in a different state for several months before moving again recently to his current home, so he is relatively new to your practice.Satish's mother is concerned not only about his communication skills but also about his attention and social skills. She notes that he often plays alone or in parallel with other children. She was also told by his first pediatrician that Satish had "a limited imagination." His parents feel that he has pretend play, in that he will pretend to get his haircut, talk on the phone, or ride on a train.Satish was born at term without complications. He passed his newborn hearing screen and a repeat hearing test at the age of 2 years. He has had no medical problems and takes a daily multivitamin. His parents are both of Indian descent. Satish's father is an engineer and had a history of being a late talker. His mother graduated from high school and is a homemaker. They are expecting their second child.Satish's developmental history is significant for language delays. He babbled at 6 months but did not have single words until he was 2 years. When he was 2 1/2 years, he had 2 to 3 word sentences. He responded to his name at 15 months and could follow single step commands by the age of 2 years. Currently, Satish is noted to have difficulty with "back and forth conversation." He sometimes repeats what others are saying.The family speaks Hindi, their native language, exclusively at home. When Satish speaks, he usually speaks in Hindi. His parents describe him as using "odd language" in that he will often mix up his pronouns. Satish is in an English-speaking preschool. His preschool teachers report concerns that he seems to "withdraw into his own world," and does not interact well with the other children. They also report attentional problems and poor eye contact.In the office, Satish makes good eye contact with the examiner and his parents. He looks to his parents for approval when completing a task requested of him. He seems to like an Elmo toy that is in the room but holds it and looks at it closely rather than pretend to do anything with it. You ask him to feed Elmo, and he says, "Feed Elmo." Because it is not clear whether he understands the verbal cues given to him, his parents repeat English directions to him in Hindi several times. He eventually complies but then leaves his chair to explore the room. His parents continue to translate your questions to him with variable results. He becomes increasingly difficult to engage, despite repeated attempts, in both English and Hindi, to attract his attention. Where do you go from here?