Patient Presentation
A 7-year-old male came to clinic for the first time to establish care and for his health supervision visit.
He moved to the community only 2 weeks ago. Although his mother has already contacted the school district, she needs some help in locating a private speech and language pathologist and other specialists for her son who has autism.
His autism was provisionally diagnosed at ~ 15 months of age and as he has grown older his clinical signs are consistent with this diagnosis.
He has problems making friends, has little social play and has some sterotypical motions/play and language. He is verbal but has problems with production, content and sustaining a conversation. He is very interested in science, but has a restricted range of interests and needs to follow routines.
He has been making progress in a separate special education classroom with integration into a regular classroom for art and music. He has received speech and language services in the classroom and at home. He has a current individualized education plan (IEP) that his mother is happy with.
He has also worked with a behavioral psychologist to improve his interactions with his family members and other children.
The past medical history includes an extensive and appropriate evaluation since his provisional diagnosis. He has not had seizures, or other behavioral problems that have required medication for control. He is otherwise well.
The pertinent physical exam shows a healthy male with normal growth parameters. He has restricted social and verbal interactions. He is able to follow the physician’s instructions and is fairly compliant with the examination.
The diagnosis of autism is confirmed by history, office observation and review of his medical records. The physician offers the mother several options for obtaining speech and language services, behavioral psychology services as well as other options in the community such as specialists in developmental disabilities, developmental play groups and general community family activities.
A social service referral is also offered to the mother.
Discussion
Autism is a social communication disorder of unknown cause that is usually diagnosed in infancy or early childhood. The prevalance is .05 – .15 % with males affected more frequently. The recurrance risk in a family in a subsequent child is 3-5%.
The cause is unknown but underlying brain disease may occasionally be identified including congenital infections, developmemtal brain abnormalities (i.e. microcephaly), metabolic diseases (i.e. phenylketonuria), acquired destructive disorders (i.e. herpes simplex, lead encephalopathy), tumor and some genetic disorders (i.e. tuberous sclerosis).
As most children with these brain diseases are not autistic, it is probably the location of the neuropathology that determines the development of autistic behaviors.
The American Psychiatric Association classifies Autistic Disorder with other similar disorders such as Pervasive Developmental Disorder, Childhood Disintegrative Disorder, Rett’s disorder and others.
The diagnostic criteria for Autistic Disorder are:
A. A total of 6 or more items are needed. At least two items items must be from group 1 and one each from groups 2 and 3:
- 1. A qualitative impairment in social interaction manifested by:
- Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
- Failure to develop peer relationships appropriate to developmental level
- A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
- Lack of social or emotional reciprocity
- 2. Aualitative impairments in communication as manifested by:
- Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
- In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
- Stereotyped and repetitive use of language or idiosyncratic language
- Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
- 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by:
- Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
- Apparently inflexible adherence to specific, nonfunctional routines or rituals
- Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)
- Persistent preoccupation with parts of objects
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:
- Social interaction
- Language as used in social communication
- Symbolic or imaginative play
C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder
As the underlying cause is not known at this time, treatment involves three main areas – educational/behavior management, medications and family support.
Education usually involves special education with a major focus on communication skills. Classrooms are often highly structured with much one-on-one instruction and consistent routines.
Behavior managment is similar with family routines, structured home environment and continued communication skills being emphasized by the family members. Social skills including basic life skills are also taught in the classroom and at home.
Many autistic children have behaviors which are disruptive. Positive reinforcements are used whenever possible and the management plan needs to be consistent between the child’s environments (i.e. school, home, workshop, other, etc.)
Sometimes medications are used for autistic children with other conditions such as seizures or attentional problems. Neuroleptics can be used for severe behavioral upset on a short-term basis.
Family support is very important. Families need to attend to all the members needs and wishes, which is often difficult to balance with the sometimes overwhelming needs of a child with autism. Social workers may provide direct emotional support and/or mental health needs to family members.
Learning Point
Community social services are a key component of helping children and families. Since each community has different social services available, it may be helpful for the family to have a consultation with a social worker or similar community agent.
The goal is to orient the family to the local educational services including the local and intermediate school districts and special educational services provided in the state. The social worker can also orient the family to services such as play groups, child care and parent support groups.
The social worker can also help arrange appointments for medical and ancillary services care such as speech and language therapy or behavioral therapy. Additionally the social worker may help the family with finances, transportation, respite care, legal and other family needs.
Questions for Further Discussion
1. If you are unfamiliar with the local community, how would you locate social services needed for a child with a disability?
2. What are the differences between Autism and Pervasive Developmental Disorder?
3. What are the child’s educational rights under Public Law 94-142, the Education of the Handicapped Act?
4. What should be included in the evaluation of a child for possible Autism?
Related Cases
- Disease
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Asperger’s Syndrome and Autism.
To view current news articles on this topic check Google News.
Parker S, Zuckerman B. Behavioral and Developmental Pediatrics; a handbook for primary care. Little Brown and Co. Boston, MA. 1995:75-77.
American Psychiatric Association. DSM-IV-TR.
Available from the Internet at http://www.behavenet.com/capsules/disorders/autistic.htm (rev. 2000, cited 6/13/05).
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
August 22, 2005
Pediatric Education 