Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

from 1 mg fast-release to 4 mg controlled-release in the few controlled studies for insomnia in youth with autism spectrum disorder. Minor Infections and Gastrointestinal Symptoms .  Young children with autism spectrum disorder have been reported to have a higher-than-expected incidence of upper respiratory infections and other minor infections. Gastrointes- tinal symptoms commonly found among children with autism spectrum disorder include excessive burping, constipation, and loose bowel movements. Also seen is an increased incidence of febrile seizures in children with autism spectrum disorder. Some children do not show temperature elevations with minor infectious illnesses and may not show the typical malaise of ill children. In other children, behavior problems and relatedness seem to improve noticeably during a minor illness, and in some, such changes are a clue to physical illness. Assessment Tools A standardized instrument that can be very helpful in eliciting comprehensive information regarding autism spectrum disor- der is the Autism Diagnostic Observation Schedule-Generic (ADOS-G). Brett was the first of two children born to middle-class parents both in their early 40s after difficult pregnancy, with an induced labor at 36 weeks due to fetal distress. As an infant, Brett was undemanding and relatively placid; he did not have colic, and motor development proceeded appropriately, but language devel- opment was delayed. Brett’s parents first became concerned about his development when he was 18 months of age and still not speak- ing; however, upon questioning, they noted that, in comparison to other toddlers in his play group, Brett had seemed less uninterested in social interaction and the social games with toddlers and adults. Stranger anxiety became marked at 18 months, much later com- pared to the other toddlers in his day care program. Brett would become extremely upset if his usual day care worker was not pres- ent and would tantrum until his mother took him home. Brett’s pediatrician initially reassured his parents that he was a “late talker”; however, when Brett was 24 months old he was referred for developmental evaluation. At 24 months, motor skills were age appropriate. His language and social development, however, was severely delayed, and he was noted to be resistant to changes in routine and unusually sensitive to aspects of the inanimate envi- ronment. Brett’s play skills were quite limited, and he played with toys in repetitive and idiosyncratic ways. His younger sister, now 12 months, was beginning to say a few words, and the family his- tory was negative for language and developmental disorders. A comprehensive medical evaluation revealed a normal EEG and CT scan; genetic screening and chromosome analysis were normal as well. Brett was diagnosed with autism spectrum disorder, and he was enrolled in a special education program in which he gradually began to speak. His speech was extremely literal and characterized by a monotonic voice quality and an occasional pronoun reversal. Brett often spoke and was able to make his needs known; however, his language was odd and the other tod- dlers did not play with him. Brett pursued mainly solo activities and remained quite isolated. By age 5 years, Brett was quite attached to his mother and often became separation anxious and

Differential Diagnosis Disorders to consider in the differential diagnosis of autism spectrum disorder include social (pragmatic) communication disorder, the newly described DSM-5 communication disor- der; schizophrenia with childhood onset; congenital deafness or severe hearing disorder; and psychosocial deprivation. It is also difficult to make the diagnosis of autism spectrum disorder because of its potentially overlapping symptoms with childhood schizophrenia, intellectual disability syndromes with behav- ioral symptoms, and language disorders. In view of the many concurrent problems often encountered in autism spectrum dis- order, Michael Rutter and Lionel Hersov suggested a stepwise approach to the differential diagnosis. Social (Pragmatic) communication disorder This disorder is characterized by difficulty in conforming to typical storytelling, understanding the rules of social com- munication through language, exemplified by a lack of con- ventional greeting others, taking turns in a conversation, and upset when she went out, exhibiting severe tantrums. Brett also had developed a number of self-stimulatory behaviors in which he engaged, such as waving his fingers in front of his eyes. His extreme sensitivity to change continued over the next few years. Intelligence testing revealed a full-scale IQ in the average range with relative weakness in the verbal subtests compared to the performance subtests. In the 4 th grade, Brett began to have seri- ous behavioral problems at school and at home. Brett was unable to complete his class work, would wander around the classroom, and would begin to tantrum when the teacher insisted that he sit in his seat. He would sometimes begin screaming so loudly that he had to be asked to leave the classroom. He would then become upset and throw all of his books off his desk in a rage, sometimes inadvertently hitting other students. It took him up to 2 hours to calm down. At home, Brett would fly into a tantrum if anyone touched his things, and he would become stubborn and belligerent when asked to do anything that he was not expecting. Brett’s tantrum behavior continued into middle school, and by the 8 th grade, when he was 13 years old, these behaviors became so severe that the school warned his parents that he was becom- ing unmanageable. Brett was evaluated by a child and adolescent psychiatrist who recommended a social skills group for him and prescribed risperidone, starting with 0.5 mg p.o. b.i.d. and titrat- ing up to 1.5 mg p.o. bid. At that dose, Brett’s tantrums were less frequent and less severe. Brett seemed calmer in general, and did not become physically out of control during tantrums. Brett continued in middle school in a combination of special educa- tion classes and regular classes. Brett’s social skills group was helpful in terms of teaching him how to approach peers in ways that would lead to less rejection. Brett had made some acquain- tances, and by the time he started high school, he had acquired two friends who would come to his home and play video games with him. Brett knew that he was different than the other stu- dents, but he had trouble articulating what was different about him. Brett continued in high school with a combination of spe- cial and regular education and had plans to attend a community college and live at home for the first year. (Adapted from a case by Fred Volkmar, M.D.)