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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).
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
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
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.)
