Autism Spectrum Disorder

Question 1

Case 1: A 2 year old child presents with no speech. He is obsessed with Thomas the Tank engine and is distressed by change in routine. How would you assess and manage this child?

Case 2: A 2 year old brought to GP, as mother is concerned that she engages poorly with other children and only says 3 words. She is very fixated on the spinning car, does not respond to name or point to objects of interest, her gross motor skills are age appropriate and she has had a normal hearing test

Case 3: A 7 year old boy is referred because of his antisocial and isolated behaviour at school, and non compliance at home. He has a history of “being different”, few friends, and poor attention except for spending most of his time pre occupied with his coin collection. His father is a computer expert and his mother is a maths teacher. The parents have difficulty communicating and are contemplating a trial separation. You are about to see the parents. What are the issues?

Answer 1

Impression
Autism spectrum disorder. Lifelong condition, neurologically and cognitively heterogeneous. Affects the way one communicates with others and interacts with their environment. DSM-5 characteristics for diagnosis include characteristics in 2 main domains;
- impaired social communication and interaction in multiple contexts
- restricted, repetitive patterns of behaviour, interest or activities

Ddx to consider in this setting:

• Other neurodevelopment disorder
• Global developmental delay/intellectual disability
• ADHD
• Conduct disorder
• Schizoid personality disorder
• other psychiatric disorders (depression, anxiety etc)

Would use an open-minded, non-judgemental and collaborative approach to my assessment of this patient.

Question 2

ASD - History

Answer 2

History

• sx: social and family communication impairments (can’t form friendships, etc), age of onset, fixation on particular tasks, restricted interests
• apply DSM-5 diagnostic criteria, may require additional consults
• Risk: fam history, obstetric complications, prenatal infections (no specific causes found)
• Systems review (for ?organic causes)

Question 3

ASD - Examination

Answer 3

Examination

• observe child in play, conversation
• anthropometric measurements
• dysmorphic features (suggestive of intellectual/physical disability - e.g. fragile X syndrome,

Question 4

ASD - Investigations

Answer 4

Investigation

• Formal vision/hearing/psychometric testing
• speech/language assessment
• genetic testing if indicated/suspicious
• can utilise diagnostic/grading tools as required

Question 5

ASD - Management

Answer 5

Management
Early intervention is important, thus early diagnosis critical for gaining access to services and treatment which can benefit the child.
Requires ongoing specialist input, MDT approach, regular review.

Social Mx:

• behavioural education interventions: emphasis on teaching skills associated with social interaction, listening, empathy, imitation, communication, play, etc
• family therapy/education

Biological Mx:
Prior to starting any medications, the target symptoms should be clearly defined as the treatment goal.
- inattention and hyperactivity: stimulants
- Depression/anxiety: SSRI’s, CBT
- repetitive behaviour: SSRIs
- aggression/agitation: atypical antipsychotic