Pediatric Primary Care Case Studies (12 page)

Educational Plan

One month later Ms. Jones telephones your office to ask what caused James’s autism. She is particularly concerned about the vaccines both boys received and whether they should continue to receive any additional vaccines. She heard on the news that some vaccines can cause autism. She wonders if Peter may be at risk as well.

How do you respond to her questions?

You inform Ms. Jones that the latest research has not shown a causal relationship between any of the routine childhood vaccines and autism. On the contrary, not vaccinating children places them at higher risk for developing complications secondary to diseases such as rubella, a known cause of autism.

It is most important to monitor the development of younger siblings of autistic children. The incidence of autism in monozygotic twins is 60%, while dizygotic twins and other siblings have a 5–6% risk of recurrence of autism (Bailey, Le Courteur, & Gottesman, 1995; Muhle et al., 2004). Although Peter shows no developmental delays at 18 months of age, he should be screened specifically for autism at 24 months of age. Some children will demonstrate a regression of developmental milestones between 18 and 24 months of age, so you will want to monitor Peter’s development carefully during the next year.

What additional information do you want to give James’s mother at this time?

Because caretakers of children with ASDs are frequently desperate to pursue any intervention that offers hope for improved outcome, it is imperative that providers educate them about unsubstantiated and ineffective therapies. These include sensory integration therapy, auditory integration training, behavioral optometry, craniosacral manipulation, dolphin-assisted therapy, music therapy, and facilitated communication. Likewise, there is as yet insufficient scientific evidence to support the use of biologic therapies such as restrictive diets, chelation therapy, gastrointestinal treatments, and dietary supplementation regimens (Barbaresi et al., 2006). Such ineffective therapeutic approaches offer false hope and may place unnecessary financial burdens on families.

Pharmacologic regimens may be indicated to alleviate disruptive behaviors such as aggression, self-injurious behaviors, sleep disturbance, and mood lability. Practitioners may consider a therapeutic trial of medication in the case of maladaptive behaviors not amenable to behavioral therapy. The U.S. Food and Drug Administration has approved risperidone (Myers et al., 2007; Shea et al.,
2004) for the symptomatic treatment of aggressive and self-injurious behaviors in children with ASDs.

Rearing children with ASDs generates significant stress in families. The primary care provider can provide key support to the family through education and anticipatory guidance, and by serving as an advocate for the child. In some cases, referring family members for appropriate mental health services may be indicated. Longitudinal support can be accomplished by maintaining contact with the family through periodic health maintenance visits.

Expected Outcomes

What is the long-term outlook for children diagnosed early with ASD?

A diagnosis of ASD is usually confirmed with clear behavioral indicators by 2 to 4 years of age. The earlier the diagnosis is made, the better the long-term outcome, assuming the child is placed in an early intervention program tailored to meet the needs of children with ASDs.

Key Points from the Case

1. All children should be screened for development at well child visits, with special attention given at the 9-month, 18-month, and 30-month visits (AAP, 2006).

2. Survey all children at every well child visit for early subtle signs of ASD, especially younger siblings of a child already diagnosed with an ASD.

3. Screen specifically for ASD at 18 and 24 months of age, consistently using at least one standardized screening tool.

4. If screening results are negative but concerns by parents or the clinician persist, schedule an early targeted visit to reassess the child.

5. Take action if the results of a screening test are positive or if the child demonstrates two or more risk factors. Rather than adopting a “wait-and-see” approach, refer the child for a comprehensive ASD evaluation, an audiologic evaluation, and an early intervention program in a timely manner.

6. Maintain a supportive, coordinating role as the primary care provider for the family with an autistic spectrum disordered child.

(See additional resources in
Box 3-2
.)

Box 3–2   Autism Resources for Providers

Journals:

Choueiri, R., & Bridgemohan, C. (2005). To make the biggest difference, screen early for autistic spectrum disorders.
Contemporary Pediatrics, 22
, 54–67.

Johnson, C. P. (2008). Recognition of autism before age 2 years.
Pediatrics in Review, 2
, 86–96.

Mauk, J. E., Reber, M., & Batshaw, M. L. (2007). Autism and other pervasive developmental disorders. In M. L. Batshaw (Ed.),
Children with disabilities
(5th ed., Chapter 21). Baltimore: Brooks.

Zwaigenbaum, L., Bryson, S., Rogers, T., Roberts, W., Brian, J., Szatmari, P. (2005). Behavioral manifestations of autism in the first year of life.
International Journal of Developmental Neuroscience, 23
, 143–152. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/15749241

Internet Resources:

Autistic Spectrum Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment
, California Department of Developmental Services:
http://www.ddhealthinfo.org/documents/ASD_Best_Practice.pdf

Autistic Spectrum Disorders (Pervasive Developmental Disorders)
, National Institute of Mental Health:
http://www.nimh.nih.gov/health/publications/autism/summary.shtml

First Signs, a
Web site dedicated to the early identification and intervention of children with developmental delays and disorders. This site also contains an ASD video glossary that clinicians can access to view video recordings of diagnostic signs demonstrated by autistic children:
http://www.firstsigns.org

Learn the signs. Act early
, Centers for Disease Control and Prevention:
http://www.cdc.gov/ncbddd/autism/actearly/

REFERENCES

American Academy of Pediatrics Council on Children with Disabilities. (2006). Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening.
Pediatrics, 118
, 405–420. Retrieved March 2, 2009, from
http://pediatrics.aappublications.org/cgi/content/full/118/1/405

American Psychiatric Association. (2000).
DSM-IV-TR diagnostic criteria for the pervasive developmental disorders
. Retrieved November 23, 2008, from
http://www.CDC.gov/ncbddd/autism/overview_diagnostic_criteria.htm

Autism and Developmental Disabilities Monitoring Network Surveillance Year 2000 Principal Investigators. (2007). Prevalence of autism spectrum disorders—autism and developmental disabilities monitoring network, six states, United States, 2000.
Morbidity and Mortality Weekly Report
, 56(SSO1), 1–11.

Bailey, A., Le Courteur A., & Gottesman, I. (1995). Autism as a strongly genetic disorder: Evidence from a British twin study.
Psychological Medicine, 25
, 63–77.

Baird, G., Charman, T., Baron-Cohen, S., Cox, A., Swettenham, J., Wheelwright, S., et al. (2000). A screening instrument for autism at 18 months of age: A 6-year follow-up study.
Journal of the American Academy of Child and Adolescent Psychiatry, 39
, 694–702.

Barbaresi, W., Katusic, S., & Voight, R. (2006). Autism: A review of the state of the science for pediatric primary health care clinicians.
Archives of Pediatric and Adolescent Medicine, 160
, 1167–1175.

Filipek, P., Accardo, P. J., Ashwal, S., Baranek, G. T., Cook, E. H., Dawson, G., et al. (2000). Practice parameter: Screening and diagnosis of autism.
Neurology, 55
, 468–479.

Muhle, R., Trentacoste, S., & Rapin, I. (2004). The genetics of autism.
Pediatrics, 113
, 472–486.

Myers, S. M., & Johnson, C. P. (2007). Management of children with autistic spectrum disorders. AAP Council on Children with Disabilities.
Pediatrics, 120
, 1162–1182.

Robins, D. I., Fein, D., Barton, M. I., & Green, J. A. (2001). The modified checklist for autism in toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders.
Journal of Autism and Developmental Disorders, 31
(2), 149–151.

Schopler, E., Reichler, R. J., DeVellis, R. F., & Daly, K. (1980). Toward objective classification of childhood autism: Childhood Autism Rating Scale (CARS).
Journal of Autism and Developmental Disorders, 10
, 91–103.

Shea, S., Turgay, A., Carroll, A., Schultz, M., Orlik, H., Smith, I., et al, (2004). Risperidone in the treatment of disruptive behavioral symptoms in children with autistic and other pervasive developmental disorders.
Pediatrics, 114
(5), e634–e641.

Siegel, B. (2004a). Early screening for autism using the PDDST-II.
AAP Society for Developmental and Behavioral Pediatrics News, 13
, 4.

Siegel, B. (2004b).
Pervasive Developmental Disorders Screening Test-II (PDDST-II): Early Childhood Screeners for Autistic Spectrum Disorders
. San Antonio, TX: Harcourt Assessment.

Chapter 4

A School-Age Child with School Failure Problems