Transcript Peds-Psych Conference

Peds-Psych Conference
Jennifer Gibson, PGY-2
Department of Pediatrics
October 11, 2010
Case Vignette
A three-year-old boy presents to the behavioral clinic with
parental chief complaint of delayed speech; the patient’s
pediatrician referred the child for concerns about physical
aggression after the patient reportedly hit the physician at a
well-child visit. The patient’s mother reports that the child has
approximately ten words in his vocabulary and usually
communicates with different cries. She has no concerns about
the patient’s relationship with herself or his younger sister and
reports the presence of affection towards other family
members. She denies any history of abnormal movements. The
patient also has a history of clubfoot which required one year
of casting of the left leg followed by surgery and another year
of bracing. The patient has never received speech and
language, occupational, or physical therapy.
Case Presentation

Language
– Mom does not recall at what age he said his first word
– Currently has ~10 words in his vocabulary (“Mama,” “kitty”);
does not put two words together
– Communicates by crying—mom has learned what his cries
mean; he does not grunt or point at what he wants
– Parents believe that he understands more than he can express
Case Presentation

Behaviors
– No history of hand wringing, flapping, spinning in circles
– Loves one plastic dinosaur—has carried it everywhere for 5 mos
– Mom denies physical aggression towards herself, dad, and
animals; patient does hit out at sister when she takes his toy
– Will watch the same movies over and over; stares at the screen as
though he is fascinated (his favorites are Cars and The Land
Before Time)
– Daily, the patient stares off into space without responding
Case Presentation

Social
– Will make eye contact for a second or two
– Does not babble responsively when someone speaks to him
– Gives hugs and kisses on his own—grabs the receiver by
the ears and pulls him/her to him for a kiss
Case Presentation

Physical/Gross Motor
– Born with a clubfoot
– Spent first year in a cast on the left from his foot to his hip
 Crawled
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at 9 months by dragging left extremity behind him
Had surgery at Shriners’ in Greenville, SC during first year
Spent second year in bilateral lower extremity braces
Walked at 2½ years
Never had physical therapy except during hospitalization in SC
Case Presentation

Nutrition
– Picky eater—will eat chicken, bacon, and potatoes
– Drinks 40+ ounces of milk per day, 18 ounces of juice per day
– Mom giving Carnation Instant Breakfast to increase calories
Watches television for most of the day
 Discipline

– Occasional timeouts; no spanking

Sleep
– Gets 12 hours of sleep per night and takes one 2-hour nap
– Falls asleep quickly and sleeps through the night
Case Presentation

Past Medical History
– Born at 34 weeks via spontaneous vaginal delivery
– Spent 2 weeks in the NICU
– History of maternal methadone use during the pregnancy;
mom denies any withdrawal symptoms during
hospitalization
– Jaundice requiring phototherapy for 5 days
– Since birth, hospitalized twice—once for dehydration, once
for surgical repair of the clubfoot
Case Presentation

Family History
– Mother with history of narcotic addiction following a car
accident; receiving methadone therapy for 8 years
– Mother also with history of anorexia and depression
– Father with history of congenital unilateral blindness,
hypertension, diabetes, and MI prior to age 50 years
– Older brother with history of abnormal balance and gait
Case Presentation

Social History
– Biological parents are in a relationship but unmarried
– Biological father lists a separate address but spends most of his
time at the biological mother’s home
– Biological father is currently disabled following an accident in
which he fell 20 feet—experienced multiple fractures
– Biological mother is a stay-at-home mom
– Lives with biological mother, two half-siblings, and a full
younger sister; has three half-siblings living outside the home
Case Presentation

Observations
–
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–
–
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No language heard during interview (2+ hours with patient)
Clutches a dinosaur toy in his hand but does not play with it
Does not look to mother for comfort
Does not make eye contact with mother or examiner
Crawls through and around examiners’ legs as if they are
furniture; sits at examiner’s feet and hits head on examiner’s knee
– Nearly crawls off exam table; when examiner picks him up and
speaks to him, he does not look at examiner or respond
Case Presentation

Physical Exam Abnormalities
– Weight <3rd percentile
– Testes non-palpable
– Abnormal gait and balance—does not fully bend knees when
walking (“Tin-Man walk”)
– Reflexes equal and appropriate
Diagnosis?
Autistic Spectrum Disorder
and
Gross Motor Delay
Autistic Spectrum

Range of neurodevelopmental disorders
– Includes autism, Asperger Syndrome, Rett Syndrome, childhood
disintegrative disorder, and Pervasive Developmental Disorder (PDD)

Etiology is unknown but strong genetic basis has been noted
– Siblings of an affected patient are more likely to show signs and
symptoms of autistic spectrum disorder


Prevalence of all disorders on the spectrum is around 58/10,000
Patients demonstrate impairment in language development or
communication skills, impairment in social interactions and
reciprocity, and stereotypical patterns of behavior, interests, and
activity.
DSM-IV
Diagnostic
Criteria
Screening Tools
Several screening tools have been developed to aid in
the diagnosis of autistic spectrum disorders
 CHAT (Checklist for Autism in Toddlers)

– Designed to be used at 18 months in the primary care setting
– Combines a brief parent interview with direct observations in
the clinic
– High positive predictive value but low sensitivity

M-CHAT (Modified Checklist for Autism in Toddlers)
– 23-item parent questionnaire
– Adapted from the CHAT
– Improved sensitivity and specificity
Appropriate
answers are
marked in red.
Critical
questions are
marked in blue.
An abnormal
screen is a child
who incorrectly
answers two or
more critical
items or three
of any of the
questions.
Screening Tools

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As the physician, use your judgment too!
What you see does matter!
If you have concerns about a child’s development, plan an
evaluation of some type.
– Even if the parents have no concerns.
Management

Intensive behavior therapy
– If possible, should begin prior to age 3 years
– Focus on speech and language development
Most effective when geared towards an individual’s
particular behavior patterns and language function
 Parent education, training, and support are crucial
 In our state, Tennessee Early Intervention is a great
resource for children younger than 3 years. Older
children will need referrals to area therapists.

Management

The patient presented will need speech therapy as
well as occupational therapy for fine motor
development and physical therapy for his gross
motor delay.
Iron Therapy in Autism

Iron is known to play an important role in the
development of the brain.
– Iron deficiency affects over 200 enzyme functions.


Because of abnormal eating habits (issues with food
textures or smells, lack of interest in red meats, excessive
milk intake), many autistic children demonstrate
nutritional deficiencies, including iron deficiency.
Ferritin levels are a commonly-used screening test for
depleted iron stores.
– Ferritin levels may increase with infection but are only
lowered by iron deficiency.
– “Normal” ferritin ranges are debated.
Iron Therapy in Autism

In 2002, Latif et al found that of 96 children with autistic
spectrum (52 with autism, 44 with Asperger Syndrome):
– 8 children demonstrated iron deficiency anemia (8%)
– 6 of the children were diagnosed with autism, 2 with
Asperger Syndrome

In 2006, Dosman et al found that of 96 children with
autistic spectrum disorder:
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–
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15 children demonstrated low ferritin levels (15%)
7/49 children ages 3-5 years had low ferritin (14%)
7/35 children ages 6-10 years had low ferritin (20%)
In both age groups, the percentage with low ferritin was more
than double that seen in the general population for the same
age range
Iron Therapy in Autism
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Ferritin levels are often (but not always) decreased in
patients who have been diagnosed with autistic spectrum.
Iron supplementation does effectively raise ferritin levels
and replenish iron stores.
Any patient who has a diagnosis of autistic spectrum
should have a serum ferritin level measured.
If levels are low, supplementation may lead to
improvement in the symptoms.
Conclusions

Autistic spectrum disorder is a fairly prevalent
neurodevelopmental diagnosis.

Children with autistic spectrum disorder typically
demonstrate delays in language and social skills as well as
stereotypical movements, behaviors, or interests.

Primary care providers of young children should ask about
development at every well-child visit and screen for autistic
spectrum with a parental questionnaire such as the M-CHAT.

Outcomes can be improved with early and targeted
speech/language therapy and behavioral interventions.

Iron deficiency may contribute to symptoms of autism; all
children with this diagnosis should be screened with a serum
ferritin and supplemented as necessary.
References
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Shah P, Dalton R, Boris N. Pervasive Developmental Disorders and
Childhood Psychosis. In: Kliegman R, Jenson H, Behrman R, Stanton
B eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, PA:
Elsevier; 2007:133-136.
American Psychiatric Association. Autistic Disorder. In: Diagnostic
and Statistical Manual of Mental Disorders. 4th ed. Arlington,
Virginia: American Psychiatric Publishing, Inc.; 2000:70-75.
M-CHAT Information Website:
http://www2.gsu.edu/~psydlr/Diana_L._Robins,_Ph.D..html
Latif A, Heinz P, Cook R. Iron deficiency in autism and Asperger
Syndrome. Autism. 2002:6:103:103-114.
Dosman C, Drmic I, Brian J, Senthilselvan A, Harford M, Smith R,
Roberts S. Ferritin as an indicator of suspected iron deficiency in
children with autism spectrum disorder: prevalence of low serum
ferritin concentration. Developmental Medicine and Child Neurology.
2006:48:1008-1009.