CASE: A 7½-year-old boy is brought to a new primary care pediatrician because his grandparents, who have legal custody, want a “fresh look” at his behavior. Ian's grandmother begins the history with the comment, “He started out kind of rough.” He was exposed to methamphetamine and marijuana throughout gestation and his mother had bipolar disease and hypertension. A Cesarean section for failure to progress was followed by normal Apgar scores and an unremarkable neonatal course. Ian's parents physically fought during the first 6 months of his life; at that time, the parents separated and the grandparents assumed care.
Ian was expelled from three preschools due to physical aggression directed at other children. He also found it difficult to separate from his grandmother. In first grade, Ian often ran out of the classroom and was verbally, and at one time, physically abuse to his teacher. When he was expelled from school, the grandparents decided to home school Ian. Ian learned to read about 100 words and his spelling improved. Currently, Ian is in the first grade in a class of 10 children with behavioral problems; Ian has his own aid to insure his safety while in school. His teacher reports frequent fidgety behavior, difficulty sitting in his seat or at circle time, and trouble focusing on learning tasks.
While his grandparents describe Ian as a “sweet and happy” child at home, they are concerned with repetitive behaviors (e.g., frequent flushing of the toilet because he worried that it is broken and brushing his teeth over 10 times each day), fear of leaving the house, and insisting on order to certain things such as his toys and having a “meltdown” when they are not in order. Severe tantrums are limited to once each month.
A receptive and expressive language disorder was diagnosed at 4-years old followed by speech therapy and a social skills-language group program. A few months before the current pediatric visit, Ian had psychoeducational testing: The Wechsler Intelligence Scale-IV revealed verbal intelligence quotient (IQ) of 75 and a performance IQ of 108 with a full scale score of 81. The Gilliam Autism Rating Scale-2 indicated a probability of autism with significant scores in stereotype behavior, communication, and social interactions.
During the physical examination, he constantly moved while in chair and required frequent redirection and refocusing on many tasks. Eye contact was appropriate, but he often used words out of context with scripted references to videos at home. Foul language was used both randomly and directed to the examiner. After saying, “here comes the bitch,” he apologized. Ian demonstrated appropriate joint attention and reciprocal play without over-focusing on a single toy. Growth measurements were at the 95th percentile. Physical and neurological examinations were normal with the exception of mild asymmetry of auricle size and slightly abducted auricles in association with mildly small palpebral fissures.
Amy Drahota, Ph.D., Department of Psychiatry, University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA.
Denise A. Chavira, Ph.D., University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA.
Martin T. Stein, M.D., University of California San Diego, Rady Children's Hospital San Diego, San Diego, CA.