CASE: Elisa is a 6 ½-year-old white female who has a follow-up appointment in the Developmental Clinic where she is seen for autism, developmental delay, and significant behavioral problems. Her grandparents, who are her legal guardians, request an opinion on a proposed surgery for developmental dysplasia of the hip that will require several months in a whole body cast. Reconstruction of the hip was recommended by 2 pediatric orthopedic surgeons to prevent later disability and pain.
Elisa was born following a 41-week gestation. She sat without support at 7 months, but she did not walk until 23 months of age. An evaluation at the Developmental Clinic at 28 months of age documented gross and fine motor delays, cognitive impairment, and autism. A karyotype, fragile X, and microarray were normal. Elisa has a brother with autism and a maternal cousin with mental retardation. After her mother's death from meningitis 2 years ago, her maternal grandparents became her legal guardian.
Behavior problems include significant hyperactivity, impulsivity, and aggressive behaviors. She seldom sits still. She also has frequent stereotypies, such as jumping and arm flapping when she is excited or upset. Methylphenidate was associated with increased hyperactivity and irritability.
Physical examination demonstrates that she can walk with a very wide gait and swings her right foot out. A magnetic resonance imaging of her brain, acoustic brain response audiometry, and metabolic studies are normal. Other medical issues include gastroesophageal reflux, recurrent pneumonia, and ear infections. Radiographs of the hip reveal a steep acetabulum and a hip that easily dislocates. A magnetic resonance imaging of the hip shows early formation of a pseudoarthrosis. Her grandparents and pediatrician are concerned about managing her behavior after the surgery when she will be in a body cast.