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“Different Is Nice, but It Sure Isn't Easy”: Differentiating the Spectrum of Autism from the Spectrum of Normalcy

Costello, Eileen MD; Blenner, Stephanie MD; Augustyn, Marilyn MD

Journal of Developmental & Behavioral Pediatrics: November-December 2010 - Volume 31 - Issue 9 - p 720-722
doi: 10.1097/DBP.0b013e3181fa6b17
Challenging Case

CASE: Brian is a 15-year-old boy who has been just changed to your practice because of a change in insurance plans. When taking the social history, his parents note that he has “the hardest time relating to other kids.” Sometimes he will be in the middle of a conversation with a friend and then discuss tangential topics. His father reports that Brian “…has always been an easy target. He has always been sort of bigger than other kids, but being bigger than other kids, he has a hard time standing up for himself.” He seems to expect to be picked on in any new social situation.

When Brian likes something, he really goes after it with a passion; for example, he is very interested in knowing all about the dynasties in China. His interests are dinosaurs and anime. He is described as “An all-or-nothing type kid” when it comes to his interests. If his father tries to explain to Brian why he would like something done in a particular way, Brian will explode, and at times, he has even tried to shove his father.

He does not really have any friends. His mother finds it hard knowing that Brian cannot make friends because he “is the sweetest kid you will ever meet.” Brian sometimes thinks he needs to master things right away. He is not very good at abstract thinking, and “he can't think outside of the box.” Eye contact has always been something that has been difficult for Brian as well. He can sit in front of the TV watching a show and repeat the entire series word for word.

His parents initially had concerns about Brian, when he was 3 or 4 years old. After a specialty evaluation, he was diagnosed with sensory integration disorder and attention-deficit hyperactivity disorder. He is currently starting the 10th grade this year.

Brian was born at 9 months, weighing 7 pounds 10 ounces. There were no complications. He was treated with stimulants for attention-deficit hyperactivity disorder in the past, and he is currently on a long-acting amphetamine with equivocal efficacy. The parents are primarily here to refill his medication, but you wonder about their understanding about Brian's condition and where to head next during this visit.

Eileen Costello, MD, Southern Jamaica Plain Health Center, Boston, Massachusetts.

Stephanie Blenner, MD, Division of Developmental and Behavioral Pediatrics, Boston University School of Medicine, Boston, Massachusetts.

Marilyn Augustyn, MD, Division of Developmental and Behavioral Pediatrics, Boston University School of Medicine, Boston, Massachusetts.

The next case is posted at for discussion on the Clinical Conversations blog.

© 2010 Lippincott Williams & Wilkins, Inc.