Challenging Case Blog

Viewpoints from the interdisciplinary leaders in optimal developmental and behavioral health for all children.

Tuesday, February 20, 2018

Aaron is an 11-year-old boy with Autism Spectrum Disorder (ASD), with cognitive and language skills in the above average range, whose parents have recently separated.  Aaron’s mother initiated the separation when she learned that Aaron’s father had maintained a relationship with a woman with whom he has a ten-year-old daughter.  When Aaron’s mother discovered this relationship, she demanded that Aaron’s father leave their home.

Aaron’s father has moved in with his long-term girlfriend and keeps in contact with Aaron by calling once a day.  Neither Aaron’s father nor mother has discussed the reason for their separation with Aaron.  So far, they have explained their separation by telling Aaron that they are “taking a break.” 

Aaron’s mother has been deeply hurt by Aaron’s father’s infidelity and does not want to reconcile with him. Aaron’s father recognizes this, but would like to continue to have a close relationship with his son.  He would also like Aaron to get to know his half-sister. 

Aaron’s mother seeks guidance regarding how to talk to Aaron about the separation and his father’s second family.  Given Aaron’s diagnosis of ASD she is particularly concerned about his ability to cope with this unexpected change in circumstances.  What is your advice?

Friday, January 12, 2018

Sonia is a 4 1/12-year-old girl with Waardenburg syndrome and bilateral sensorineural hearing loss who had bilateral cochlear implants at 2 7/12 years of age. She is referred to Developmental-Behavioral Pediatrics by her speech/language pathologist because of concerns that her language skills are not progressing as expected after the cochlear implant. At the time of the implant, she communicated using approximately 20 signs and 1 spoken word (mama). At the time of the evaluation (18 months after the implant) she had approximately 70 spoken words (English and Spanish) and innumerable signs that she used to communicate. She could follow 1-step directions in English but had more difficulty after 2-step directions.

Sonia was born in Puerto Rico at 40 weeks gestation after an uncomplicated pregnancy. She failed her newborn hearing test and was given hearing aids that did not seem to help

At age 2 years, Sonia, her mother, and younger sister moved to the United States where she was diagnosed with bilateral severe-to-profound hearing loss. Genetic testing led to a diagnosis of Waardenburg syndrome (group of genetic conditions that can cause hearing loss and changes in coloring [pigmentation] of the hair, skin, and eyes). She received bilateral cochlear implants 6 months later.

Sonia's mother is primarily Spanish-speaking and mostly communicates with her in Spanish or with gestures but has recently begun to learn American Sign Language (ASL). In a preschool program at a specialized school for the deaf, Sonia is learning both English and ASL. Sonia seems to prefer to use ASL to communicate.

Sonia receives speech and language therapy (SLT) 3 times per week (90 minutes total) individually in school and once per week within a group. She is also receiving outpatient SLT once per week. Therapy sessions are completed in English, with the aid of an ASL interpreter. Sonia's language scores remain low, with her receptive skills in the first percentile, and her expressive skills in the fifth percentile.

During her evaluation in DBP, an ASL interpreter was present, and the examiner is a fluent Spanish speaker. Testing was completed through a combination of English, Spanish, and ASL. Sonia seemed to prefer ASL to communicate, although she used some English words with errors of pronunciation. On the Beery Visual-Motor Integration Test, she obtained a standard score of 95. Parent and teacher rating scales were not significant for symptoms of attention-deficit/hyperactivity disorder.

What factors are contributing to her slow language acquisition and how would you modify her treatment plan?

Friday, September 8, 2017

Tuesday, September 6, 2016

Kendra is a 4-year-old girl with Autism Spectrum Disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. Kendra is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with GERD associated with persistent bottle refusal, and the acceptance of few pureed foods. At 13 months, milk and peanut allergies were diagnosed. Following a feeding clinic evaluation at 24 months, Kendra was prescribed a soy milk supplement and an H2 blocker. There was no concern for oral-motor dysfunction. She was also referred to Early Intervention for feeding therapy. However, her parents terminated participation after six months because she became anxious and tantrumed prior to treatment groups.


Kendra was seen in another feeding program at age 3 years;zinc, folate, thyroid, and a celiac panel were normal and an endoscopy was negative for eosinophilic esophagitis. She began individual feeding therapy, where concerns for rigidity, difficulty transitioning, and limited peer interactions led to a neuropsychological evaluation. Kendra was diagnosed with an ASD and Avoidant/Restrictive Food Intake Disorder (ARFID). Her cognitive skills were average, and expressive and receptive language skills were low average.


Kendra’s diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines two months prior. She controlled other aspects of feeding, insisting on a specific parking spot at a fast food restaurant and drinking from a particular sippy cup. Her parents accepted these demands with concern about her caloric intake, which they tracked daily.


Following diagnosis with ARFID, Kendra resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, Kendra kissed and licked two new foods without gagging. Her mother appeared receptive to recommendations that included continuing the “food game” at home, replacing one ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands. [does this describe elements of  the “food game”?]


Currently, Kendra’s parents plan to discontinue feeding therapy with concerns that the treatment was “too harsh.” Her father produces logs of Kendra’s caloric and micronutrient intake as evidence that Kendra did not replace missed formula with other foods, and reports that Kendra subsequently became more difficult to manage behaviorally. Kendra’s father now demands to see randomized-controlled trials of feeding therapy approaches. Kendra’s weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?


Monday, May 2, 2016

​A 5 year old non-verbal male with autism spectrum disorder (ASD) was admitted to
inpatient pediatrics with new onset agitation and self-injurious behavior. His parents described
him as a pleasant child without previous episodes of self-injury. Four days prior to admission,
the parents noted new irritability followed by two days of self-injury to the face without clear
precipitant. His hitting intensified with closed fist to face, and he required parental physical
restraint to prevent further injury. Car rides and ibuprofen provided only temporary relief. He
consumed minimal liquid and ate no solid food for two days. The parents denied any changes to
the environment or routine and denied recent travel, sick contacts, fevers, cough, otalgia,
vomiting, diarrhea, and constipation. The patient had been diagnosed with ASD at age eighteen
months old but had no other significant medical history.

On examination, the child was alert but distressed and restless, wearing padded mitts as
his parents attempted to calm him by pushing him in a stroller. He had multiple areas of severe
bruising and facial swelling in the right periorbital area, cheek, and jaw. The rest of the physical
exam was unremarkable. Laboratory results included a leukocytosis with left shift, a normal
metabolic panel, and an elevated creatinine kinase. Other investigations included a normal
lumber puncture, chest radiograph, head and face computerized tomography without contrast,
and brain magnetic resonance imaging. A dentist consultant examined him and noted an erupting
molar but no decay or abscesses. A psychiatric evaluation was requested as there was no clear
medical source for the patient’s distress.