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social interactions. Even when he attempted to, he ended up in emotionally challenging situations where he made other people uncomfortable. For further evaluation and educational support, he was referred for assessment for eligibility for an individualized education program (IEP). He was evaluated by his school district’s autism support team. It was found that he was ineligible to receive educational services as a student with
Due to the patient’s behavioral and social communication concerns, his mother wanted to revisit the diagnosis. The patient was admitted to the psychiatric hospital for one week in April 2017 for displaying physical violence towards his hospitalization. He received a provisional diagnosis of ASD and disruptive mood dysregulation disorder. The diagnostic recommended at the time of his discharge.
Psychological evaluation was conducted to obtain further insight into his behavioral and social emotional functioning. Autism Diagnostic Observation Schedule - Second Edition (ADOS-2) and Social Responsiveness Scale - Second Edition (SRS-2) were used for his assessment. His ADOS-2 score indicated a moderate level of autism spectrum-related symptoms. His spoken language had the majority
of sentences used in correct fashion,
with complex speech. His speech was characterized by little variation in pitch and tone and loud volume at times. He did not use echolalia or stereotyped words
or phrases. In terms of reciprocal social interaction, he directed appropriate facial expressions to questions to communicate affect. However, his use of eye contact was poorly coordinated with speech. Most of his social overtures were related to his interests and were less frequent than in typically developing peers; his responsiveness to most social contacts was awkward or limited. He did not
demonstrate any unusual sensory interests or sensory-seeking behaviors during
that evaluation. He did not display any
body mannerisms or movements. He demonstrated excessive interest in the Titanic the ship and its route.
SRS-2 for school age was completed by the patient’s mother and teacher. The patient’s SRS-2 score indicated clinically behavior that lead to severe interference in everyday social interactions. Scores in this range are usually associated with a clinical diagnosis of ASD.
The psychological evaluation results indicated that the patient met the criteria for a diagnosis of ASD due to persistent social interaction as well as restricted
and repetitive patterns of behaviors and interests, with level 1 in severity. He was also found to meet criteria for intermittent explosive disorder. His behavioral outbursts and failure to control aggressive impulses were grossly out of proportion to any precipitating stressors or provocation.
During his stay at the residential facility, the patient was closely monitored by the staff members. It was noticed that he had and expressing himself. He was found disruptive in the classroom and on the etiquette of conversation, as he would speak out of turn. He was often seen walking out of his classroom without permission of his teachers and was
found sleeping in the hallways. Efforts
to prompt him to return to class would often result in verbal and physical acts of aggression and self-harming behaviors. He avoided participation in group therapy and play activities. His social interaction with his peers was limited. However,
he was observed to more readily and
appropriately interact with peers also diagnosed with developmental disorders. He was observed to frequently make
an effort to initiate communication appropriately with adults, although efforts were observed to be awkward and stilted with regard to his ability to select appropriate topics of conversation and utilize appropriate facial and other non-verbal expressions. His attachments to staff members were developmentally immature but present. There were no observed RRIBs, including for interest in the Titanic as mentioned earlier. He displayed episodes of severe aggression, with banging of his head and property destruction.
The center’s multidisciplinary treatment team suggested that his anger outbursts, violence, and self-injurious behavior were precipitated by his lack of communication skills. Staff and clinicians observed very few to no stereotyped behaviors. Based on psychological test results of SRS-2 and ADOS-2 and his clinical presentation,
the team revised the treatment approach. The patient was assigned short-term behavioral goals along with medications and behavioral interventions. See Table 1 for the list of his medications and behavioral plan.
After being engaged in therapy and
patient’s targeted symptoms improved in the areas detailed in Table 2.
DISCUSSION
The patient does not meet the full criteria for ASD. Stereotypies were minimal. Interests seemed age-appropriate and varied. Reciprocity in relationships
was not consistent but still substantial. For example, during his assessment,
he took an interest in the examiner and asked her about her experiences. The patient was able to comprehend the gist
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Del Med J | March/April 2019 | Vol. 91 | No. 2
