Challenging Case: New-Onset Hallucinations and Developmental Regression in a Child with Autism Spectrum Disorder.

CASE: Nick is a 5-year-old boy who began displaying self-stimulating behaviors and decreased social interactions shortly before turning 3 years. At the age of 3.5 years, he was diagnosed with autism spectrum disorder by a local developmental-behavioral pediatrician. His parents recall that the physician described Nick to be "high functioning" and encouraged them to expect that he would attend college and live independently as an adult. Upon receiving the diagnosis, intervention was initiated using an applied behavioral analysis (ABA) approach. With this intervention, he demonstrated initial gains in the use of complex language and improved social interactions.Concerns regarding suspected psychosis emerged just before starting kindergarten when Nick began experiencing ego-dystonic visual and auditory hallucinations. Initially, Nick verbally responded to the hallucinations and vividly described what he was experiencing. Shortly after the onset of these hallucinations, Nick experienced a significant decrease in the frequency and complexity of his expressive language and became more withdrawn. Over time, his hallucinations intensified, and his parents became increasingly fearful for his safety. Various antipsychotic and mood-stabilizing medications, steroids, and immunotherapy have been trialed with limited improvement of his symptoms.An extensive medical evaluation yielded the following:1. Magnetic resonance imaging of the brain: dilated perivascular spaces.2. Urine organic acids: ketosis and increased lactic acid.3. Antinuclear antibody: minimally positive.4. Vitamin B12: elevated.All other studies, including lumbar puncture, electroencephalogram (awake and asleep), genetic studies (chromosomal microarray, fragile X testing, and whole exome sequencing), metabolic studies, inflammatory markers, and thyroid panel, were negative/normal.Nick is enrolled in a special education classroom within a school that utilizes an ABA-based approach for all students. As part of his educational programming, he receives 25 hours of ABA in a 1:1 setting, 2 hours of speech therapy, 3 hours of occupational therapy, 1 hour of physical therapy, and 30 minutes of music therapy weekly. Current concerns include significant head-banging and thrashing before falling asleep, hyperactivity, unsafe behaviors (e.g., banging on windows, climbing high to reach desired items), aggression toward caregivers, limited ability to complete self-care tasks (e.g., personal hygiene, toileting), significant decline in expressive language, and continued response to internal stimuli.Nick's parents now present to a multidisciplinary center seeking guidance regarding additional therapies/interventions to assist in management of his current developmental and behavioral challenges as well as information regarding his expected developmental trajectory as he reaches adulthood.

Supporting Development During Military Deployment and After April 2018.

CASE: Ryan is a 6-year-old child new to your primary care practice after relocating from out of state with his father and younger sister. Ryan's grandmother recently expressed concerns about Ryan's social skills and behavior. He was subsequently diagnosed by a developmental and behavioral pediatrician with autism spectrum disorder, global developmental delay, and attention deficit hyperactivity disorder. At your first visit with Ryan, his father provides the following history: When Ryan was 3 years old, he was living with his mother and infant sister while his father was serving his fourth tour of duty with the marines in Afghanistan. One night, while Ryan was sleeping in bed with his mother, she died suddenly from a pulmonary embolism. Ryan's father was then called home from Afghanistan to take care of the children.Ryan's father explains that this was his first time serving as a primary caregiver for any prolonged period. He felt overwhelmed and unprepared, both cognitively and emotionally, to return from a combat zone and assume full-time, single-parent responsibilities. Ryan's father admitted knowing little about child development and had not had sustained interactions with his own children because of frequent deployments. He did not appreciate the delays and atypicalities in Ryan's development until he moved back home with his own mother and she expressed concerns. Ryan's father had his own psychological, emotional, and physical challenges from participating in active combat, including chronic pain in his shoulder from multiple gunshot wounds. Despite moving back home to be close to his family, Ryan's father admits feeling isolated and reports that "no one knows what it feels like."How would you provide unique support to Ryan and his family? What treatment modalities are particularly important to emphasize?

International/Institutional Trauma in Developmental Pediatric Practice.

CASE: "Aabis" is a school-aged boy from a predominantly conservative Muslim nation who presented to a tertiary developmental-behavioral pediatric (DBP) clinic to seek "expert opinion" for significant social and learning difficulties in the context of a history of frequent falling and "clumsiness." He was seen by a psychiatrist in his home country, who ordered an electroencephalogram and "brain map" (both normal), and received occupational and physical therapies. Frequent tantrums and intense emotional reactions to minor events-revealed to be related to a history of repeated physical beatings from groups of his "friends"-prompted referral to the DBP clinic. When asked why he did not fight back, Aabis said that he did not want to lose his friends. He and his parents further explained that this kind of organized aggression is considered part of normative development in their country and that Aabis needed to "toughen up."Aabis was described by his parents as being very "sensitive" when others raised their voices, shivering when reprimanded and profusely apologizing for real and imagined mistakes. He bit his nails until they bled, washed his hands repetitively, and changed his clothes several times per day. On witnessing his parents arguing, Aabis threatened to harm himself with a decorative knife.The assessment presented with several procedural complications specifically the use of an interpreter and the cultural differences regarding many of the topics discussed. Aabis spoke very little English, and an interpreter was not available in person on the initial day of the assessment. Telephonic phone translation services were attempted, but there were concerns that Aabis would not feel comfortable with sharing his emotions over the phone with an unidentified individual. As feared, Aabis was resistant to discuss emotionally charged topics (e.g., feeling sad, being bullied, hearing or seeing things) and grew impatient and irritated with the phone interpreter. After some unsuccessful experimentation with a Google-based translation system (implemented at Aabi's request to help build comfort and rapport), a second telephonic interpreter was brought into the session, who Aabis later described to his parents as "mean." (Aabis clarified that the second interpreter had been brusque and insensitive to his tentative attempts to express his feelings, e.g., by telling him to "Speak up. Spit it out.")Toward the end of the interview, Aabis seemed to dissociate and insisted anxiously that he did not want to relay certain information without his parents present in the room. What would you do next in this situation?Details about this case, including name and age, have been altered to protect the child's identity.

Autism Spectrum Disorder and Avoidant/Restrictive Food Intake Disorder.

CASE: Kendra is a 4-year-old girl with autism spectrum disorder (ASD) who presents for follow-up of feeding problems to her pediatric clinician. She is an only child in a family where both parents are scientists. Feeding concerns date to infancy, when she was diagnosed with Gastroesophageal Reflux Disease (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, she 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 6 months because she became anxious and had tantrum prior to treatment groups.She was seen in another feeding program at 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.Her diet consisted of French fries, Ritz crackers, pretzels, and 32 ounces of soy formula daily. She had stopped accepting Cheerios and saltines 2 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, she resumed feeding therapy using a systematic desensitization approach with rewards. At the first session, she kissed and licked 2 new foods without gagging. Her mother appeared receptive to recommendations that included continuing the "food game" at home, replacing 1 ounce of soy formula by offering water each day, limiting between-meal grazing, and refusing specific feeding demands.Currently, her parents plan to discontinue feeding therapy with concerns that the treatment was "too harsh." Her father produces logs of her caloric and micronutrient intake as evidence that she did not replace missed formula with other foods and reports that she subsequently became more difficult to manage behaviorally. Her father now demands to see randomized controlled trials of feeding therapy approaches. Her weight is stable, but she has now limited her pretzel intake to a specific brand. How would you approach her continued care?