Answer with minimum 2 paragraphs each the following questions based in the bellow clinical case:
1. What is the behavioral approach if you have a child (patient) that present with autism or ASD? Explain
2. What type of special diets you can recommend, or there is any research supporting a special type of diet?
3. What type of resources you can offer to the parents in term of programs at school or what kind papers you can offer to them, so they can have a better experience?
CC (chief complaint): The child has problems with communication in social gatherings and at home and does not enjoy the company of others.
HPI: Patient 11 is a 9-year-old male Caucasian American child brought into the hospital on the seventh day of December 2022 for psychiatric assessment from 8:00 AM. The mother has been worrying over her child’s inability to communicate at home and in other social spaces. Further, she states that she has noticed her child’s unusually easily irritable state in the past months but has not been worrying as much about it, stating that it is what children are like sometimes. She adds that her son does not enjoy the company of others, even at school, and she thinks that it may be why he is not doing well in class.
Substance Current Use: The client denies using illicit hard drugs like marijuana. No alcohol or tobacco abuse.
Medical History:
• Current Medications: Daily multivitamin supplements once daily orally.
• Allergies: no known food, drug, or environmental allergies noted.
• Reproductive Hx: No history of sexually transmitted diseases. He has not fathered a child.
ROS:
• GENERAL: denies weight changes and chronic pains. Sometimes feels fatigued
• HEENT: No eye pain or conjunctivitis; swallowing is okay. Denies sore throat. Denies any alterations in head physiology. No changes in the sense of taste.
• SKIN: Denies skin redness. Denies alopecia.
• CARDIOVASCULAR: Denies murmurs, arrhythmias, and lower limb edema.
• RESPIRATORY: Denies chest pressure, congestion, cough, hemoptysis, and wheezing.
• GASTROINTESTINAL: Denies bloating and constipation or GERD. Denies nausea, vomiting, or abdominal pain.
• GENITOURINARY: Denies dribbling of the bladder and itching.
• NEUROLOGICAL: Denies visual changes, muscle loss, changes in reflexes, and no balance problems.
• MUSCULOSKELETAL: Denies numbness or tingling and muscle or joint strength loss.
• HEMATOLOGIC: Denies easy bruising.
• LYMPHATICS: Denies neck, axillary or inguinal swelling or lymphadenopathy
• ENDOCRINOLOGIC: Denies known endocrine disorders.
Objective:
Physical exam:
Vital Signs: B.P.: 118/78, Pulse:94, RR: 20, non-labored, Temp: 36.0, BMI: 19.1
General: Alert and oriented, pleasant and cooperative. Not in any acute distress.
HEENT: No head or neck anatomical disruptions. No redness of the tympanic membrane on otoscopic examination. Moist throat. No cervical lymphadenopathy. No cobblestoning pattern of the oropharynx.
Chest/Lungs: Expansion of both lungs is equal. No chest congestion or pressure. Lung and voice sounds are present and equal in all auscultated lobes, and lung fields are clear.
Heart/Peripheral Vascular: Regular rate and rhythm noted. No lower limb edema. No murmurs. No palpitations at time of interview. The internal jugular vein is not distended.
Gastrointestinal: Purcussed regions of the abdomen are tympanic. No abdominal mass was noted or palpated. Normal bowel sounds in all four quadrants of the abdomen.
Genital/Rectal: Continent bladder and bowel.
Endocrinologic: No increased perspiration.
Skin: No tenting.
Lymphatics: No lymphadenopathy.
Diagnostic results:
• Childhood Autism Rating Scale: this is an observational ranking used in assessing additional ASD manifestations through a caregiver/parent interview, professional observation of the child’s behavior, a case-narrative examination, or a blend of these elements. It comprises 15 items designed to adequately differentiate features of autism spectrum disorder from those of developmental delays without autism (Moulton et al., 2019).
• Social Phobia and Anxiety Inventory for Children (SPAIC): evaluates cognitive and behavioral aspects of social phobia. This tool is intended for individuals in late childhood and early adolescence (between the age of 8 and 14). It comprises 26 items scored on a three-point Likert scale ranging from 0-52 and a cut-off at 18 points, indicating probable social anxiety disorder (Bunnell et al., 2015).
1. CARS scores – 48 – severe autism.
2. SPAIC – 28 – increased likelihood of social phobia or social anxiety disorder.
Assessment:
Mental Status Examination: the client is a 9-year-old well-groomed for the weather and event. His speech was clear and appeared focused on the topic of the interview. He maintains eye contact but wanders most often throughout the interview. Generally, he is relaxed throughout the discussion. Affect is suitable for the topic of dialogue. He rejects experiencing any visual or auditory hallucinations. Intact and judgment are grossly intact and readily appreciated.
Differential Diagnoses:
1. Autism Spectrum Disorder – is a neurodevelopmental health condition marked by deficiencies in contact (initiating or reciprocating) that can occur in different situations and impairments in social restriction (Soto et al., 2016). The child may also demonstrate little interest in engaging others in their play and often want to play alone.
2. Social phobia – persons with social anxiety often have difficulties encountering or engaging with others. They also have a finite number of companions and evade circumstances where they may be the center of concentration. This is a probable diagnosis since the child does not engage actively with peers and has academic challenges (Colonnesi et al., 2016). This may be caused by inadequate class participation from fear of embarrassment when mistakes occur.
3. Social Communication Disorder – pragmatic communication disorder is marked by difficulties in verbal and non-verbal communication patterns demonstrated by impairments in the capacity to transform communication to correspond to various contexts, using communication for social purposes, or challenges following rules of conversation. These elements may result in functional limitations in contexts that require exceeded capacities in communication, according to the American Psychiatric Association (American Psychiatric Association, 2013).
The primary diagnosis for the client is ASD which presents at any age of the child’s developmental period. Challenges in social interaction and poor communication mark it. Further, associated behavioral concerns, such as irritation and impulsivity, may cause maladaptive behaviors. A pragmatic communication disorder may be ruled out since it is a condition that is often noted earlier in the developmental period. Children should possess satisfactory vocabulary and speech capabilities by five years to allow the diagnosis. The longer time taken by the manifesting symptoms would mean otherwise.
Looking back at the evaluation I did for this patient; I realize that I should have followed the patient’s lead by allowing him to talk until he ran out. I assumed he had most likely gotten done speaking after the occasional long silence, which was not the case. Allowing and encouraging the patient to complete their speech helps acquire all the necessary information to diagnose correctly.
Case Formulation and Treatment Plan
1. Psychotherapy – Applied Behavioral Analysis is a valuable behavioral treatment method in improving the self-care, contact, and play dexterities of kids with ASD to manage their behaviors. It may also reduce other co-occurring behaviors, such as irritability and impulsivity, and limit the occurrence of aggression.
2. Pharmacology – Risperidone (an initial 0.25mg P.O. QDS) for managing impulsivity and irritability, thus reducing the core signs of ASD. The dose will be titrated every two weeks to the maximum dose.
3. Health Promotion – Promoting physical activity in the client. Patients with ASD have low levels of physical activity. Promoting exercise, regardless of the type, improves executive functions and self-management (Lydell et al., 2022).
4. Patient education – should involve information on drug prescription and administration to prevent medication errors.
5. Social Determinant of Health – community understanding of ASD will be vital to improving client support through treatment, thus improving patient outcomes of health and life.
