Mason's Autism Report for all who want to read it, we have no secrets here.
Reason for Referral:
Mason was referred by his speech-language therapist, for further assessment of possible autism spectrum disorder given concerns noted regarding his social language and play skills.
History of Concerns and Developmental Profile:
Mason lives in Surrey, BC with his parents, Dana and Nicolas, and his two brothers. Mason was born full-term weighing 7lbs, 10oz. He suffered from prolonged failure to thrive in his first year of life. He was in and out of hospital. There are no developmental or behavioural concerns for his brothers. Family history is positive for some concerns with attention and hyperactivity.
Developmentally, Mason receives early childhood intervention services through the Sources Infant Development programs. His infant development consultant is Ms.XXX. She has noted concerns with repetitive behaviours and destructive behaviours. He will repeat conversations and play with the same toys repeatedly. There are concerns about a lack of remorse when he hurts others. Mason is noted to be fearless and will put himself in very dangerous situations. A development assessment was completed in September 2010. At 30 months of age, motor skills were noted to fall at the 24 month age level. Adaptive skills ranged from 21 to 36 months of age and language skills ranged from 24 to 30 months. Personal and social skills were more delayed and fell around the 18 to 24 month level. Mason is noted to prefer repetitive play activities and is interested in repetitive play with keys. He will repeat phrases. Mason was assessed by Occupational therapy in March 2010 by XXXX (Surrey Memory Hospital). He was noted to have a sensory processing disorder and severe oral motor dyspraxia.
A psychological assessment was completed in April 2010 by Dr. XXXX. Results of the developmental assessment noted that his overall skills fell in the High Average range for his age (77th percentile). Skills in all areas fell within expected limits (gross motor, visual reception, fine motor, and receptive/expressive language skills).
Medically, Mason has been diagnosed with a genetic syndrome, Smith-Magenis syndrome. This syndrome is characterized by significant behavioural issues including self-injurious behaviours and significant difficulties controlling aggression. There are often severe tantrums associated with this syndrome which occur throughout the day. Mason’s behavior is consistent with this profile and he will often bite, hit, scratch, and kick his parents and siblings. He has sleep problems including troubles falling asleep and frequent waking during the night. He has a high pain tolerance. Often, children with Smith-Magenis experience developmental delays and there are associated autistic behaviours. Mason has experienced a history of significant feeding difficulties and is completely dependant on G-Tube feeds. He has been diagnosed with gastroesophageal reflux disease (GERD) which is life-threatening. There are safety issues around eating food. Liquids need to be thickened and he needs to be told to swallow each bite while eating.
Developmental Review / Autism Symptom Review
The Autism Diagnostic Interview-Revised (ADI-R) was completed with Mason’s mother. She provided the following information regarding Mason’s developmental history and current symptom presentation.
With regard to his language and communication skills, parents report the use of odd and repetitive phrases. He will repeat over and over phrases he has heard and his own made up phrases. It is very difficult to engage in social chat with Mason. He responds in formal ways and responses are short. He often talks about the topic of his dad working and will repeat information over and over about his dad being at work. It is often difficult to know what Mason wants. He will often make inappropriate comments and is unaware these would upset others. There is no history of using others’ body to communicate or pronoun reversals. He has had difficulty with learning his name and
when asked his name would respond with his age. He often makes up his own idiosyncratic words and his own names for people he knows. He engages in verbal rituals and wants to recite sections of favorite t.v. shows, for example. His parents have to recite or sing these songs in a very specific manner or he gets upset. Use of gestures has been delayed but he has started using some gestures in the past few months. He has learned more gestures by copying his younger brother. He needs prompts to use gestures. He will point but it is difficult to know what he is pointing at because of lack of integrated eye contact.
With regard to his social development and play, eye contact is variable. You can catch his eye but it is not sustained. He does engage in some imaginative play by himself (playing tea party, pretending to be Harry Potter) but does not engage much with other children. Social smiling is variable and only occurs with certain people. He generally only shows objects of interest or brings things of interest if he wants or needs something. He never offers to share. He often does not engage in or participate in social play. He generally ignores the other children in group settings. He will cover his head if they approach him. He can get obsessed with a certain child at times and following them around and wrestle them.
With regard to the presence of unusual interests or preoccupations, Mason is very interested in keys. He collects keys and likes to put keys in and out of objects. He likes to collect little bits of things (erasers, foil, bits of paper). He chews on rubber or metal objects. He is obsessed with Harry Potter but is not interested in children’s programs designed for his age. He will often act like Harry Potter. He will throw toys repetitively. He will spin wheels of cars or take cars apart into pieces. He is a very hyperactive boy and he often does not focus on one activity or toy for very long. There are lots of compulsive behaviours and rituals. He has to sit at the same spot at the table, his bed has to made in a very specific manner, and he has to sleep in jeans, for example. He smells everything and licks things. He flaps his hands when excited or when he sees water (at the beach, when washing his hands). He loves spinning.
In sum, given the information provided by Mason’s caregivers, scores on the ADI-R fell in the autistic range in all areas: qualitative abnormalities in communication, qualitative abnormalities in reciprocal social interaction, and engagement in restricted, repetitive, and stereotyped patterns of behaviour. Information regarding developmental history revealed the presence of developmental concerns prior to age 3.
Assessment of Child’s Presentation and Behavior
The Autism Diagnostic Observation Schedule – Module 1 (ADOS) was completed with Mason.
With regard to his language and communication, Mason did speak in phrases and sentences during the assessment. There was no immediate echolalia but speech was quite repetitive. He had a few phrases he would repeat over and over at times. He did point at objects of interest but this was not consistently coordinated with eye contact. Use of gestures was limited. It was difficult to have a sustained or back and forth conversation with Mason. He did not respond to conversational attempts at times. He rarely made requests and would just reach for objects of interests without asking. Voice intonation was appropriate.
With regard to his reciprocal social interactions, eye contact was variable and often not sustained. Mason was a generally happy child and did smile at others. He did not always respond to social smiling and responses were often on his own terms. He did not respond consistently to his name being called by either the examiner or his mother. He did give objects to others at times but did not show objects of interest on a regular basis. He did not respond to joint attention tasks. With regard to his play behaviors, play was repetitive with particular toys and imaginary play was limited. He would repeatedly throw the same toy or play with keys. He smelled objects. He was quite aggressive in his play and in interactions with others with minimal awareness of the impact of these behaviours on others. There was no engagement in hand or finger mannerisms.
In sum, scores on the ADOS fell in the autism spectrum range in the areas of Communication and Reciprocal Social Interactions. The combined Communication and Social Interaction score fell in the autism spectrum range.
Videos of Mason in social and group settings were viewed. In group settings with Mason, he is noted to be off on his own and engaged in a solitary activity of interest. He does not participate in group activity or circle time. He can just get up and leave a situation or room without awareness of others in the room. While he can be very active in certain situations, he was noted to sit quietly when engaged in a repetitive interest or engaged in non-functional play (repetitively playing with someone’s shoe).
A speech-language assessment was completed by XXXX as part of the current assessment process. Language skills fell within average for his age and expressive language skills are age appropriate. Social and pragmatic use of language is significantly delayed, however. Please refer to complete speech-language report for details.
Mason is a 2 year old boy who was referred for an assessment for suspected autism spectrum disorder by his speech-language pathologist. The results of the current assessment found that Mason does meet criteria for an autism spectrum disorder. He meets DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, Text Revision) criteria for a diagnosis of Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS), given the milder nature of some areas assessed and presence of social initiative at times, although on his own terms. These findings were based on clinical interviews, review of developmental history, and interactions and observations of Mason, including the use of standardized instruments for the assessment of autism symptoms (ADOS and ADI-R). While Mason can be responsive to others at times, his responses are very inconsistent. He responds better to adults but has no interest or response to peers. He engages in repetitive and unusual activities of interest. Language skills are good but he often does not initiate or respond to day to day conversations. He repeats certain phrases or talks repetitively about topics of interest to him.
Cognitively, Mason is high-functioning and language skills are within expectations. Despite these age-appropriate cognitive and language skills, social and play skills are significantly delayed. Mason has difficulties using language appropriately in social contexts
and play is very repetitive. Socially, responses are variable and he is often on his own terms. He engages in some unusual interests.
Mason has Smith-Magenis syndrome and children with this syndrome can often also display autistic behaviours and have co-diagnoses of an autism spectrum disorder. Mason does not exhibit the global developmental delays often associated with this syndrome, but despite his higher cognitive and language skills, exhibits significant impairments in social and play skills. The behaviours of children with Smith-Magenis syndrome have been noted to respond to the interventions for their autistic behaviours but it is important to understand Mason’s difficulties in the context of this genetic syndrome. The severe behavioural issues and aggression (including self-injurious behaviours) are associated with Smith-Magenis and have underlying genetic causes. This will be important to understand when working towards managing his behaviours and adapting environments to his needs.
1. Feedback regarding the current assessment has been provided to Mason’s parents. They have been provided with a copy of the Autism outcome assessment form to initiate autism related funding with the ministry for children and families.
2. Mason will need intensive intervention focused on social skills development, communication, play skills, and behavioural management.
3. Information regarding community resources and support for children with autism spectrum diagnoses is available on the website www.actcommunity.net. Parents can access resources and supports for children with autism. Mason’s parents will also benefit from resources and support in parenting a child with autism. This should, in part, be provided through the autism intervention services recommended to the parents.
4. Speech therapy services are strongly recommended for Mason to develop social communication skills. Please refer to the speech report by XXXX for full details.
5. Children with autism spectrum disorder may benefit from a variety of interventions. In general, when younger, these children need to “learn how to learn”, and the emphasis of beneficial supports can be on speech and language therapy, behavioural intervention, and social skills training. The exact nature and intensity of the intervention will be different for each child and will change over time. General information on different types of intervention strategies and their apparent efficacy can be reviewed via the Knowledge Network (“Autism, the Road Back”; http://www.knowledgenetwork.ca/autism/index.html) and the Canadian Autism Intervention Research Network (http://www.cairn-site.com/research4.html).
6. Mason will require significant intervention focused on social skills development (i.e., eye contact, responding to and initiating social exchanges, communication and speech-language development, behavior skills development, and the development of safety skills. One-to-one intensive therapy is recommended and social exposure to peer groups with adult support. A list of organizations which provide such services for autistic children is available on the ActBC website.
7. Cognitively, Mason skills are within age expectations. Interventions can be geared to his level of understanding. Use of visual supports is recommended given his attention difficulties.
8. A copy of this report should be provided to Mason’s school when parents are registering him for kindergarten. Mason will need an Individualized Education Plan in place at school which contains adaptations or modifications to his educational program. He will require the level of supports and services appropriate for a child with an autism diagnosis. Developing a program which meets his variable needs will be important. While Mason will need intensive supports for behavioural, social and communication needs, how much support he will need for academic development will need to be assessed further once he is in school.
9. Given his young age, reassessment of his cognitive abilities and academic skills will be important in determining appropriate academic goals. This can occur in the school setting once he is in school.
10. Mason will continue to benefit from regular one-to-one time and interaction with his caregivers. Spending time engaging in some activity with Mason each day where he is required to respond to conversation and attempts to engage in social interactions with him will be important to his social and emotional development. Talking with him, engaging in joint play with him, and trying to initiate some back and forth play will be important.
11. If Mason is becoming frustrated, check for triggers that can be dealt with (i.e., Are there sensory issues that are overwhelming him such as noise? Is he having difficulty communicating his needs? Does he need more explanation or warning about changes in his routine and environment??). Provide a designated quite space to calm down as needed.
12. Occupational therapy services are recommended given the significant sensory issues noted for Mason. Strategies for helping him manage his sensory needs will be important.
13. Mason’s overall development should continue to be monitored by his community pediatrician given the complexity of his medical and developmental needs. Concerns with inattention and hyperactivity can be monitored as he gets older.
It was a pleasure working with Mason and his family and I wish them all the best. Given the multiple and significant challenges he presents with, intensive supports will be needed for both Mason and his family. If there is any further information I can provide, please do not hesitate to call me at....