A BOY WITH NO FRIENDS
History Adrian is a 10-year-old boy with difficult behaviour at home, who comes for a review to the community paediatric clinic. He was thought to have attention deficit hyperactivity disorder (ADHD) after an initial consultation in the clinic. However, information obtained from his school indicated that his teacher did not find his behaviour to be hyperactive or inattentive. His mother had mentioned that he didn’t seem to have any friends to play with and that this seemed to be the reason he was always causing trouble at home. It is decided that it might be helpful to observe his behaviour in school. You observe Adrian at school over a 2-hour period. He does not know that you are specifically watching him. Initially he has a games lesson: the children are practising football skills. Adrian seems interested, but whenever the task involves a complex instruction, he doesn’t seems to be able to follow it. When this happens, he stands still or does his own thing. He doesn’t ask anyone else to explain what he is supposed to do. He doesn’t join in with the playground banter between the other children and the teacher. At the end of the lesson, there is a short game of football and he is the last to be picked for a team. He seems to find it hard to anticipate the flow of the game and runs around almost aimlessly. When he does get the ball he runs straight down the pitch with it and ends up colliding with another child who is trying to tackle him. Next he is observed in the classroom, where he is doing mathematics. Again he participates very little in the classroom discussion and he doesn’t really speak to the other children. He sits quietly, fidgets and slouches frequently, but doesn’t leave his seat. He places his pens and ruler in a neat row and gets quite upset when another child borrows his ruler and disrupts the pattern. When he is asked a question, he mumbles only half of the answer. His book shows that he has worked out most of the simple sums correctly but has struggled with the questions that required more reasoning. His teacher reports that the staff find Adrian quite bewildering. Frequently he just doesn’t understand the task he is asked to do and he often does his own thing, but sometimes he is able produce complex pieces of work. Even with one-to-one teaching it has been impossible to determine his true academic potential, and sometimes he gets very upset when teachers try to give him extra guidance. His social interaction is always odd, he doesn’t have any real friends, and although the other children will tolerate him joining in their games, this frequently results in trouble. Sometimes he will just play on his own, e.g. opening and closing the lock on the playground gate. He won’t participate in discussions or drama and when he does speak in front of the class he may speak with a strange intonation or say things that are not appropriate to the context. He gets very anxious about apparently minor things such as changes in the day’s timetable. Last week he got upset several times each day because the classroom clock had not been set to the right time.
Questions
• What underlying causes may explain Adrian’s problems?
• What additional assessment would be helpful?
• How might making a diagnosis help Adrian to achieve his full potential at school?
Medicine
Adrian displays evidence of difficulties with social communication, social interaction and obsessional behaviour. He may have an autistic spectrum disorder, possibly Asperger’s syndrome. This diagnosis cannot be made with certainty from the brief history, and further assessment would be needed. Other underlying or contributing problems might include hearing difficulties, specific learning difficulties, social and emotional problems. Autism is characterized by the triad of impairment of social communication, social interaction and rigidity of thought and behaviour. Unusual routines and interests, abnormal sensory sensitivity and learning or other developmental difficulties may coexist. The term autistic spectrum disorder is now widely accepted and recognizes that there can be considerable variation in the severity of symptoms. Autistic disorder is the most severe end of the spectrum and is usually diagnosed in early childhood. Affected children are often non-verbal, with cognitive impairment and highly stereotyped behaviours. At the milder end of the spectrum there may be relatively little impairment of communication, leading to a diagnosis being made later in life, if at all. Asperger’s syndrome is at the mild end of the autistic spectrum and individuals are usually of average or above-average intelligence, have difficulties understanding non-verbal communication cues, find it difficult to form friendships and difficult to empathize with others. Autistic spectrum disorders may affect up to 1 per cent of children in the UK. Additional assessment should include a hearing test and assessment by a paediatrician with an interest in autistic spectrum disorders (usually a community paediatrician) or a child and adolescent mental health team. Often a clinical psychologist or a multidisciplinary team of other professionals will be involved in the assessment. Detailed developmental, medical, family and social histories should be taken. Adrian’s social skills, communication and behaviour will be observed. Sometimes this is done in a standardized way using an observational assessment. The process needs the support of the family, who should understand that the eventual outcome might be a diagnosis of autistic spectrum disorder. Making a diagnosis of autistic spectrum disorder can be very emotive. It can bring great relief to parents and the child, but can also be met with denial or dismay. Understanding the diagnosis will enable the teachers at Adrian’s school to understand why he behaves in the way he does. It will allow the school to implement strategies to help Adrian to be included as fully as possible in the curriculum. This will include individualized measures to support social communication and behavioural interventions to assist the development of adaptive skills. The special educational needs coordinator at the school will help to develop an individual education plan to help staff to know what Adrian’s needs are and how they can best be met.
KEY POINTS
• Autism is characterized by impairments of social communication, social interaction and rigidity of thought and behaviour.
• Autistic spectrum disorders may remain undiagnosed in late childhood and adolescence.
• Making the diagnosis may help to find strategies to improve learning and behaviour.
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