A 3-year-old girl is brought to the clinic for evaluation after she hit a teacher for putting banana slices on her plate. Her mother says, "She's never been aggressive before, but she has always been particular about food. She likes bread and pasta but screams if I put avocados or broccoli on her plate. She's always been pretty easy to take care of—she stacks blocks on her own for hours at a time, which allows me to focus on my 6-week-old." The patient recently started preschool after the birth of a baby sister. She was born at full term without complications and has no significant medical history. The patient is able to kick a ball, draw a circle, pedal a tricycle, and say 4-word phrases. Vitals signs are normal, and she is tracking adequately on growth curves. During the evaluation, the patient sits in the corner of the room playing with blocks. She does not follow her mother's gaze when she points to other toys in the office. When the physician tries to examine her, she begins screaming and rocking backward and forward. Which of the following best explains this patient's behavior?
Autism spectrum disorder | |
Clinical |
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Several features of this patient's presentation suggest autism spectrum disorder (ASD), including her preference for solitary play, restricted interests (stacking blocks for hours), lack of joint attention (ie, not following her mother's gaze to a shared focus), and extreme food selectivity. Abnormal sensory sensitivity is a core feature of ASD, which can manifest as an aversion to foods with certain tastes or textures. Other examples include aversion to or fascination with certain sights, sounds, or textures (eg, compulsive touching of clothing) and/or a lack of expected response to sensory stimuli (eg, not reacting to pain or extreme temperatures).
Restricted interests are often accompanied by repetitive movements or behaviors, such as rocking back and forth. Impulsive, aggressive outbursts (eg, hitting, screaming) may occur as a response to sensory sensitivities or when the patient is prevented from following routines or pursuing fixated interests, as in this patient. Early detection is critical because intervention can improve outcomes.
(Choice A) Children often have behavioral or emotional disturbances in response to stressors such as the birth of a sibling or starting preschool, which could account for this patient's aggressive outburst. However, adjustment disorder would not explain sensory aversions or a preference for solitary, restricted play.
(Choice C) Avoidant/restrictive food intake disorder involves sensory sensitivities to food or concern about the consequences of eating (eg, vomiting, choking) resulting in weight loss or poor growth. It would not explain autistic features.
(Choice D) Disruptive mood dysregulation disorder is characterized by an irritable or angry mood together with temper tantrums that are out of proportion to age and situation. This diagnosis is not made prior to age 6 or after age 18.
(Choice E) Although some children may go through a normal phase of picky or selective eating, children at age 3 should be displaying joint attention, playing with others, and using a range of toys.
(Choice F) Rett syndrome can also present with deficits in social interaction; however, it is also accompanied by regression in speech, loss of purposeful hand movements, and gait disturbance.
(Choice G) Individuals with social (pragmatic) communication disorder also display deficits in verbal and nonverbal communication. However, they do not have restricted interests or demonstrate repetitive behaviors.
Educational objective:
Autism spectrum disorder is characterized by deficits in social interaction, restricted interests, repetitive behaviors, and abnormal sensory perception. Food selectivity is common.