An 11-year-old boy is brought to the office by his mother due to concerns about his anxiety and adjustment to school. Six months ago, the patient started a new school that requires him to change classrooms for different subjects. The mother says that he has always been shy and had difficulty making friends. She says that the change has been stressful for him and has not become easier over time. The patient reads at grade level and does well in math; however, he has difficulty in classes that require oral participation or group involvement and gets into trouble because he blurts out answers. The patient's behavior outside school causes problems as well. Last week, when morning traffic required departing from routine by taking a different route to school, he became agitated and threw his school bag, hitting his brother in the face. While the mother is speaking, the patient interrupts to say that he would rather read about astronomy on his own because school is "a stupid waste of time." Physical examination is remarkable for a repetitive opening and closing motion of his hands—which becomes more intense when he is asked about school—but is otherwise normal. Which of the following is the most likely explanation for the patient's behavior?
Autism spectrum disorder | |
Clinical features |
|
Assessment & management principles |
|
This patient has:
These features are suggestive of autism spectrum disorder (ASD).
Patients with milder autism frequently have normal or near-normal language and intellectual ability that may lead to a delay in diagnosis (whereas more severe ASD is usually diagnosed by age 5). However, as social expectations increase with age, deficits in social awareness and interpersonal skills become more noticeable.
Concerning features include inability to interpret and respond appropriately to nonverbal cues; abnormal eye contact; intense, perseverative interests or one-sided conversations; difficulties understanding sarcasm, metaphors, or humor; and abnormal sensory sensitivity. In addition, changes in routines commonly cause anxiety and can provoke agitation or behavioral dysregulation (such as this patient's bag throwing).
(Choice A) This patient's social deficits have become more apparent with the increased demands of his new school. Stressors often exacerbate the symptoms of a preexisting condition; however, his difficulties are preexisting manifestations of ASD (always had difficulty making friends) and not simply a time-limited response to a stressor as seen in adjustment disorder.
(Choice B) This patient's blurting out of answers is likely due to difficulty interpreting and responding appropriately to social cues. He does not display multiple symptoms of hyperactivity, impulsivity, and/or impaired attention in multiple settings to warrant a separate diagnosis of attention deficit hyperactivity disorder.
(Choice D) Patients with obsessive-compulsive disorder (OCD) can also present with rigid adherence to specific routines. However, this patient lacks the intrusive obsessional thoughts and corresponding compulsive rituals characteristic of OCD.
(Choice E) This patient's outbursts are a response to difficulty tolerating change or navigating social cues. He does not display the pattern of willful disregard for authority or vindictiveness seen in oppositional defiant disorder.
(Choice F) Tourette syndrome is characterized by multiple motor and vocal tics, often with premonitory urge, which can worsen with stress. However, this patient's motor stereotypy helps him self-soothe during distressing thoughts about school. Furthermore, social deficits and insistence on routine are not consistent with Tourette syndrome.
Educational objective:
Autism spectrum disorder is characterized by social deficits, behavioral rigidity with resistance to change, and repetitive movements. Onset is in early development; however, patients with normal language and intellectual ability may be diagnosed later, when social demands make deficits more apparent.