autism
Doctor Information
Harry Lloyd, age 2 years 5 months
No PMH or current medication
No known allergies
No PMH or current medication
No known allergies
Patient Information
Harry Lloyd, age 2 years 5 months
You are Karen Lloyd, Harry’s mother. Harry is not with you today.
History: You are worried about Harry. He is so different to you other children, and it is so hard to put your finger on what exactly is wrong. He just doesn't seem interested in things and doesn't want to play with other children at playgroup.
If asked only: Harry has always been on the quiet side. He learned to walk at 11 months but didn't say his first word until 15 months. Even now he barely speaks, and it is really hard to engage him in activities. You have tried with blocks, crayons, duplo toys, but he just ignores them or walks away. When your friends come round to see you, he is shy and doesn't look at them or smile. He won't wave bye to you and hates being cuddled. He has one set of trains that he has to have to play with at all times, and gets very upset if you take them away. He seems to be able to play by himself for hours on end.
He was born at 38 weeks, forceps delivery and no problems after birth. There is no history of seizures or other health problems, and he is fully immunised.
You live with your husband Grayson, and Harry’s siblings 5 year old Chloe and 8 year old Michael. Your older two children were so different when they were small - always chatting and wanting to play, and both of them always came for cuddles. You feel quite sad that Harry has no interest in this. Harry eats well and has no problems with his bowels or urination. You work part time in a clothing store, and Grayson is a solicitor. The health visitor has always said Harry was fine, just on the quiet side, but your mother thinks he might be a bit ‘slow’. She used to work as a nurse and has mentioned autism to you several times. You really don’t want Harry to be labelled as autistic because it will affect him for the rest of his life, but at the same time you want to know if this is normal or if something is wrong.
Ideas: You hate to say it but you think Harry is just a bit slow, mainly because you thought autistic children like to line things up and were a bit eccentric.
Concerns: You do not want to put Harry through any horrible tests that will upset him, or have a label of autism if he doesn't have it, but you are desperate to know why he is this way
Expectation: you will probably be told you are worrying over nothing
If the doctor is kind and discusses autism, you will open up about your feelings and fears for Harry. You are happy to bring him in to be examined, and would be pleased at the concept of being referred to a community paediatrician for an opinion.
You are Karen Lloyd, Harry’s mother. Harry is not with you today.
History: You are worried about Harry. He is so different to you other children, and it is so hard to put your finger on what exactly is wrong. He just doesn't seem interested in things and doesn't want to play with other children at playgroup.
If asked only: Harry has always been on the quiet side. He learned to walk at 11 months but didn't say his first word until 15 months. Even now he barely speaks, and it is really hard to engage him in activities. You have tried with blocks, crayons, duplo toys, but he just ignores them or walks away. When your friends come round to see you, he is shy and doesn't look at them or smile. He won't wave bye to you and hates being cuddled. He has one set of trains that he has to have to play with at all times, and gets very upset if you take them away. He seems to be able to play by himself for hours on end.
He was born at 38 weeks, forceps delivery and no problems after birth. There is no history of seizures or other health problems, and he is fully immunised.
You live with your husband Grayson, and Harry’s siblings 5 year old Chloe and 8 year old Michael. Your older two children were so different when they were small - always chatting and wanting to play, and both of them always came for cuddles. You feel quite sad that Harry has no interest in this. Harry eats well and has no problems with his bowels or urination. You work part time in a clothing store, and Grayson is a solicitor. The health visitor has always said Harry was fine, just on the quiet side, but your mother thinks he might be a bit ‘slow’. She used to work as a nurse and has mentioned autism to you several times. You really don’t want Harry to be labelled as autistic because it will affect him for the rest of his life, but at the same time you want to know if this is normal or if something is wrong.
Ideas: You hate to say it but you think Harry is just a bit slow, mainly because you thought autistic children like to line things up and were a bit eccentric.
Concerns: You do not want to put Harry through any horrible tests that will upset him, or have a label of autism if he doesn't have it, but you are desperate to know why he is this way
Expectation: you will probably be told you are worrying over nothing
If the doctor is kind and discusses autism, you will open up about your feelings and fears for Harry. You are happy to bring him in to be examined, and would be pleased at the concept of being referred to a community paediatrician for an opinion.
Examination Findings
Not applicable in this scenario
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination - able to assess for possibility of autism Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Explains autism coherently, and discusses probability of this Develops a management plan (including referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate decision to examine and assess child Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
Explanation: Autistic spectrum disorders (ASD) describes a group of conditions that are usually diagnosed in childhood. Autistic children have difficulty with communicating to other people, interacting in social situations, and tend to struggle with things that involve imagination. The condition can vary from being barely noticeable to very severe. There are several groups of specialist that can get involved to help autistic children with day to day activities and provide support for families.
A case of suspected autism is very reliant on the history from the mother, and watching the child behave. You need to assess the three areas as best you can, keeping in mind the child’s age and what is considered to be ‘normal’ development:
Social interaction - will they play with others, will they seek attention, do they interact with you in games or saying bye-bye?
Communication -is there a delay in speech development, or little vocalisation?
Imaginitive play - are they restricted in their ability to play, do they have a strong attachment to certain toys, do they have difficulty with pretend play?
If any of these features are consistently present, then autism is certainly a possibility. Remember that developmental delay can often give similar features.
While is vitally important to bring the child in and examine them yourself (a developmental assessment), here the main aspect of the case is counselling the mother. ICE is very useful - does she think he has autism? what does she know about autism? how would she feel if this diagnosis was confirmed? What is she expecting to happen now?
It is difficult for you as her doctor because nothing is confirmed, but giving her the information she wants, with more of a positive spin might help with her anxieties here. For example lots of children with ASD go to mainstream school and some just have a little bit of extra help and support with their education. There are a lot of support groups for families to meet and talk about things, as well as to engage with behaviour specialists and children’s specialists. Speech and language therapy can help children with their communication and understanding. Many autistic children can improve dramatically with the right help, and go on to live full and happy lives.
When you meet Harry, if you suspect that he may have an ASD, you can refer him onto a community paediatrician who will assess him. Offer mum support should she have any further questions in the meantime.
A case of suspected autism is very reliant on the history from the mother, and watching the child behave. You need to assess the three areas as best you can, keeping in mind the child’s age and what is considered to be ‘normal’ development:
Social interaction - will they play with others, will they seek attention, do they interact with you in games or saying bye-bye?
Communication -is there a delay in speech development, or little vocalisation?
Imaginitive play - are they restricted in their ability to play, do they have a strong attachment to certain toys, do they have difficulty with pretend play?
If any of these features are consistently present, then autism is certainly a possibility. Remember that developmental delay can often give similar features.
While is vitally important to bring the child in and examine them yourself (a developmental assessment), here the main aspect of the case is counselling the mother. ICE is very useful - does she think he has autism? what does she know about autism? how would she feel if this diagnosis was confirmed? What is she expecting to happen now?
It is difficult for you as her doctor because nothing is confirmed, but giving her the information she wants, with more of a positive spin might help with her anxieties here. For example lots of children with ASD go to mainstream school and some just have a little bit of extra help and support with their education. There are a lot of support groups for families to meet and talk about things, as well as to engage with behaviour specialists and children’s specialists. Speech and language therapy can help children with their communication and understanding. Many autistic children can improve dramatically with the right help, and go on to live full and happy lives.
When you meet Harry, if you suspect that he may have an ASD, you can refer him onto a community paediatrician who will assess him. Offer mum support should she have any further questions in the meantime.