AL is an 8-year old girl who presented with a 4-year history of impairments in all aspects of the autistic triad: social interaction , imagination, and social communication. Her teacher noticed a lack in the drive to explore environments and ability to ‘parallel play’, a developmental concept whereby infants begin to play alongside each other. However, a regression of verbal communication caused the greatest concern. As a result, AL had poor interpersonal relationships, driven by poor verbal and non-verbal comprehension. She experienced delayed echolalia, predominantly associated with a fascination in cartoons. Furthermore, AL’s parents reported a sleep-latency problem. An autistic diagnostic assessment observation schedule (ADOS), and an autistic diagnostic interview (with the parents) were conducted. The ADOS is a ‘gold standard’ 30-60 minute semi-structured assessments allowing the examiner to observe social and communication behaviors. Three diagnoses of moderate learning disability, profound global developmental delay, and autism were made.

Developmental assessment

AL had a developmental age of approximately 2½ years.

Past obstetric history

AL was born five weeks pre-term weighing 4 lbs and 9 oz. She spent four weeks in a neonatal unit to gain sufficient weight.

Family history

Questions were asked about a childhood developmental delay and learning disabilities. None relevant.

Management

Management of autism was in accordance with the British Medical Journal Publications of the Scottish Intercollegiate Guidelines Network [1]. This states; ‘Treatment and Education of Autistic and related Communication handicapped Children (TEACCH)’ can be used to reduce symptom frequency and severity, and increase the development of adaptive skills [2]. Pharmacological use of melatonin was introduced to treat the co-morbid sleep-latency problem [3]. Parent-mediated interventions were used to aid AL’s parents through improvement of their knowledge and awareness of autism [4,5].

Autism is an early-onset neurodevelopmental disorder in which three characteristics prevail: poor social reciprocation, a qualitative impairment in communication, and idiosyncratic behavior. These characteristics are pervasive and persistent over more than one context i.e. home or school-and are age inappropriate [4,5].

For example, sense perception differs for a child with autism . The paradoxical phenomenon of hyper-or hyposensitivity to sound, taste, touch and smell is experienced as a separate entity. Given this, a child with autism may not share the same pattern of human behavior the way that is “neurally” typical; this difference is known as the ‘Culture of Autism’ [5,6]. Thus autism concerns the whole person, their relationships and social circumstances [6,7].

Families of a child with autism face many challenges, from deciding whether to place a child in mainstream or a specialist school, to relentless worrying whether their child will be ‘socially accepted’. This debate is further complicated by Bandura’s social learning theory that “most human behavior is learnt observationally by modeling” [8]. Self-reports of children with autism show that they are more likely to report feelings of social isolation at school [7]. There is also an increased risk of exploitation, ranging from emotional to physical abuse [8,9]. It is unknown whether bullying is due to their limited ability to effectively communicate disapproval, or inability to comprehend advances of others [7].

Since 1966, TEACCH was uniquely designed comprehensive model founded by Dr Eric Scloper [10,11]. This internationally renowned philosophy takes into account the culture of autism, placing an emphasis on structure of class environments and predictability [11,12]. It uses visual cues, such as sign language and picture words, to promote self-help, independence and communication. This allows better functioning in the community [12]. Therefore, TEACCH can be employed in the working environment, at home and at school from a young age thought to adulthood by parents, teachers and employers. In the UK, the National Autistic Society provides and easily accessible two day course for those wishing to learn how to TEACCH [13].

Furthermore, lack of sleep is a concern for both teachers and families. Often chronic and disabling, it can result in difficulties in behavior and learning. Meta-analyses show that melatonin is an endogenous substance that can produce sleep phase shifting and has hypnotic properties [3]. In many children, administrating melatonin has shown to be effective in increasing the length of ‘total sleep time’ and overall improving the child’s wellbeing [3].

Whilst we as doctors can do little to control external factors, we can have some control over the clinical environment. Medical management of a child with autism can be difficult; the unfamiliar, chaotic environment of a hospital can sometimes trigger significant distress [10]. In this instance, AL was treated in the community with specialist nursing visits at home. There is limited literature regarding the effectiveness of managing autism in a hospital environment vs. community management. Current interventions of bringing familiar objects from home or reducing noise are not always feasible and may not suffice [10]. This may be an important point to consider in future when consulting an autistic patient, in order to provide an effective and appropriate service.

Autism is a complex, disabling disorder that is physically and emotionally demanding on both the patient and their family. It has a breadth of psychosocial impacts beginning in childhood and persisting throughout life. It is only when we can accept and value the difference between our culture and the culture of autism that we can help ameliorate the impact of the disorder.

I would like to thank the patient AL and her family for their kind approval.