Boston University School of Medicine for Reddy, Boston, MA, USA.
J Dev Behav Pediatr. 2011 Oct;32(8):616-8. doi: 10.1097/DBP.0b013e318231066f.
Sam is a 27-month-old boy who you have followed since birth. He lives with his parents in a small resort town approximately 90 miles outside a major city. Both his parents are professionals in their late 30s and have been highly involved in his care since birth. At the 12-month visit, they were concerned about his difficulty regulating. He was not sleeping through the night and had significant difficulty with baths. His physical examination and growth were normal. His eye contact was good, although it was difficult to see him smile. He had 1 or 2 words and was beginning to walk independently.At the 15-month checkup, they continued to be concerned about his poor regulation. He napped sporadically, and he was very difficult to take out on errands as he did not like his car seat. He now had approximately 10 single words, was using his fingers to point, and very clearly waved "bye bye" as soon as you entered the room.At the 18-month checkup, they state that he has not yet learned the word "no." He will follow a 1-step command when he wants to but now has 15 single words without any combinations. He points for his needs and to show them something. He has become increasingly "shy" around strangers and prefers to play with one other child as opposed to a larger group. He does not like loud noises and prefers to go barefoot constantly. His physical examination was again normal as was his growth. He is referred for a full hearing evaluation, which is also normal. The family was referred to early intervention, and he began receiving speech and language therapy and occupational therapy for his sensory challenges as well as a play group.At the 24-month checkup, his language continued to consist of single words-now approximately 30. When the parents do not understand what he wants, he will often tantrum and has started banging his head on the floor when frustrated. He has no repetitive behaviors and is starting to demonstrate imaginative play. Bath time has becoming increasingly challenging because he does not like the sensation of soap and the water temperature must be "just right." You refer the child to a Developmental and Behavioral Pediatrician for evaluation and at 28 months he is seen. During his testing visit, he had decreased eye contact and followed his own agenda but improved significantly as testing progressed. As he got more comfortable, he began making good eye contact, social referenced, and exhibited joint attention with his parents and the examiner. He did not meet criteria for an autism spectrum disorder or specifically pervasive developmental disorder-not otherwise specified (PDD-NOS). He was given a diagnosis of mixed receptive and expressive language delay and disruptive behavior disorder with sensory processing problems.The parents come to you a month after their evaluation visit asking you to give him a "listed diagnosis of PDD-NOS" that could be removed when he turns 3 years so that he may qualify for increased hours of services-up to 15 hours per week-as well as applied behavioral analysis therapy. A behavioral therapist through early intervention has told the family that he would benefit from this increased intervention, specifically applied behavioral analysis but the only way he can receive it is with a "medical diagnosis" on the autism spectrum. What do you do next?
山姆是一个 27 个月大的男孩，你从他出生起就一直在关注他。他和父母住在一个离大城市 90 英里的小镇上。他的父母都是 30 多岁的专业人士，从他出生起就一直非常关心他的成长。在 12 个月的随访中，他们对他的调节能力感到担忧。他不能整夜睡觉，洗澡时也有很大困难。他的体检和生长都正常。他的眼神交流很好，尽管很难看到他的微笑。他会说 1 到 2 个字，并开始独立行走。在 15 个月的检查中，他们继续对他的调节能力差感到担忧。他偶尔会小睡一会儿，而且带他出去办事非常困难，因为他不喜欢他的汽车座椅。现在他大约有 10 个单词，会用手指指，只要你一进房间，他就会清楚地挥手说“拜拜”。在 18 个月的检查中，他们说他还没有学会“不”这个词。当他想做某件事时，他会听从一个简单的指令，但现在他有 15 个单词，没有任何组合。他会用手指表示自己的需求，或者给你看东西。他变得越来越“害羞”，只喜欢和一个孩子玩，而不是和一群孩子玩。他不喜欢吵闹的声音，喜欢一直赤脚。他的体检和生长都再次正常。他被推荐接受全面的听力评估，结果也正常。该家庭被转介到早期干预机构，他开始接受语言和言语治疗、职业治疗，以应对他的感官挑战，以及参加游戏小组。在 24 个月的检查中，他的语言仍然由单个单词组成——现在大约有 30 个。当父母不理解他想要什么时，他经常会发脾气，当感到沮丧时，他会开始用头撞地板。他没有重复行为，并且开始进行富有想象力的游戏。洗澡时间变得越来越有挑战性，因为他不喜欢肥皂的感觉，而且水温必须“刚刚好”。你将孩子转介给发育和行为儿科医生进行评估，他在 28 个月大时接受了评估。在他的测试就诊期间，他的眼神交流减少，按照自己的计划进行，但随着测试的进行，他的情况有了显著改善。当他变得更加舒适时，他开始与医生进行良好的眼神交流，进行社会参照，并与父母和检查者进行共同关注。他没有达到自闭症谱系障碍或特定广泛性发育障碍未特指（PDD-NOS）的标准。他被诊断为混合性接受性和表达性语言延迟以及伴有感觉处理问题的破坏性行为障碍。在评估后的一个月，父母来找你，要求你给他一个“列出的 PDD-NOS 诊断”，以便在他年满 3 岁时可以将其删除，这样他就可以有资格获得更多的服务时间——每周高达 15 小时，以及应用行为分析治疗。一位早期干预的行为治疗师告诉这个家庭，他将从这种增加的干预中受益，特别是应用行为分析，但他唯一能得到的方法是在自闭症谱系上有一个“医学诊断”。你接下来会怎么做？
