This is post 2 of 2 on Curt's initial autism diagnosis shortly before he turned 3 years old. He's made continuous strides though early intervention services and people who Curtis meets today, shortly before his 8th birthday, often have no idea that he even has autism. He is also coming off his most successful Halloween ever, a day he used to dread, complete with lots of door to door trick or treating with one of the "coolest" kids in class.

Educational and Service History: Curtis has just started therapeutic development preschool in Portland. Occupational therapy, his parents believe, twice monthly and speech therapy twice weekly will start next week.

Office Observations: Curtis had a pacifier in his mouth, looked up at me when I entered the room, and then ran to a corner. He commented "in" when he put magnets into a magnet tube. He then climbed into the table and set there, playing with the magnets quietly for some time. Curtis did not respond to his name when it was called. He did not engage with the psychology intern. He interacted with the child development specialist after she introduced a pop up book that caught his eye. He made squeaking noises as he looked through and giggled, sitting close to the specialist but with limited eye contact. He did not want to transition toys and did not take any toys and hold them out to show his parents during the assessment.

Assessment and Recommendations: In summary, Curtis is a 2-year 8-month-old boy with developmental delays in a number of areas, including particularly communication and social skills. Concerns have been raised by previous evaluators through the Child Development Services that Curtis may fall in the autism spectrum. In addition to extensive discussion with Curtis's parents today, observation of Curtis, and review of his records, I reviewed criteria for autism from the Diagnostic and Statistic Manual of Psychiatry-Fourth Edition with Curtis's parents. In the area of impairment in social interaction, Curtis can show varied eye contact depending on the situation, but overall I feel it is decreased. It was certainly decreased in the office today even when a very engaging adult play partner was interacting with Curtis, and it was also decreased when previous evaluators entered his home. Curtis shows a lack of spontaneous seeking to share enjoyment, interest, or achievements with adults, including his parents. His parents feel that he does not show show much response to their emotional state and seems perplexed by his cousin's temper tantrums.

In the area of communication skills, Curtis certainly has an expressive and likely also a receptive delay. He engages in some stereotypical language use, such as repeating the last word of a question asked to him. We did not echolalia during today's assessment. Curtis does not show any interest in imitative play skills, though this may be a product of his developmental level. In the area of restricted, repetitive, and stereotype patterns of behaviors and interest, he does show preoccupations with certain subjects, such as letters, numbers, and puzzles. His ability to learn and manipulate these objects are relatively high compared to his general developmental level. He also is interested in parts of objects, such as the wheels of cars. He tends to organize and line up his toys. Curtis very occasionally engages in stereotypical motor mannerisms, like flapping his hands when angry. He has some ritualistic behavior, such as touching trees and rocks on the playground.

Overall, I feel Curtis does fall on the autism spectrum. He fulfills 8 diagnostic criteria for autistic disorder, including at least 2 in the area of social impairment. However, I prefer to learn more information about his functioning in the preschool setting before refining his diagnosis to a specific autism spectrum disorder (autism versus pervasive developmental disorder not otherwise specified). I look forward to further discussion with his Child Development Services therapists and providers about this question. I am pleased that he is beginning developmental services. Given today's diagnosis, Curtis' progress in his program should be closely monitored. Consideration should be given to an autism-focused therapeutic developmental preschool program, and an increase in his speech and language therapy, particularly with a focus on social pragmatic as well as expressive and receptive skills.

As Curtis is very interested in books, I suggest this as a possible avenue for his parents to work on increasing his tolerance of social interactions wit other people. He is currently quite resistant to having someone else read to him. We suggest making a book with photographs that he may be interested in and trying to gradually increase his interest in reading with a reading partner. I gave Curtis' parents printed information today from the Maine Health Learning Resource Center, including a variety of books on autism and information about support groups such as the Autism Society, which I encouraged them to join. Curtis' parents are interested in the DAN (Defeat Autism Now) protocol. I discussed the fact that we do not specifically carry out this protocol through our office, but that certain aspects of the protocol, such as a gluten-free/casein-free diet and certain vitamins are likely not harmful, though their benefit has not been firmly established. (We discussed research findings, including a Cochrane analysis on the subject of gluten-free/casein-free diets). I suggested consideration of Fragile X and chromosomal testing, but Curtis' parents prefer to defer at the present time.

Today's assessment included 2 hours of face-to-face time and 1.5 hours of record review and report generation. I look forward to seeing Curtis back in 6 months.

Since this initial diagnosis, Curtis, mom, and dad, have been back to see this same primary care specialist every 6 months.

Greg, Dad
Dr. H, MD, MPH, PhD
Developmental-Behavioral Pediatrics

im listening to victorious soundtrack and i watched a brand new episode of spongebob squarepants yesterday and went to chuck e cheese too! i get in trouble from playing my cousin jayden on saturdays! second grade is awesome! i like my new classroom and i knew all my friends from last year! i got the school store open again and i got two new pencils and a second grade pencil! its good to be back at school but i miss summer! its almost halloween but im going to be batman this year! its getting cold out for shorts!

Curtis

This was a fun Halloween. Curt's costume was fitting as he sprinted the streets of downtown Portland in a glide that resembled flight. He didn't knock on doors so much as soar past them. He didn't care about the candy, an apple was good enough, and he didn't like getting dressed up in a costume. Over the years his mom's love of Halloween has won out over his desire not to conform to wearing a costume.This year he is already excited to sport a Batman costume more than a full month ahead of time.

Greg, Dad

At age 4, Curtis could no more understand the concept of Halloween as he could understand why someone carved a face into this pumpkin. He would not even hear of the explanation for Halloween and needed to be bribed to dress up. Even then his preference was to stay home and peek around the corner when the doorbell rang as opposed to venturing out into the weirdness. Curtis likes routine and order and to know what is coming next. I know, who wouldn't like to know what's coming next? He is put off by disruptions in his routine and often refuses to participate in non-recurring activities. Again here we pick our battles.

Last week there was a Field Day at Curtis' school. Last year we skipped the activity altogether once gauging his reaction to what a field day entails. A constant change of activities with screaming kids and rules he doesn't understand. More or less his worst nightmare. We accepted that while we like him to be challenged, this wasn't the time and it was all a little too much. When field day arrived this year he agreed to check it out and see how it went. He fought through the early part of the day but was frustrated at trying to keep up with the games which had rules that don't make a lot of sense, like egg tosses. His trusted support person brought him back inside for a bit to exercise his brain with math several grade levels in advance of the first. He aced the math to gain his confidence and then joined his friends for the real challenge, surviving field day.

Greg, Dad