Case Study Part I
Kofi is an overweight 8-year-old boy who was diagnosed with ASD and borderline intellectual functioning (IQ of 75) at 4 years of age when he presented with delays in social communication skills (lack of conversational speech, poor eye contact), repetitive and stereotyped behaviors (hand flapping and toe walking).He is receiving state-of-the-art physical, occupational, and speech therapy; social skills group therapy; and behavioral therapy.
His medical history is significant only for occasional bouts of loose, foul-smelling stools.
He presents to your general pediatric practice with his mother, who is concerned about new problem behaviors.
When asked to elaborate, his mother says that over the past several months, Kofi has been “biting, spitting, and growling” at his classmates, teachers, and 10-year-old brother. She adds that Kofi has difficulty staying in his seat and participating in class activities.
She has received numerous phone calls from his teachers, who are concerned about the safety of the other students and themselves. They have tried several behavioral interventions with limited success.Kofi’s mother reports less physical aggression at home, but notes that Kofi has become more irritable. He has tantrums nearly every hour and especially right before bedtime.
Kofi also wakes up at night upset and has trouble falling asleep again. “The police have even come a few times,” cries Kofi’s mother, “because someone thought I was abusing my child!”
Kofi’s mother buries her face into her hands and begins sobbing. “He was making such great progress with his therapies…I don’t know what happened!”
After you comfort and reassure Kofi’s mother, she tells you that Kofi has been in good health. His intermittent diarrhea was present well before these new behaviors and has not worsened.
Kofi’s mother states that the diarrhea has improved since he was put on a lactose-free diet several years ago. Kofi continues to have a hearty appetite (“He eats anything I put in front of him!”).
He had no caries or gum disease on his last dental exam and cleaning.
Kofi’s mother reports that she has tried giving Kofi a warm bath, deep pressure massage, using his weighted vest, and playing “relaxing” music to help him sleep.
In spite of these strategies, Kofi regularly wakes up three to four hours after he falls asleep. “Sometimes Kofi will wake up and just wander around the apartment,” explains the mother. “Other times he’ll start crying, or worse, screaming.”
Kofi only falls asleep when one of his parents is in the bed with him. His mother reports no heavy snoring, coughing, or times when he briefly stops breathing while he is asleep.
His mother identifies Kofi’s aggressive and irritable behavior as the highest priority. She worries that it will escalate to a point where he will “really hurt someone.”
She cannot identify any triggers for these outbursts. There have been no stressors or major changes in the family or in Kofi’s social and educational settings.
“Most of the time it just happens out of the blue,” she explains.
She and Kofi’s teachers have tried time-outs and behavior modification plans, including one based on applied behavioral analysis, to little avail.
Your physical and neurological exam reveals no changes since his last exam six months ago. His BMI remains high at 29.3.
You observe one of Kofi’s outbursts. He has a high-pitched cry and begins tossing your toys against the wall. He screams and kicks on the floor for several minutes until the screensaver of your computer captivates his attention.
Kofi’s mother is aware that children with autism can be aggressive and irritable and have difficulties with sleep regulation. She has read about other children with similar problems.
She says, “My friend’s son takes Ritalin® for his behavior problems. Do you think medication could help Kofi?”