ADI-R Summary

ADI-R Summary

Initial Concerns

• Mother reported first noticing differences at 18 months due to lack of response to his name and absence of pointing.
• Childcare educators raised concerns at age 3 regarding solitary play and distress during transitions, prompting referral for formal assessment.

Developmental Milestones

• Gross motor milestones achieved within normal limits (sat unsupported at 6 months, walked independently at 13 months); fine motor delays noted with persistent difficulty holding a pencil and using cutlery. No motor regression reported.
• Daytime bladder and bowel continence achieved at 3.5 years; continues to experience occasional nocturnal enuresis at age 6 (currently wears pull-ups at night).
• First single words emerged at 24 months ("car", "juice") and short two-word phrases at 36 months. No regression of language skills reported.

Language and Communication

• Follows simple one-step familiar instructions at home, but struggles with multi-step directions; interprets language very literally (e.g., looked at the ceiling when told "time flies").
• Frequently takes his mother's hand and places it directly onto doorknob or pantry latch to request access without making eye contact or vocalising.
• Speaks in full sentences currently, though demonstrates frequent delayed echolalia (repeating scripts from Bluey out of context) and requires his mother to reply with specific scripted phrases at bedtime.
• Rarely uses index-finger pointing to show interest; eye contact is brief and poorly modulated; limited use of conventional gestures such as waving or nodding.
• Speech is generally clear and fluent, but delivered with a flat, monotonous intonation and occasionally excessive volume.
• Does not engage in social chitchat or small talk; language is primarily used to request needs or deliver monologues about preferred topics.
• Struggles to maintain back-and-forth conversation, typically redirecting the topic back to ceiling fans regardless of the listener's input.
• Frequently makes blunt, socially inappropriate remarks to strangers in public (e.g., loudly asking a shopper, "Why are your teeth so yellow?").
• Exhibited pronominal reversal between ages 3 and 5, frequently saying "You want water" instead of "I want water" (mostly resolved now).
• Identifies basic emotions (happy, sad) in picture books, but struggles to read subtle facial expressions in others; facial affect is often flat unless highly distressed or excited.

Play and Social Skills

• Did not spontaneously imitate household routines (e.g., sweeping, talking on a toy phone) as a toddler; required hand-over-hand prompting to copy actions in nursery rhymes.
• Engages predominantly in constructive and functional play (building Lego sets strictly per instructions); complete absence of spontaneous pretend or cooperative imaginative play with peers.
• Demonstrates limited imaginative storytelling; play scripts are exact re-enactments of television episodes rather than novel storylines.
• Reluctant to share toys with his younger sister, becoming distressed if items are moved from his designated layout.
• Rarely brings toys or drawings to show parents for shared enjoyment; mother noted, "He only calls us over if a toy is broken and he needs it fixed."
• Does not spontaneously approach or attempt to comfort parents or his sister when they are crying, often walking into another room to avoid the noise.
• Social approaches are often intrusive or one-sided, such as standing too close to peers and listing train models without greeting them.
• Disliked reciprocal games like peek-a-boo and pat-a-cake as an infant; currently avoids playground games like tag due to difficulty understanding shifting rules.
• Plays in parallel alongside peers at school; tolerates their presence if they do not interfere with his play, but rarely initiates interaction.
• Has no reciprocal friendships; gravitates toward one older child at school who shares an interest in timetables, though they do not socialise outside of school.

Stereotyped Behaviours and Restricted Interests

• Intense preoccupation with ceiling fans and train timetables; spends up to 2 hours daily researching fan blade specifications and experiences significant distress if interrupted.
• Repetitively lines up toy cars by colour and size along the skirting boards, inspecting them from eye level rather than pushing them around.
• Insists on closing all internal doors in the house before leaving and must eat foods on his plate in a strict clockwise order.
• Covers ears and cries in response to vacuum cleaners, hand dryers, and blenders; extremely selective eater who gags on mixed textures (e.g., lasagne); insists on having all clothing tags removed.
• Requires daily visual schedules; exhibits prolonged meltdowns (screaming, dropping to the floor) if the driving route to school is altered due to roadworks.
• Carries a hard plastic miniature Thomas the Tank Engine figure everywhere, insisting on holding it while sleeping and bathing.
• Flaps both hands rapidly at chest level and walks on tiptoes when excited or watching spinning objects.

Aggressive Behaviours

• Hits out at mother or throws nearby objects when screen time is abruptly ended; bangs his own head against the sofa cushions when overwhelmed by sensory input or unexpected changes.

Additional Information

• Mother noted that maternal uncle was diagnosed with Asperger's syndrome in adulthood.
• Sleep onset is delayed by up to 2 hours most nights; currently trialling melatonin 2 mg PO nocte prescribed by his paediatrician.

Overall Interpretation

The developmental history provided by the mother on the ADI-R indicates persistent and pervasive difficulties across reciprocal social interaction, communication, and restricted, repetitive patterns of behaviour. Scores across all three core domains (Qualitative Abnormalities in Reciprocal Social Interaction, Qualitative Abnormalities in Communication, and Restricted, Repetitive, and Stereotyped Patterns of Behaviour) exceed the established ADI-R algorithm cut-offs, with symptom onset clearly evident prior to 36 months of age. These findings will be integrated with direct clinical observation (ADOS-2), cognitive testing, and school reports to formulate a comprehensive diagnostic conclusion.