Autism Diagnosis

Autism Diagnosis

Patient Information

• Lucas Mitchell
• 14/03/2021
• Male
• 42 Kensington Rd, Rose Park SA 5067
• 0412 345 678 (Mother: Sarah Mitchell)

Presenting Concerns

• Referred by GP for developmental assessment re: expressive language delay, poor eye contact, sensory sensitivities, and restricted play patterns noted over the past 18 months.

Developmental History

• Born at 39 weeks via NVD, BW 3.4 kg, no neonatal complications. Gross motor milestones WNL (walked at 13 months). Speech delay: first single words at 22 months, currently uses < 15 single words and no 2-word phrases. Regression of wave/point noted at 18 months.

Medical History

• Recurrent otitis media (bilateral grommets inserted 11/2023); mild infantile eczema; chronic sleep-onset insomnia.
• melatonin (Circadin®) 2 mg PO nocte, colecalciferol (vitamin D3, Ostelin®) 400 IU PO daily.
• NKDA.

Family History

• Maternal uncle diagnosed with ASD; older brother (7 yo) has ADHD.

Social History

• Lives with both parents and 7 yo brother. Attends childcare 3 days/week; educators report parallel play only, distress with routine transitions, and difficulty following group instructions.

Behavioural Observations

• Fleeting eye contact, did not respond to name on 3 attempts. No joint attention or social referencing observed. Repetitive lining up of toy cars, visual peering at spinning wheels, and intermittent hand-flapping when excited. Vocalisations limited to jargon and echolalia; used mother's hand as a tool to open containers.

Assessment Tools Used

• Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) Module 1, Autism Diagnostic Interview-Revised (ADI-R), Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), DSM-5-TR diagnostic criteria.

Diagnostic Impressions

• Meets DSM-5-TR criteria for Autism Spectrum Disorder (ASD) with accompanying language impairment, without intellectual impairment (provisional).

"Lucas Mitchell has received a diagnosis of Autism Spectrum Disorder.

Their present behavioural pattern remains consistent with the diagnostic criteria for Autism Spectrum Disorder in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, Text Revision (DSM-5-TR). The diagnosis was reached alongside the psychologist’s extended assessment report."

Severity level for Autism Spectrum Disorder

• Social Communication: Level 2 - Requiring substantial support
• Restricted Repetitive Behaviours: Level 2 - Requiring substantial support

Lucas Mitchell also experiences the following challenges or disabilities:

1. Severe expressive and receptive language delay
2. Sensory processing differences (auditory hypersensitivity and oral-motor food selectivity)
3. Emotional dysregulation and severe distress during routine transitions
4. Sleep-onset and maintenance insomnia

Lucas Mitchell would benefit from coordinated care involving multiple disciplines. I recommend the following allied health providers to address the health concerns described above:

• Physiotherapist
• Speech Therapy
• Occupational Therapy
• Psychologist / Counselor
• Dietician
• Behavioural Therapist

I also advise carer assistance because the patient has substantial support needs.

I fully support the family’s request for an early childhood intervention service.

Recommendations

• "Today’s diagnosis of Autism Spectrum Disorder will enable the child to access 20 allied health sessions under Helping Children with Autism (HCWA) funding."

Eligible Allied Health treatment practitioners include

• Psychologist (MBS items 82015, 93035, 93043)
• Speech Pathologist (MBS items 82020, 93036, 93044)
• Occupational Therapist (MBS items 82025, 93036, 93044)

Application for NDIS Early Childhood Approach (ECA) funding; formal audiology review to confirm grommet patency; baseline bloods (FBC, ferritin, lead, Fragile X, chromosomal microarray).

Follow-Up

• Review in 6 months to monitor developmental progress, sleep hygiene, and NDIS therapy implementation.

Clinician Information

• Dr Eleanor Vance
• Consultant Paediatrician, FRACP
• 24/10/2024