Expert: Celtica - 11/4/2007

Question
QUESTION: I have a four year old boy who is going through a long assessment process. His pediatrician initially felt that he may have a mild form of autism but the developmental pediatrician at this point says simply that she does not know how to diagnose him. My son suffers from severe anxiety at times when he is in public places. He will put his hands over his ears if there is a lot of noise and will tell people to talk quietly when they speak to him. Sometimes he will break down and cry and or scream until he is removed from the situation. It usually takes him about twenty minutes to calm himself down. He will thereafter insist on returning to the place in which he was experiencing anxiety but this is not always possible and sometimes the anxiety returns. Sometimes when he is very anxious he wants everything to stop. He wants everyone to stop talking, he does not want music to be played and he wants all movement to stop. For example if we are in a mall he will position himself in front of strangers’ carts to try to stop them from moving.

He does not always experience anxiety to this extreme. His anxiety levels seem to fluctuate and he can tell me before we leave the house if he is up to going out or not but I try to get him out frequently and I take him everywhere so that he is able to experience everything other children do. I am usually able to monitor his anxiety level so that we leave events on a positive note but sometimes changes in routine can send him over the edge. We have to do most things in an exact order; he has an incredible memory.

Transitions are very difficult for him but I have learned to give him sufficient notification before any changes are to be made which seems to lessen his anxiety. Still little things like when his little brother changed his mind about which movie he wanted to rent sent my four year old into a break-down in which he will obsessed over the change that had been made.

  When my four year old becomes excited or agitated he flaps his hands. Sometimes you can communicate with him when he does this but other times he does not respond and will even walk into people and objects when he flaps his hands. This motion is usually accompanied by some inaudible vocalizations and when he is very anxious he will stomp his feet too. He tends to do this a lot when we go for walks; he gets distracted and seems to phase out and I will have to call him back into focus every few minutes.

  His language is very concrete and much of it is memorized though he is just recently learning to use spontaneous forms of speech. He likes to watch movies until he has memorized them word for word and then will use these memorized words and phrases in everyday conversations but they are not always contextually relevant. He is not able to respond to any questions that are formed using the past tense.

  He is very social with familiar adults and has excellent eye contact but with children he is socially awkward. He rarely makes any attempt to speak with them and makes little eye contact with them and his play is usually inappropriate and sometimes aggressive; he tends to use physical contact to communicate though he is learning not to use hands and will engage in some forms of play like tag but only for short periods and this normally will end with him crying.  He is however beginning to engage in imaginative play with his three year old brother and for the first time has begun to play with toys though this is generally limited to Lego figurines.   

  He has some trouble with fine motor skills for example he cannot cut with scissors and has difficulty doing 10 piece puzzles. He can however, ride a bike. He has very good computer skills and can complete video game levels that I cannot. He does sleep through the night and he is very affectionate with me and sometimes with other family members. There are times however when he refuses to speak to other family members and will retreat to his room; this is typical of holidays. He is also very aware of facial expressions, tone and body language and can read people and situations well. He is a very intuitive child. He does not like certain textures but is drawn to others. He finds comfort in lying down on the floor and does this persistently in public places. He is doing well with Occupational Therapy but all interactions cause him anxiety and after these sessions he will cry and want to go home.

  Formula as a baby made him very ill until we switched him to a soya based brand. He still drinks soya milk. He also had a low immune system as a young child and had a number of ear infections. He also suffered from thrush a couple of times. I mention these because I have heard that diet, digestive difficulties and yeast are associated with autism.

  Any suggestions or information you could provide me would be greatly appreciated. As it is right now most of his difficulties are being labeled as behavioral but I believe that simple behavioral management techniques are not sufficient to help my son through some of his difficulties.

Thank-you for your time and help.

ANSWER: Hi

I can relate very much to most things you wrote.
The only thing that sounds rather unfamiliar is that he can "read" people and situations very well, which I, and most other autistic people cannot do easily.
Therefore it could also be possible that he has "just" Sensory Integration Dysfunction/Disorder (SID). This disorder is very common among people on the autistic spectrum, but there are a few people who aren't autistic and still have severe SID (this could be the case with your son). However, you should probably try to find another doctor and get a second oppinion (and get him reevaluated for autism). Since no two people with autism are the same he may still be autistic even if he can read people/situations well. I would also suggest to get him evaluated for SID. It may help alot with his anxiety if he is not in sensory overload most of the time.
A very good book to read is "too loud too bright too fast too tight" by Sharon Heller.
Reading about allergies/food issues is a very good idea (if I were you I'd start with getting your son tested for candida). Since I'm on a gluten and casein free diet I'm doing much better anxiety wise.

I hope this helps.
C.  


---------- FOLLOW-UP ----------

QUESTION: I have a question about the social anxiety. The developmental workers suggest that when my son is experiencing anxiety and cries and screams in public that I should not remove him from the situation because it is teaching him to be manipulative and that I he will learn to have tantrums to remove himself from undesirable situations. My argument is that in many cases he does not have a melt down because he didn't get his way or because he was aksed to do something he didn't want to do. He could be in a place that he thouroughly enjoys and have nothing asked of him and still break down. Sometimes it is brought by a change in routine but sometimes it all just becomes too much and his behavior will change, his face gets tight and his eyes become severe; there is a noticeable physical change brought on by anxiety and this is usually followed by crying and/or screaming. For example at the indoor pool he will be perfectly happy for the 1st half hour but then he seems to become lost within the open space and will move around without any clear direction and his social behavior changes, he may follow children too closely or get in their space or try to avoid them all together. He is aware of the other children's reactions to his behavior and this only seems to escelate his anxiety. I will at this point remove him from the setting, most times before this point to try to end the event on a positive note but sometimes it ends in screaming and then he will obsess over the fact that he was removed from the situation.

I have learned to calm him down much quicker; it usually takes about 10 minutes now when before it took nearly an hour. Sometimes just telling him I love him and am proud of him is enough to calm him down and will stop him from obsessing over what he perceived to be as poor behavior but sometimes he needs to just cry through it.

After an experience like this he usually excercises hand flapping and may phase out for a while.

I don't think this behavior is manipulative and I don't think it can be addressed with simple behavioral management. I think the prediatricians and developmental workers need to find out why he experiences so much anxiety before attributing his behavior as being manipulative. What is your opinion on the matter?

Answer
From my point of view I'd say that what you're doing is the best for your son. He is clearly not "manipulative" if he's in sensory overload (what you discribe as "anxiety" is very probably just that), so removing him from such a situation is the only right thing to do (I still have to do that now as an adult).
I would talk to his pediatrician about the possibility that he might suffer from sensory overload (which can be anxiety provoking, but from what you write I wouldn't even say he's anxious, he's in full overload) and get him evaluated for Sensory Integration Dysfunction.
Hope this helps,
C.