MEDICAL REPORT

Patient Name: Kaung Soe

DOB: 14/07/2008
ID: BRMS 718
Clinic: BR Medical Suites
Physician: Dr. Vinita Shrivastava
Report Date: 31/10/2012

Concerns:
1. Speech and language delay.
2. Social interaction difficulties
3. Social communication difficulties..

Medication: Nil.

Dear Dr. Vishwanathan:

Thank you for referring Kaung for his assessment to the Pediatric Clinic at BR Medical
Suites. Kaung is now 4 years 3 months old and today the parents were concerned about
his speech and language delay as well as lack of interaction with his peer group. They
also reported that he does not seem to have any friends.

Qualitative Abnormalities and Reciprocal Social Interaction:

Kaung has inconsistent eye contact, but parents were not concerned about his facial
expression. He does show social smiling only to a range of people but not to variety of
people. He is able to beckon parents by waving hands as well as can ask for water by
saying “water please.” He usually tends to get along well with the older age group of
children and usually plays chasing games around the children. However, generally he
does not like approaching other children. He usually prefers adult’s company and
mainly when he wants to play he usually follows the older children. However, if he is
approached by other children he would prefer to play with them. Currently, he is not
showing any participation in spontaneous games with other children.

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Sometimes when he sees his parents upset he can give them hug and sometimes can say
“no cry.” If he himself is hurt he can come to his parents and show the place where he
has been hurt. He can sing the birthday song in the birthday parties. There are no
inappropriate responses to other,s emotional status. Usually when his parents come
back home from work he gives them a hug, but it is not always a consistent reaction. He
sometimes uses made up phrases which does not make sense. Usually he tries to catch
the attention of his parents which is mainly for demand or request and looks at them
and says “ah.” When he brings any toys home, then he sometimes shows his mother as
well.

Qualitative Abnormalities and Communication:

He said his first word as daddy when he was 1-1/2 years old and his first phrase was
when he was 3 years old. He is showing the distant as well as near pointing. He does use
the hand of the parent as a tool.

Stereotyped and Repetitive Use of Language:

There was no enough language to assess for this; however, he does show echolalia.

Lack of various spontaneous make believe and social imitative play,

He tends to play with cars, football, and sometimes he tries copying fathers DIY actions
for example a screwdriver action. He is also taking saucepans and trying to cook. He is
loves being physically active like jumping on the sofa bed and likes making sounds with
the drums. He does have some imitative play as he plays as a monster.

Restricted, Repetitive and Stereotyped Pattern of Behavior:

There are concerns around this area from the parent’s report. However, he is very
much interested in computers and TV, especially on the youtube, but he is flexible
enough to let them switch off the TV. There are no rituals and no difficulty with change
in environment or the routine.

He does not prefer to go on the swings. There were no preoccupation reported with any
part objects.

There is no report of any developmental regression.

He can go on the baby toilet for poop. He can be very picky for eating and does not like
mashed foods but he loves chocolates and potato chips. There are no concerns
regarding sleep pattern or aggression; however, sometimes when is frustrated he can
bang his head on the sofa. There is no history of any fits or faints. He loves music and
loves to dance.

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Birth History
He was born by normal vaginal delivery after uneventful pregnancy and his birth weight
was 3.78 kg and he did not show any neonatal complication. He did have jaundice which
resolved in 2-3 days and he was mainly breast fed.

He started smiling at 6 weeks, sitting at 6 months, standing at one year and walking at
1-1/2 years.

Medical History:
There has been no illness or accidents reported.

Family History:
He is the only child in his house. His mother is 42years old, father is 40 years old who
has diabetes mellitus type II. There was one previous miscarriage, however, there was
no history of any problems from the point of view of genetic or development delay in
both the sides of family. There are no concerns regarding his hearing or vision.

Examination:
On observation today, Kaung was comfortable in the clinic environment, however, he
did not seem to have much eye contact, and he also had limited interaction with the
parents. He was saying some single words and however was comfortable during the
developmental assessment.

On examination today he looked well and there was no neurocutaneous stigmata. His
height was 103 cm at 25th percentile, his weight was 16.3 kg > 25 th percentile and his
head circumference was 49 cm > 3 rd percentile. Rest of his clinical examination was
unremarkable.

Developmental Assessment:
His developmental assessment was done by Griffith mental developmental scale and he
achieved the following score at chronological age of 51 months.

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 Developmental Assessment Developmental age

1 Locomotor subscale 34 months approx

2 Personal social subscale 29 months approx

3 Hearing and language subscale 27 months approx

4 Eye and hand coordination 27 months approx

5 Performance subscale 40 months approx

6 Practical Reasoning 36 months approx

He was able to say some colors such as yellow, blue and red, however, his pronunciation
was not clear. He was able to count up to 10. He was quite inattentive while the
developmental assessment. One thing peculiar about this assessment is showing that he
is very visual and as a result of that he performed very well at performance subscale
and it is not very delayed as compared to other scales. He performed better at
performance practical reasoning subscale as compared to other subscales. But all
through the subscales, he is showing the developmental delay.
Sensory Difficulties assessment

His sensory profiling was done through the parent’s questionnaire and he achieved the
following results.

He is performing typically for his age on the auditory processing, visual processing,
gustatory processing, multisensory processing and sensory processing related to tone
as well as behavioural and emotional responses.

He is showing hypersensitivity in the vestibular processing area and the modulation

related to body position and movement. He is also showing more hypersensitivity in the
oral processing area, modulation of move and affecting activity level, modulation of
sensory input, modulation of visual input, behaviour affected by sensory processing as
well as threshold for response.

On the basis of the questionnaire for his fine motor and coordination, he is showing
difficulty in several areas as well.

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ADOS assessment The ADOS is a structure observational assessment designed to
evaluate joint referencing, social relatedness and communication skills. Additionally,
this measure allows evaluation of restrictive interest, repetitive and socially
maladaptive behavior. Keith was administered the ADOS which is a semi-structure,
standardized assessment of communication, social interaction and play for use with
individual with possible autism spectrum disorder.
It was done by module 1 and it showed the following results.

Language and Communication: He was saying recognizable single words at least more
than 5, for example “blow” and he was also combining two words together, eg; “it is
working”, “ what is that”, “it is truck”. He was directing the vocalization to the examiner
and has a little variation in pitch and tone. He was also echoing the words and phrases
which are used regularly and they were almost exclusively stereotyped utterance. There
was no use of another person’s body to communicate and he was using pointing to
reference objects, but without sufficient flexibility. There was a spontaneous use of
description and conventional and emotional gesture, but they were limited in range.

Reciprocal Social Interaction: He showed poorly modulated eye contact and he was
smiling only in response if physical component was intented. He smiled fully and
sometime partially in response to a repeated action with the physical component like
tickling. He had some directed facial expression and used eye contact and vocalization
independently of each other to communicate social intention.

He was showing some appropriate pleasure in his action during several activities like
balloon and bubble. He looked immediately towards the examiner and made eye
contact when his name was called. There was appropriate exhibition of integration of
eye contact with vocalization as well as the gestures while requesting bubble as well as
balloons. He was also giving object for the purpose of getting help. He was showing
some toys or object in an inconsistent manner, however, he did not demonstrate any
spontaneous initiation of joint attention. He used the examiners eyes and face alone as a
cue to look at the rabbit and social overtures often lacked integration into context and
social quality.

Play: There was mainly play appropriately to cause and affect toys and I did not see
him do any imitative or pretend play.

Stereotyped Behaviour and Restricted Interest: There was no unusual sensory

interest in the play material and he did not exhibit any complex hand or finger
mannerism or self injurious behaviour.

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Other Abnormal Behaviour: He did not show any over activity, tantrums or any
anxiety.

Overall, Kaung’s performance on ADOS met classification cut-off for autism on communication
domain and autism on social interaction domain as well as autism in total.

Although testing with ADOS does not mandate or negate a diagnosis. It has
demonstrated utility in establishing an acute diagnosis.

Plan:
1. I discussed in detail with the parents and mentioned that he is showing sign of
autism as well as developmental delay and he needs to have specific support for
his condition
2. He will need occupational therapy for his fine motor delay as well as sensory
issues.
3. He will also need an assessment by specialist speech and language therapist who
has experience with social communication issues.
4. He will need 1:1 time at least 3-4 hours every day, special needs teacher.
5. Parents will be given several helpful leaflet in order to help him augment his
education, manage his behavior and help him with social communication.
6. A karyotype and fragile-X needs to be excluded by genetic
7. I there are any queries regarding the report please do not hesitate to contact
myself.

Thanking you

Yours sincerely,

Dr. Vinita Shrivastava MSc (London) DCH (Ireland)

Developmental & Behavioural Paediatrics.

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