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ASPERGER SYNDROME: Clinical picture at a 5-year-old boy and diagnostic work of assessment.

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(1)ASPERGER SYNDROME: Clinical picture at a 5-year-old boy and diagnostic work of assessment. Dr Paule Philippe1, Dr Jean-Marc Scholl2 1.START. Liege Autism Reference Centre www.chuliege.be/cral. The child's parents consulted the Liege Autism Reference Centre in 2007; the child was 5 years old. A diagnosis of Asperger Syndrome has been evocated . The main difficulties arise at school to the point that the child stayed at home for a few weeks and worked with his father.. 2. CLINICAL PICTURE * Language * Apprenticeship. Uncommon abilities. he began to speak when he was about 8 months, had a wide vocabulary very early; he still takes pleasure in inventing new words, in playing on words and tones Except when at school, he is very curious of everything and eager to learn series by heart, he possesses an impressive memory for his age. His interests are particular and precocious: before 3 years old, he knew the flags of the different nations, compared their colours in different dictionaries; he also knows the international code of signals and the meaning of the marine signal flags, he is an expert in coats of arms, in French medals… he is a big fan of space and knows every planet in the solar system. * Computer sciences he watched his father and learned very quickly; now he is nearly independent. * Reading he began to learn when he was 3- 4 year old and is now progressing alone with didactical softwares. * Music he prefers adults‟ songs or classical music; he „s able to beat time with the music, to sing the second voice … or to ask a precise classical piece by the composer's name, the number of the track on the CD and its exact position on the shelf. * Spatial orientation and observation: when he travels by car, he pays attention to the road and to information given by GPS, he memorizes the road as well as its difficulties.. Main difficulties. * social interaction. he presents a significant impairment in day-to-day functioning: he would like to have friends but doesn‟t know how to socialise; his games are strange: jumping on drain covers, turning around columns, continuously pressing switches on and off ,closing and opening doors; he pays very attention on details. As well home or at school as during our assessment, this boy has a major problem obeying commands and following rules: he doesn‟t obey command, disrupts the group activity; he can "sabotage" an activity by shouting, producing sounds, being violent. He doesn‟t like unexpected events or changes; he is an emotional boy, sometimes aggressive and gets angry; he needs being isolated from the situation to be able to calm down. He id also very anxious. * atypical use of language: one-sided verbosity, restricted prosody; he never understands metaphors and is very surprised by this use of language. * physical clumsiness: particular physical movements when he is under stress. * restricted stereotyped patterns of behavior and interests: he is continuously pressing switches on and off, closing and opening doors; he can also take refuge in the toilet and stay there playing with the toilet flush. He spends a lot of time looking very attentively at the pictures of a dictionary.. 3. CLINICAL ASSESSMENT * developmental anamnesis: no general delay in language or cognitive development, on the contrary: very premature: he began to speak when he was about 8 months.. * medical anamnesis: difficult pregnancy: ovarian stimulation, Endocervical polyp ablation at 6 months of pregnancy, early delivery threat at 7month of pregnancy. Delivery without problem. Birth weight: 2kg700, length 49 cm; normal neuropediatric examination. Low thyroid hormones rate and Interventricular communication without clinical repercussion. Ablation of tonsils at 4 years of age. * observations at school, at home and during consultations: sensory distinctive characteristics: - auditory hypersensibility and very good auditory discrimination ability (foreign languages – astonishing knowledge of music)- gustatory hypersensibility and high discerning ability (e.g. he can identify very accurately the different spices in a preparation). - olfactory hypersensibility AUTISM SPECTRUM - tactile hypersensibility  close attention to (both visual and auditory) details : he grasps reality from details rather than with a global view. This particularity gives him excellent skills in some fields (e.g. visuospatial markers) but puts him in some difficult positions, e.g. observation and understanding of faces and social situations.  lack of mental flexibility: he sticks to his positions without seeming to include the partner‟s demand or intention; e.g. during the neuropsychological testing, he refused to do some tests whereas he is absolutely able to do them; as a consequence, the results do not reflect his real cognitive capacities.  Hyperactivity: he can't sit still, keeps walking, running, or climbing around when others remain seated, he talks when others are talking.  Impulsiveness: he acts impetuously without thinking first; he switches very quickly from one activity to another; he has trouble taking and waiting for in conversation, in games and also while being tested. * neuropsychological tests: inhibition difficulties ++ , difficulties ++ for social relationships comprehension . no impairment for: lexical/ verbal short-term memory/ visual selective attention/ data processing speed / visuospatial abilities/ abilities in recognizing simple feelings NB: The child‟s father said to us time and time again that he had experienced the same difficulties of integration and recognition as his son. He has always had the feeling of being different;. to integrate with a group; he has searched and found techniques and has chosen amplification and humor. 4. ETIOLOGIQUE HYPOTHESIS:. developmental factors: abnormal migration of embryonic cells during foetal development may affect the final structure and connectivity of the brain, resulting in alterations in the neural circuits that control thought and behavior. (AUTISM/ a neurological disorder of early brain development R Tuchman, I Rapin).  difficulties to indentifie human stimuli: facial expressions, intonations, physical attitudes....  lack of theory of mind: impairments in understanding or anticipating intuitively the intentions and the thoughts of the other one; the boy has difficulties of social integration and instinctive understanding of the rules of life in group; he doesn‟t understand behavior or situations and becomes very anxious  imited empathy with his peers : difficulty to perceive intuitively what the other one feels  impairment to adapt its behavior  Regulation disorders of sensory processing witch “refer to child‟s difficulties in regulating emotions and behavior as well as motor abilities in response to sensory stimulation that lead to impairment in development and functioning”. (DC/0-3R)  another intelligence: better capacities to see details without deficit of global perception (L Mottron: l‟autisme, une autre intelligence). 5.DIAGNOSIS.  very numerous regulation disorders of sensory processing (DC:0-3R).: type hypersensitive negative/defiant (410)  Asperger syndrome DSM IV R: F84.5 [299.80]. AUTISM SPECTRUM.  ADHD Predominantly Hyperactive-Impulsive Type DSM IV R (F90.0 [341.01]. 6. PROPOSAL FOR GLOBAL CARE AND ORIENTATION. * A school integration assistant in his class of 1 ° year of common education: a student in psychology is present and supports him at his classroom half a day a week; * Some information to the teacher * Backing and support to his parents who are very attentive and very involved in the assistant that their child needs  A new evaluation must be made before the end of the school year,. (1) Centre de Ressources Autisme Liège, polyclinique universitaire Brull, Université de Liège; 4000 Liège ; Belgique; paule.philippe@gmail.com (2) SSM « Centre Familial d'Éducation » ; 30, rue des Déportés ; 4800 Verviers ; Belgique ; jeanmarc.scholl@freeworld.be Multidisciplinary team: prof V Ramaekers (medical director), dr P Philippe (team management), dr P Trenoye, M Di Duca, P Evrard, P Lambert, D Napieralski, M Sauveur, A Thomas, F Voz, G Vrancken CRAL quai Godefroid Kurth, 35 (11ème étage) 4020 LIEGE Tél. : 04 270 32 78 – Fax 04 270 32 92E-mail : cral@chu.ulg.ac.be.

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