Abbreviations: DTR = deep tendon reflexes, est = estimated, LOC = loss of consciousness, MA/VDL = mental age per Vineland Daily Living scale, NV = non-verbal, h = hours, d = days, m = months, y = years, yo = years old
A: 10 yo female; began school age 8. MA/VDL = 2 y, 11 m
Family history: negative for developmental disorder
Pregnancy and delivery: Normal
Medical history: Normal development to age 2 y 11 m when contracted cerebral malaria. The illness began with 3 h high fever, followed by convulsions and LOC for 20 d. Upon recovery, she was socially unresponsive and had no words. She began to walk again after about 3–4 months. No further seizures.
Pre-malaria development: Walked 10 m; toilet trained before 2 y. Single words by 9 m; phrases before 18 m; full sentences by 2 y. Normal socialization. Parents recall her as precocious.
Social Development: Does not attend to people talking to her; oblivious if parents leave the house; occasional social smile. Never offers to share; laughs when brother cries; facial expressions limited. Happiest when no one bothers her. In past 6 m tries to imitate mother cleaning, and carries the plates away after the meal. She looks at things with interest (e.g., notices when her mother changes hairstyle), but makes no attempt to share this interest. Upset if mother does not return home when expected.
Language development: A few words and gestures. To indicate toilet, puts hands on thighs and walks backward. Since starting school, says words of greeting and parting but has an abnormal pronunciation. Bites wrist to reply in the negative. Comprehends a few words: bath, meal, undress.
Repetitive behaviors: Marked insistence on sameness. Each morning goes directly to the bathroom to wash. If there is no water, must stay there until water is brought for washing. Fears the toilet and defecates next to the hole. After washing, she will dress and only after that will she eat. The same bathroom routine is carried out in the evening. Does not like to be touched, smells objects. Furniture must stay in the same place; puts things back if they are moved. Sits only on her own stool. Must have clean dress every day. If she sees the floor is wet, she gets a rag and wipes it up.
Examination: Examination limited because she was fearful of Caucasians. Saccadic intrusions into pursuit eye movements, dystonic posturing when walking and running, and intermittent toe-walking. Neurological findings typical for autism.
Diagnosis: typical low functioning autism.
B: 9 y.o. male started school age 8. MA/VDL = 18 m
Family history: Youngest of 5; mother one miscarriage. No FH developmental disorders
Pregnancy and delivery: Normal
Medical history: Normal development until malaria encephalitis at 42 m. High fever, convulsions for 1 w. Post-recovery: no convulsions, severe hypotonia for 18 m, hyperactivity began 1 y. afterward.
Pre-malaria development: Walked 10 m; toilet trained by 2 y; single words 9 m; phrases 23 m; full sentences soon after. Normal socialization.
Social Development: Since starting school, has begun to look at people briefly and to smile. Will use eyes to indicate something of interest but has only once sought to share pleasure when he successfully made a noise on his harmonica. Notices when family members are distressed. Limited facial expressions. Apprehensive interest in visitors. May bite children at school when they attempt to interact with him. Limited facial expressions used appropriately.
Language development: Since malaria, only speech is echolalia of phrases that teachers use to call him. Will repeat speech sounds and imitate the Muslim Call to Prayer. Communicates needs by putting mother’s hand on desired item. No gestures. Does not point to express interest but since starting school, uses eye contact to get mother’s attention. Recently, imitation of some actions (e.g., sweeping).
Repetitive behaviors: Likes cleanliness; will pretend scrub with a cloth. Likes to drum and hear drums and music. Attachment to a harmonica and plastic car. Has set morning ritual ending with putting on his school uniform, after which they must leave for school immediately. No self-injury or hand mannerisms. Occasional rocking.
Examination: Healthy, hyperactive boy. Bowed legs. Calm if undisturbed. Anxious when asked to do something novel. No speech or gestures. Frequent high-pitched screeches. Fleeting eye contact. No play. Allowed himself to be held by examiner. No repetitive behaviors noted. Poor imitative skills. Poor fine/gross motor coordination. Poor arm/leg coordination with gait. Neurological findings typical for low functioning autism; no localizing signs.
Diagnosis: PDD because of time of onset, but above threshold on other 3 ADI domains.
C: 10 yo female Began school age 7. MA/VDL = 4 y, 4 m
Family history: Youngest of 8; no developmental abnormalities; 1sib died of malaria age 2 y.
Pregnancy and delivery: Normal
Medical history: Hospitalized with malarial infection at 22 mos., Dr. told mother that she had “a very large load” of parasites. Probably not her first infection but much worse than the previous infections; not hospitalized for others. Pneumonia and severe convulsions treated with Valium. LOC postictal. Still seizes every 3–6 mos. depending on medication availability.
Pre-malaria development: “Exactly like my other children” before attack. Walked 18 mos; saying many self-initiated single words; normally interactive for age.
Social Development: At 5 y, no social interactions, eye contact, or laughing. Progress in last 3–4 y but still socially inappropriate; e.g., asks strangers for money. Near normal eye gaze, social smiling at parents, sharing. Does not show comfort to mother but comes near to her when she is crying; then tells neighbor. Range of social expressions, looked annoyed when someone refused to give her money. Spontaneous laughing. Sits in corner at school, demands that no one disturb her. Will leave or attack another child if approached. Uninterested if mother leaves but shows her things from school.
Language development: Made sounds at 3 y while looking at mother or sibs, speech therapy at 4, phrases at 5 poorly pronounced. Currently normal articulation, sentences, complex construction. No immediate echolalia, language is stereotyped and restricted. Only talks about topic of her choosing. Likes to recite family relationships, “my father will bring me...” No reciprocal conversation, inappropriate statements. Awkward imitation of other’s actions. Recently points to express interest, nods, shakes head. Good comprehension, can fetch things from store. No play with toys, no imaginative play.
Repetitive behaviors: Used to collect string, sharp objects. If starts song, mother must complete it, angry if mother refuses. Strict morning routine: wake, bathroom, dress, snack. Bed must be made properly with same sheets; if changed she sleeps on sofa. If her sheets put on guest’s bed, she tears them off. Likes to taste new things. Used to shake body.
Examination: Happy, active, uninhibited, easily irritated. Immediately asked friends and strangers for money. Good eye contact with mother, attended to name. Stereotyped, repetitive speech. Oblivious to visual confrontation from the right side. Poor visual fixation but possibly impeded by hyperactivity. Imitated facial movements without dyspraxia. Decreased tone, 1 + DTRs. Smooth, rhythmic finger motions by testing but functionally clumsy, unable to tie shoes. Poor gross motor coordination. Gait: good balance, walking, running, could not tandem walk.
Diagnosis: Typical verbal autistic child with mild to moderate MR.
D: 15 yo male Started school age 9. MA/VDL = 3 y, 3 m
Family history: Second of five children, only boy. One sister walked 3 y, possible language delay.
Pregnancy and delivery: Normal
Medical history: Salmonella Type B meningitis at 6 mos. with grand mal seizure, LOC for 30 minutes. Age 4–5, 2 or 3 seizures/day; currently, every 3 mos.
Pre-malaria development: Sat age 5 m; social development appeared normal. Family insists he could name family members at 6 m, but most likely normal babble.
Social Development: Unresponsive for some time after meningitis. Now, looks and smiles at people briefly, brings objects for parents to see. Only shares food. Will kick football with other children but otherwise does not initiate or accept approaches. No empathy. Stilted but readable facial expressions. Incorrect interpretation of others’ actions: if someone falls down, thinks his father will hit him, even though he was uninvolved.
Language development: No comprehension until 6 y; no words until 9–10 y. Currently understands many words, can fetch things by verbal request, e.g., find cell phone if it is lost. Currently, few words: mama, baba, come, don’t know. Says, “I’ll tell the father.” when sees sisters playing with stereo. Gestures for wants: toilet, toothbrush, TV. Nods yes and no, attends to name. Excellent memory for people and where they live.
Repetitive behaviors: No interest in toys. Flicks bottle tops for hours to obtain a particular sound. Collects, sleeps with more than 10 footballs. Invariant routine: At night, footballs go into bed first; morning, counts them, throws them off, makes motions of washing, takes tea in same place. Only after tea will he dress; then must get into car immediately to go to school. Siblings cannot play with their toys in his presence since it involves moving them. Likes to line up bottles, move them front to back. Puts hands in front of face, crossing fingers over each other. Occasional rocking.
Examination: Slender, passive, smiling boy. Long face but not dysmorphic. No eye contact or interest in examiner. Occasional smile. No words, some babble. Liked to clap, cross fingers. Poor smooth visual pursuit, saccades during fixation. Imitated facial movements awkwardly. Hypotonic. Decreased power. Hypopigmented triangle under L shoulder-blade. Poor gross/fine motor coordination by history. Gait: Good balance, slightly wide base. Reluctant to run; short steps, dystonic arm posturing. Toe-walking.
Diagnosis: Typical autistic child with non-verbal skills exceeding verbal.
E: 17 yo male Attended school only 1 ½y, age 13–14; no transportation. Est. MA/VDL = 18 m
Family history: First of four children. Youngest brother abnormal development with impulsiveness and learning disability.
Pregnancy and delivery: Mother had bleeding with cramps for 2 days at 3–4 m gestation. Caesarian section because of non-advancing labor
Medical history: At 18 mos he had his first malaria followed by seizure, LOC 3 h. Hospitalized 1 w with high fever. High malarial load (3 + parasitemia) confirmed by slide. Seizures every month with or without fever when not treated with anticonvulsants. Mood worsens hours to days before seizures.
Pre-malaria development: Sat at 6 m, walked at 12 m; single words at 14 m.
Social Development: No direct gaze, recently smiles, greets with prompting, not consistently. No social interactions. Only shows excitement with food. Does not offer comfort. Gets agitated and yells loudly if not understood. No pretend or social play. Used to avoid other children, now ignores them.
Language development: Some words remained after initial malaria, but gradually lost as seizures, fevers continued. No speech currently. Leads parents to object he wants. No gestures, imitation, pointing, expression of interest in objects. Understands yes and no, purse, pouch, food items, can fetch object from its usual place.
Repetitive behaviors: Likes to gather stones, paper, and throw them at his feet; agitated if interrupted. No circumscribed interests. Walks in circles. Recently started sniffing, tasting objects. Used to twist and flap hands; occasionally rocks when seated. Hits wall with head, hand when agitated.
Examination: Stocky, well-proportioned young man. Large head, protruding upper teeth, open mouth. No speech, occasional exhaling noises. Walked in circles until dizzy if not stopped, sometimes covering his eyes. No social smile. Avoided looking at faces. Unable to fixate, looked at objects from corner of eye. Saccades present during visual smooth pursuit. Unable to imitate facial movements. Slightly hypotonic. Slightly brisk upper and lower extremity DTRs. Poor fine motor coordination by history. Gait: Dipped right shoulder when walking. Decreased arm swing, slow gate, elbows at sides. Would not run.
Diagnosis: Low functioning autism
F: 8 yo female Attends local school for Mentally Retarded for last 6 m. MA/VDL = 2 y, 8 m
Family history: Oldest of three children. Except for brother walking at 18 m. all normal development.
Pregnancy and delivery: Long labor, normal delivery.
Medical history: At 9 m, continuous fever and convulsions for 1 week. LOC following seizures. After 1st episode, fever with convulsions every two weeks, then 1/month; last seizure 1 yr. ago. Not tested for malaria. No loss of milestones after this illness.
Development before malaria: Except for lack of babble, seemed normally responsive: liked to be picked up, good eye-contact
Motor Development: Sat 9 m; walked 18 m.
Social Development: Poor eye contact following malaria. Starting to improve: will answer the phone using stereotyped phrase; shares things but not enjoyment. Starting to notice others’ feelings: cries when brother cries, respectful of mother’s moods. When younger, would not let other children near her; now enjoys being near them. Recently, rudiments of pretend.
Language development: Did not babble before malaria at 9 m. Described as “silent”. Developed some words at 7 yo. Echolalic phrases, mainly songs, well articulated. Non-echoed speech poorly articulated. Tries to wave bye-bye but points fingers toward head. Bites hand/wrist for “no.” No comprehension at 4 y; now follows simple commands, e.g. goes to neighbor to get vegetables.
Repetitive behaviors: Likes music. Can repeat songs after one hearing. Puts paper in particular tin, stirs as if cooking vegetables. If tin is misplaced, looks for it constantly. If stopped from stirring, used to cry, scream, bite wrist; can now be distracted. Likes cleanliness. Licks new objects. Dislikes loud noises. No hand/finger mannerisms, jumps in place frequently.
Examination: Albinism but not dysmorphic. Neutral mood. No facial expression. Sang softly, hands over ears. Looked around room but not at people. Held but did not play with doll. Searching nystagmus. Difficulty imitating facial movements. Hypotonic. Trace DTRs in UE. Poor fine/weak gross motor skills. Gait: Slightly wide-based, flat-footed gait; walked and ran slowly. Could not tandem walk. Except for albinism, typical exam.
G: 12 yo male at school for MR since age 6. Est. MA/VDL = 19 m
Family history: Oldest of 3. Father hearing impaired. Two maternal uncles with developmental disorders. Brother has febrile convulsions preceded by headache; concern about development.
Pregnancy and delivery: Mother severe hypertension at 38 week. unresponsive to treatment. Unsuccessful induction of labor, subject delivered by Caesarian section. Oxygen for 2–3 h after delivery.
Medical history: Prior to malaria, mother told he “would be slow”. At 17 m, 2 febrile convulsions in quick succession without LOC. Hospitalized, received quinine for 8 days. Parents think development slowed and he gradually lost words afterwards, becoming non-verbal.
Motor Development: Sat at 6 m, crawled at 12 m., walked at 17 m
Social Development: Responds to name with a strong command. Greets upon mother’s request. Pushes younger siblings away; likes to be with mother. Likes to play hand games; will watch others play them and laugh. Never shares or offers comfort.
Language development: Words at 12 m, phrases at 15 m. After hospitalization, speech development slowed, lost all words and phrases by 30 mos; no speech currently. Some understanding of language, e.g., food names. Mother discerns wants by a series of questions. Indicates interest by looking at objects from corner of eye.
Repetitive behaviors: Holds piece of string/grass, rotates it until tired; this started after illness at 17 m. Looks sad and cries if taken away. Likes daily routines. Sits in only one chair, keeps track of its whereabouts. Likes to run in place holding chair or to hold and run around a standing pipe. Laughs while watching fingers and hand.
Examination: Wide-eyed, fearful boy, anxious in new setting. Exam therefore limited. Possible left exotropia. Would not imitate. Possible weak upper extremities, normal lower extremity strength. Poor fine motor coordination. Gait: Normal gait; does not like to run.
Diagnosis: Typical low functioning autism.
Case I. 11 yo male. Little schooling. Enrolled in autism unit but no transportation. MA/VDL = 2 y, 3 m
Family history: Only child. Parents both well educated. Mat cousin severely retarded, died at age 20
Pregnancy and delivery: Nl. preg and vaginal del. Large baby
Medical history: Normal. No Epilepsy
Motor Development: Sat 6 mos; walked 11 mos. Dry by 24 months
Social Development: Typically autistic at age 4–5 but is now developing some empathy. Helps grandmother when she is ill, but still does not share toys or enjoyment but will rarely point to show interest. On the bus he screams with excitement, which is embarrassing to his family. No tolerance for young children; watches older children play but withdraws if they approach him.
Language development: Still non-verbal, but uses social gestures if prompted, shakes head yes and no, and understands enough language to fetch things from another room.
Repetitive behaviors: Attached to one thing at a time—deck of cards, which he shuffled repeatedly, a particular magazine. Collects grass and leaves and tears them. These behaviors have a compulsive quality in that he is very upset if someone tries to stop them or hides a favored object. Frequent hand and finger mannerisms; callused elbows from spinning around on them.
Examination: Thin, cheerful child in continuous motion. Found a magazine and had to flip all the pages to the end. Normal eye movements; some facial dyspraxia. Decreased tone and reflexes, not particularly strong. Can button and tie, but fine motor coordination is poor, as is gross motor coordination—catches large ball but not small one. Walks with shambling flat-footed gait; toe-walked in past.
Diagnosis: Typical non-verbal autism
J: 13 yo male; started school age 10. MA/VDL = 2 y, 2 m
Family history: Negative; two normal sibs
Pregnancy and delivery: Pregnancy and term delivery normal.
Early development: Mother thought, from the beginning, that he was different from other children: hard to feed, did not learn to feed himself, did not speak nor indicate wants, not active, Walked 38 m; toilet trained age 6 y.
Medical history: Healthy; no serious malaria; no seizures
Social Development: Earlier, aversive to children’s approaches. Now approaches children only to chase them away if they take his soccer ball. He smiles at mother and one uncle and when begging for money. He is interested in showing money he gets to his mother, but not other things. In the last three months, he has started to wipe his mother’s eyes if she is crying. Fairly wide range of facial expression, from extreme fear and crying to happy and angry. Fearful of new places and new people. May laugh without any reason.
Language development: Since starting school, he has learned several words and signs and has more verbal comprehension. Still occasionally uses his mother’s hand for a tool to get what he wants. Now points at a few things of interest (since age 9), including a bus, motorcycle, a Caucasian. Recently learned gestures indicating “no” and “goodbye”. If distressed, will look at mother; has always attended to her voice.
Repetitive behaviors: Spends an hour each day building “villages” with bits of tin. First smoothes the sand on the ground and then arranges the bits of tin, always in same arrangement. He lets other children watch him, but if they move the bits of tin, he will fight them. Not attached to particular bits—if they are lost he looks for more. Spends long hours kicking football with other children. If someone takes the ball, he fights fiercely—it takes three big boys to overcome him. Takes ball to bed and to the dinner table. Since starting school, likes to carry around books and pens, pretending to be the teacher (says “teacher”). He may take these to bed. He has no abnormal sensory interests or finger mannerisms.
Examination: Thin, fearful of Caucasians. Insisted on keeping door opened during exam. Smooth pursuit was interrupted by saccades but saccades normal; no ptosis or strabismus; visual fields were normal. Very strong; DTRs 1+; gait normal except decreased arm swing. Good coordination, balance.
Diagnosis: Typical non-verbal autism.
K: 22 yo male Began kindergarten age 6; boarding school for special needs age 8–10; out of school until age 19 when accepted to autism unit. MA/VDL = 1 y, 10 m
Family history: Older of two children; brother normal; father died from diabetes complications.
Pregnancy and delivery: Normal
Medical history: No serious illnesses including malaria; no epilepsy; overweight and early signs of diabetes
Motor Development: Walked 18 m
Social Development: At 8 m, head-banging, improved social interaction when started school age 8 y. Will now sometimes share objects and notes mother’s distress. Limited facial expression may be inappropriate. Communicates to get needs met.
Language development: Some imitative language did not progress; is non-verbal but understands fair number of words and gestures. Pointing began recently.
Repetitive behaviors: He has been attached at various times to sticks and bottles and would line them up; now he carries a string in which he makes knots. He walks up to people and insists that they untie them, with distress, anger if he is refused; used to line up sticks, bottles. Unvarying daily routine; angry if interrupted. Good self-care; scrupulously clean.
Examination: On examination he is a short sturdily built young man with a large head, protruding widely spaced upper teeth. He has cauliflower ears and bitemporal scars from self-abuse. He smelled objects. He could not fixate on object; would or could not follow object past midline on left. Poor fine and gross motor coordination. Flat-footed, slapping gait without arm swing.
Diagnosis: Low functioning autism
L: 12 yo male Started at autism unit age 9. MA/VDL = 1 y, 8 m
Family history: Eldest of four children; others normal and good students
Pregnancy and delivery: Not recorded
Medical history: First convulsion at 24 m, non-febrile. Frequent malarial infections that increase convulsion frequency.
Motor Development: Walked 24 m
Social Development: Seemed normal first year of life, then became unresponsive. No social smiling, sharing, comprehension of distress. Brief direct gaze. Limited facial expressions, often inappropriate; mother can tell when happy. Tolerates but does not approach other children.
Language development: Some imitative speech at 8 m. Stopped speaking at 12 mos., never had phrase speech. Currently says an occasional understandable word, which is not then repeated. Uses adult’s hand as tool: on swing, door-handle, thermos. No gestures. Comprehends a few words: “tea-time”, “come get nuts”.
Repetitive behaviors: History of self-abuse, banging head or biting hypothenar eminence. Does not like pictures on the wall. Interested in airplanes; sensitive to other noises. Plays with string. Smells objects. Typical hand and finger mannerisms.
Examination: Short for age. Unusual head shape: wide and square at top. No social initiation, response, or eye contact with strangers. Typical hand mannerisms before eyes. Unwilling/unable to imitate facial movements. Low tone; DTRs could not be elicited. Poor gross/fine coordination by history. Gait: slow, flat-footed, dystonic posturing of arms while running.
Diagnosis: Low functioning autism with dysmorphic head shape
M: 9 yo male Began school at autism unit age 9. MA/VDL = 1 y, 8 m
Family history: Father deceased (possible yocardial infarction). Older sister and fraternal twin normal.
Pregnancy and delivery: 2nd born twin, transverse lie and fetal distress. Caesarian section. Breathing at birth. Birth wt: 2.5 kg (twin: 3.5 kg).
Medical history: Strabismus at 9 m. (resolved). Malaria with febrile convulsion at 18 m. Unresponsive for a few hours, hospitalized overnight. Hospital admission 8 y for fever, treated for malaria. Has febrile seizures that are atypical and focal (left face, arm, leg).
Motor Development: Sat 7 m; walked 24 m (later than twin)
Social Development: Seemed normal first 6 m, but active and did not like to be held. Recently notes mother’s mood. No play except kicks football to and fro with peers. Occasional social smile but no sharing of interest.
Language development: Single words at 8½ y, currently many words, some 2-word phrases. Abnormal articulation. Pronoun reversal; will now greet. No imitation or pointing; has learned to wave goodbye.
Repetitive behaviors: Attached to rubber duck and never puts it down. Before the duck, attached to other objects. Hand and finger mannerisms. Rearranges furniture if moved; likes all doors in house closed. When speaks, insists on particular answers.
Examination: Thin, happy boy, holding rubber duck. Some eye contact; odd social approach and talkative despite limited language. Occasional immediate echololalia. Visual smooth pursuit broken by saccades; saccades normal. Dystonic posturing when distressed. Limited imitation; facial movements apraxic. Poor fine/gross motor coordination. Gait: wide based, poorly uncoordinated, flat-footed gait.
Diagnosis: Low functioning autism
N: 14 yo female School for handicapped children age 7–11; Autism unit since then. MA/VDL = 4 y, 7 m
Family history: Language delay in father and younger brother.
Pregnancy and delivery: Hypertension but labor and delivery normal.
Birth Weight: 2.5 kg with good sucking and rapid weight gain.
Medical history: No epilepsy. Menarche age 11.
Motor development: Walked at 11 m; toilet trained 2 y.
Social Development: Abnormal social development obvious by age 2½. Little social interaction but improved lately. If happy, does not share this with others, but may rarely wipe the tears of a family member who is crying. You can tell her feelings from her facial expression. Greet mother’s friends if prompted. No peer interactions but likes to be around adults.
Language development: Single words at 18 m and phrases at 24 m, but since age 3, there has been no increase in vocabulary. Articulation always poor. Currently she uses 2–3 word phrases to request things, especially food and soda. To indicate agreement, she echoes. No social chat. Occasionally imitates mother sweeping and may pretend to use mother’s purse and imitate her walk. Rarely points to express interest and gestures are limited. Seems to understand most speech of others and can be sent on an errand.
Repetitive behaviors: When alone, she plays with string—pulling it, knotting and unknotting it. While sitting, bounces on her heels and claps her hands. She likes to straighten the couch cover. She puts each piece of clothing in the same place in her cupboard, and prepares her clothes the night before. She won’t wear dresses with pleats and won’t wear nylon; likes to dress up to go out. In the past bit herself and hit one temple but this has stopped. Still occasionally covers her ears at high-pitched sounds.
Examination: Tall, healthy girl, not dysmorphic. When seated, she gazed about the room, speaking softly to herself. For example, “When are the children to have eggs”. She did this while putting her hand to her mouth in an eating motion. Her mood was neutral and she was not too anxious. She twisted a blue handkerchief in her hands or used it to “clean”. Sometimes tapped the tabletop. She made some eye contact, but did not respond to greeting. Neurological examination was normal except for mild gross and fine motor incoordination. Not dysmorphic except that her right hand was slightly smaller than her left and somewhat less well coordinated. HC: 562 mm.
Diagnosis: Typical autism.