Age: 1.08
Sex: M
Vaccine: MMR, FLUX, MMR, VARCEL
Symptoms: Aggression, Autism spectrum disorder, Decreased eye contact, Hypoacusis, Irritability
Clinical narrative: dizzy response after swinging; on one ocassion with a pear he was chewing and gagging it; decreased strength in arch of feet per observation of flat feet; After that day, the patient had fevers, he was fussy, he stopped making eye contact, he started ignoring us, he would not look at us, he would not listen to his name, started throwing tantrums, and making unique hand movements very close to his eyes; After that day, the patient had fevers, he was fussy, he stopped making eye contact, he started ignoring us, he would not look at us, he would not listen to his name, started throwing tantrums, and making unique hand movements very close to his eyes; After that day, the patient had fevers, he was fussy, he stopped making eye contact, he started ignoring us, he would not look at us, he would not listen to his name, started throwing tantrums, and making unique hand movements very close to his eyes; This spontaneous report as received from the patient's mother and refers to her 17 month old son.  The patient's concurrent conditions included allergy to eggs (for which he had urticaria (hives)) and strawberries (for which he had rash) (conflicting information , also reported as there were no food related allergies). There was no concomitant therapies. His medical history included, but was not limited to: born full-term via spontaneous vaginal birth without reported pregnancy or birthing complications. There no other reported serious illness, injuries or hospitalizations; no previous Occupational Therapy (OT), Physical Therapy (PT), or Speech-Language Therapy (ST) evaluation or treatments; no-known seasonal allergies, no-known prescription or over-the-counter medication uses; and he passed newborn hearing screening (NBHS). On 26-NOV-2019, he was vaccinated with DTaP-hepatitis B and polivirus vaccine, haemophilus b conj (PRP-OMP) vaccine, pneumoccocal 13-valent conjugate and rotavirus, live, monovalent vaccine. On 29-APR-2020, he was vaccinated with DTaP-hepatitis B and polivirus vaccine and pneumoccocal 13-valent conjugate. On 06-FEB-2020, he was vaccinated with other dose of DTaP-hepatitis B and polivirus vaccine, rotavirus, live, monovalent vaccine, pneumoccocal 13-valent conjugate and haemophilus b conj (PRP-OMP) vaccine.  On 26-OCT-2020, the patient was vaccinated with measles, mumps, and rubella (wistar ra 27-3) virus vaccine, live (M-M-R II) (dosage, route of administration, anatomical location, lot number and expiration date were not reported); varicella virus vaccine live (oka/merck) (manufacturer unknown) (dosage, route of administration, anatomical location, lot number and expiration date were not reported); and influenza virus vaccine (unspecified) (dosage, route of administration, anatomical location, lot number and expiration date were not reported); all for prophylaxis. The patient's mom was already aware of all the issues linked to certain vaccines which was she did not wanted him to get all of the ones he wads due to, instead she chose those three. She stated "this has been the worst mistake of my life, I should've not gotten any of the vaccines because one of them was the measles, mumps, and rubella (wistar ra 27-3) virus vaccine, live (M-M-R II) vaccine".  On 27-OCT-2020, she noticed that her son changed. Prior the vaccine, her son was sociable, he played with his brothers, laughed and made eye contact. After that day, the patient had fever, he was fussy, he did not laugh anymore, was not playing with his brothers, no longer made eye contact, he started ignoring his parents, he wound not listen to his name, started throwing tantrums, and making unique hands movements very close to his eyes. Also, the patient had not developed any further since the vaccine was administered. On 02-DEC-2020, she took him to the physician due to her concern of autism. On 01-MAR-2021, he had multiple test completed. On the Developmental Assessment of Young Children (DAYC-2), Social/Emotional: Raw score: 19, Standard Score: 80, Developmental Age: 10 months (express affection, plays simple games, repeats activity that elicits laughter or positive response from other; "17, 18, 20"); Adaptive/Self Help: Raw score: 20, Standard Score: 87, Developmental Age: 13 months (sleep through the night; may tale one nap during the day, sips liquid from glass or cup using straw, fusses when diaper needs to be changed; "18, 20, 22"); Fine Motor: Raw Score: 15, Standard Score: 89, Developmental Age: 10 months (picks up a small object using the thumb and forefinger, pokes with index finger, turns pages in book; may be thick pages; "12, 13, 14"); Cognitive: Raw Score: 26, Standard Score: 92, Developmental Age: 13 months (attempts to start toy if he has seen someone else make it work, places a small object into small container, imitates scribbling; "24, 25, 26"); Communication Receptive Language: Raw Score: 6, Standard Score: 59, Developmental Age: 3 months (smiles at person who was talking or gesturing, turns and looks toward noise; "5, 6"); Expressive Language: Raw Score: 10, Standard Score: 82, Developmental Age: 9 months (produces string of constant-vowel sounds, uses word for parent or caregiver discriminately; "9, 10"); Gross Motor: Raw Score: 37, Standard Score: 101, Developmental Age: 18 months (runs at least 10 fl without falling, walks backwards at least 10 ft, walks swinging arms and legs freely in cross pattern similar to adult walk pattern; "36, 39, 41"). According to the standard score result of the DAYC2: domain of communication, the patient demonstrates below average receptive and expressive language skills compared to typically developing, age-leveled peers. He also demonstrated a 33% delay in receptive-expressive language development as identified by his age-equivalence score. The Receptive-Expressive Emergent Language Test (REEL-3) showed that Receptive language: Raw Score: 16, Ability Score: 55, Age Equivalent: 3 (units not reported); and Expressive Language: Raw Score: 25, Ability Score: 67, Age Equivalent: 9 (units not reported). According to the results of REEL-3, the patient demonstrated below average receptive and expressive language skills as compared to typically developing as identified by his age-equivalence score. Receptive language skills Noah demonstrated during testing, included: Reacting differently and appropriately to another's change in mood or tone of voice; Quickly finding where a voice was coming from and looking at the speakers face; Stopping at least temporarily when someone says "No" or "Stop that"; Sitting and listening to someone who was showing and naming pictures of familiar things for at least a minute; Smiling at the person who was talking or gesturing. However, receptive language skills that the patient was not yet demonstrating that were appropriate for his age as compared to typically developing, age-leveled peers include: Consistently responding to his name; Identifying a variety of salient items/objects; Responding appropriately to "where" questions; Following simple, single-step commands (e.g., give me, show me); Appearing to understand more new words each week; Identifying a variety of vocabulary terms like pictures/actions/objects/people/animals/foods/etc. Expressive language skills the patient demonstrated during testing, included: Engaging in reciprocal play ( e.g. chasing); Seeming to use complete sentences or phrases even though he was not using real words; Imitating what he heard others said around him; Babbling for long periods of time with toys or people as if he was talking to them. Expressive language skills the patient was not yet demonstrating that were appropriate for his age as compared to typically developing, age-leveled peers include: Using a variety of consonant-vowel combinations for reduplicated and variegated babbling; Producing at least 10 single words/approximations; Using "no" in protest; Combining words with gestures to let others know what he wanted; Using real words during babble; Greeting and saying good-bye by using words such as "hi" and "bye-bye-" or his version of them. At the time of the evaluation, the patient's speech/articulation and fluency/voice assessment were not appropriate. On the occupation therapy evaluation, showed that the patient's developmental millstones were at the following ages: rolled over at 6 months, sat unassisted at 6 months, walked at 8 months and has not yet said his first word; per Grasp Pattern, he was not yet grasping a crayon or marker consistently to scribble which may be due to lack of opportunity or exposure per him mouthing marker and crayon, disinterest in the activity, and/or poor muscle tone and hand strength; he was not yet using his index finger to gesture or communicate he wanted or needed something which could impact his social participation, reciprocal interaction, and interpersonal relationships with family members and other; Visual motor was within normal limits; per Self care/Activities of daily living (ADL), the patient  was not trying to wash his own hands and face, was not removing loose clothing independently and was not opening doors using the handle or knob, therefore, demonstrated delay in age-appropriate self-care skills which could impact his independence with self-feeding, dressing, and hygiene skills and future independence in the school setting and during mealtimes using appropriate utensils/drinking devices; as per Feeding skills, the patient was drinking from his mother's nipple breast milk, drank from straw  and finger-feed himself independently, he ate from all food groups, however, he was not yet using the spoon and fork to eat his meals, moreover on one occasion with a pear he was chewing and gagging it, however, once she gave him thin slices, his gagging terminated. This may be due to overstuffing and not identifying an appropriate amount of food to eat safely; he liked to took small crumbs and other small object to put in his mouth, and he had not gag, coughed or chocked on liquids; he was not yet drinking from a bottle, sippy, cup or open cup. Per Participation, he did not like to interact with other children yet and preferred to play by himself, he demonstrated minimal reciprocal interaction, joint attention and lack of eye contact with his mom, also there was no verbal communication with parents. Additionally, he did not frequently scribble at home, he picked up the crayon, mouth it, push the paper away and/or took all the crayons out of the package and threw them onto the floor rather than scribble onto the paper. The patient demonstrated to engaged in parallel play which may impacts his social participation and reciprocal interaction with same-age children and family member. Per Body Function and Structures/Impairments, in strength, he demonstrated decreased strength in arch of feet per observation of flat feet; his range of motion was within normal limits; and in muscle tone, he demonstrated low muscle tone when grasping a crayon or marker in attempted to scribble. Per Sensory Processing, the patient's mom reported that he liked to look up and put his neck into extension when walking and seemed to had a dizzy response afterwards yet continued to performed it. He was observed going into the corner of the room and crouch to play with his water bottle. During the parent interview and/or clinical observation: Vestibular processing (sense of movement/gravity), the patient seek out and enjoys rhythmical and physicals movements, spinning and jumping, he wanted to be breast fed he rock back and forth, and he got a dizzy response after swinging; Tactile processing (touch sense) there was poor awareness when his face was dirty, and reacted negatively to food play with variety of textures; Visual Processing (sigh sense), he demonstrated hypersensitivity and/or avoided behaviors; Auditory processing (hearing sense), he demonstrated hypersensitivity and/or avoided behaviors, had difficulty tuning out extraneous stimuli, easily distracted, and became agitated with sound: hair/hand dryers, lawn mowers, blenders, or when his older bothers yell or scream, he had difficult responding to his name or questions; Oral processing (taste sense), he frequently mouths/chews inedible objects, limited oral motor awareness affecting safety like overstuffing on one occasion, pocketing of food; Organization of Behavior (giving attention, change in routine, transitions, etc), he displayed limited frustration tolerance, he could walk away when he got frustrated, or he got frustrated when he could not figure something out throw himself and wanted to be breastfed. Also , the patient was recommended to: 1. received individualized occupational therapy 1 time per week for 60 minute to address sensory integration challenge, age-appropriate  fine motor, self-care, eating and feeling skill; 2. Occupational therapist recommended the patient to received a referral for an orthotist to be assessed and received orthotics for arch support per flat feet and compensatory gait patterns; 3. Occupational therapist recommends for to received intensive program for overall development delays; 4. The patient's parent were recommended to seek out referral to a pediatric developmentalist, neurologist, psychologist, or psychiatrist to rule out Autism Spectrum Disorder, as per The Modified Checklist for Autism in Toddlers (M-CHAT) score 13, which placed the patient at a high-risk; 5. Child-specific goals to be set by treating physician. The patient's social skills/behavior was most content during breast feeding with his mother. Eye contact, joint-attention, and response to his name were inconsistently achieved throughout the evaluation. As the assessment progressed, a play scheme identified or reported included: functional ( e.g., rolling cars). Play schemes not identified or reported included: self-directed ( e.g., pretending to eat from a spoon/baby bottle); relational ( e.g., putting the baby doll to sleep using the crib and  blanket); and pretended play (e.eg., feeding a baby doll/stuffed animal). Other behaviors identified included: closed mouth vocalizations, preference for objects that spin, disinterest in toys and different objects, preference for play away from other children, preference for independent play away from others, not interacting or showing interest to other children, increased sensitivity to certain sounds like others crying, turning a car upside down and spinning the wheels by hand while watching the tires spin. On 04-APR-2021, the patient was diagnosed with autism. The outcome of pyrexia, dizziness, foot deformity and irritability postvaccinal were not reported.   The reporter stated that she believed that the vaccine measles, mumps, and rubella (wistar ra 27-3) virus vaccine, live (M-M-R II) gave him autism. The causal assessment between varicella virus vaccine live (oka/merck) (manufacturer unknown) and influenza virus vaccine (unspecified) and the events were not reported.  Upon internal review, the event autism spectrum disorder was determined to be medically significant.