Age: 1.5
Sex: M
Vaccine: HEP
Symptoms: Eye disorder, Laboratory test abnormal, Mental retardation severity unspecified, Nervous system disorder, Speech disorder
Clinical narrative: This report describes the occurrence of autism in an approximately 1.5 to 2 year old female who was vaccination with hepatitis B vaccine for prophylaxis. This report was received as part of litigation proceedings, with forwarding of medical records. The prenatal history included premature labor beginning at 28 weeks gestation. The subject's mother was treated with bedrest, oral tocolytics, and SC tocolytic infusions. The subject was born at 36 weeks gestation. Birth weight was 6 pounds 6 ounces. His mother reported that the subject turned blue upon delivery and was treated with oxygen. He required care in a neonatal intensive care unit for eight days, but did not require mechanical ventilation. He also experienced jaundice. His mother reported that he was difficult to console as an infant and had difficulty early regulating his behavior. She also described him as a ill tempered baby. The subject's medical history included upper respiratory infections, eczematous rashes, asthma, probable viral illness, croupy tracheitis, impetigo, left otitis media, gastrenteritis, gastritis, conjunctivitis, and gastroesophageal reflux disorder. At 17 months of age, his mother took the subject to the pediatrician because she was concerned because he seems to be bowlegged, in toes bilaterally, and is tripping over own feet. The physician noted, Developmentally, doing well. On physical examination, the physician noted, He does have some bowing to the legs and also in toes. The subject was referred to an unspecified specialist. Developmental history was provided by the subject's mother to several specialists. The mother reported that the child reached all developmental milestones at appropriate times. He was crawling at 8 months, sitting and standing at 8 to 10 months, walking by 12 months and feeding himself at 11 months. She also reported that the child was speaking normally as a baby and quit talking at 1.5 to 2 years of age. He reportedly did not speak again until he was 4 years of age. The mother told another specialist that the child said single words at 12 months and walked at 14 months. He was toilet trained at 4.5 years of age. The subject received an injection of hepatitis B vaccine on 8/10/96. He also received hepatitis A vaccine; combination diphtheria and tetanus toxoids and pertussis/Haemophilus influenzae type B conjugate vaccine; diphtheria and tetanus toxoids and acellular pertussis vaccine absorbed; Haemophilus influenza type B conjugate vaccine; oral poliomyelitis virus vaccine; MMR; and varicella virus vaccine. The subject's attorney alleged that as a result of the mercury in the thimerosal containing vaccinations that the subject received as an infant, he now suffers, and in the future will continue to suffer, from the toxic, neurological effects of mercury poisoning. After his discharge from the hospital, the subject came under the care of another pediatrician on 8/21/96. He remained under the care of that pediatrician until at least 5/27/98. There were no notations in the physician's office records of any developmental delays. The subject was evaluated by a psychologist at a tertiary care center on 5/23/00. he was referred by his parents for assessment of concerns about language problems and temperment. The parents state that his speech is frequently difficult to understand. In addition, the mother describes him as very angry when upset. The psychologist noted that the subject made no response to the examiner's greeting and demonstrated little eye contact...He demonstrated little structured or goal-directed play. He would not stay with tasks very long....He was noted to use only a few words appropriately. He would occasionally babble (especially when excited). Otherwise, he did not vocalize much during play or demonstrate any apparent self-talk. Vocalizations primarily occurred when he was trying to make a request or indicate a preference....He was content as long as he was allowed to self-direct his own activities. He would protest vigorously when others would push him to comply with a task in which he was not interested....he seems to prefer manipulative toys. He also seems to show a preference for stacking objects (such as blocks) or lining up objects and small toys. This strong preference seems to preclude his ability to engage in varied activities with those materials. Even when given models, prompts, and encouragement, he tended to repetitively engage himself in the same manner....Play observations and interactions were used in scoring the Social/Emotional Scale of the Early Intervention Developmental Profile. Parent report was also used as a source of information. Resulting scores indicated that the subject's general level of social development is below chronological age expectations. Current level of social/emotional functioning is estimated between the 12 to 18 month level....His apparent language and communication difficulties certainly contribute to problems in social and play interactions. However, they do not appear to be the sole factor influencing social development. The psychologist states, in summary, The subject demonstrates noticeable differences in the quality of his social interaction and sharing of social and emotional events with others. These differences contribute to significant impairment in his ability to establish and maintain patters of adult and peer interaction that would be expected for children of his age. These differences are also consistent with a diagnosis of Autistic Disorder. Of particular concern is his persistent use of negative behaviors to successfully avoid compliance. His apparent difficulties with understanding of spoken language undoubtedly contributes to problems with compliance. He would benefit from participation in a structured preschool classroom which provides an emphasis on development of language/communication skills and functional skills for relating to others. On 5/23/02, the subject also underwent an educational evaluation at the same tertiary care center. Using the Uniform Performance Assessment System PreAcademic Scale, the subject earned credit for seventeen of eighty-two items. His performance earned a percentage score of 208. Children of his chronological age are expected to pass roughly 50% of the UPAS PreAcademic Scale items. Put another way, the subject's performance is equivalent to that of a child at 24 to 26 months of age. His performance of the UPAS activities (in which he could be engaged to participate) indicated that he has a delay of at least 20 months, and this is considered a moderate to severe delay in the development of preacademic skills. He is a candidate for a structured preschool program. The subject also received a speech and language evaluation at the tertiary care center on 5/23/00. he was referred for an interdisciplinary assessment due to concerns about his delayed speech/language skills and behavioral concerns. According to mothers report, the subject's receptive and expressive language is delayed, although motor skills seemed to have developed at a normal rate. He reportedly has difficulty comprehending language even when given the benefits of gestures and contextual cues. He also has a rather extensive repertoire of single words and familiar phrases, but does not use language appropriately. He reportedly prefers to play alone. He displays violent and disruptive behaviors in many settings. The subject's mother also reported that the subject's engages in imaginative play at home (i.e. dresses up like Superman, and jumps off the dresser), but this level of imaginative play was not observed during the evaluation. He typically communicated using one word utterances, many of them echolalic. He used very few spontaneous gestures, but was not observed using dictal gestures (i.e. pointing at objects he desired). Using the Preschool Language Scale-3, his auditory comprehension was rated at an age equivalent of 1 year. Expressive comprehension was rated at an age equivalent of 2 years, 1 month. The total language score was 1 year, 7 months. Using the language subtest of the Early Intervention Developmental Profile, the subject obtained an overall equivalency of 16 to 19 months with some correct responses in the 20 to 23 month level. Expressive skills were higher than receptive skills. The speech/language pathologist concluded, the subject's overall speech and language skills fall in the 18 to 24 month range and are significantly delayed when his performance is compared to chronological age expectations....his communication skills are not following a normal pattern of development and are quite atypical. His language disorder is characterized by a poor understanding of verbal stimuli. He also does not respond to or use nonverbal communication in a normal fashion. His play is also significantly delayed. All of these are characteristic of a child with pervasive developmental disorder. Speech/Language therapy was recommended. On 5/23/00, the subject also underwent occupational therapy evaluation at the tertiary care center. In addition to concerns regarding speech/language skills and social skills, There were also concerns with atypical behavior displayed in the preschool classroom, such as avoiding initiation of conversation, being non-verbal except for single words and echoing, poor attention span, avoiding play with other children and difficulty comprehending preacademic concepts. On neuromuscular examination, no tonal abnormalities were noted except for a slight decrease in proximal stability in the shoulder girdles and the hips. Using the Early Intervention Developmental Profile, the subject was functioning at the two level for fine motor skills. Skills were scattered from 16 to 19 months up to the 2.5 year level. The therapist observed that hand dominance has not been established....he was not noted to cross the midline and most of his hand functions were noted to be ipsilateral. While evaluating gross motor skills, the therapist noted that the subject does have some difficulty with rapid changes in movement patters, this is partially attributable to his lower extremity alignment....Gross motor skills are a strength for this child, however, he appears to have some difficulty with praxis (motor planning) and therefore at times appears clumsy. This is not due to decreased strength or abnormal muscle tone but is felt to be related to his sensorimotor processing difficulties. Self-care skills, based on observation and parent report, indicated that the subject was functioning in the 2 to 2.5 year range. The sensorimotor history revealed multiple areas of sensory processing dysfunctions. The subject was observed to exhibit some signs of tactile defensiveness. This was evident by his avoiding textures on the palms of his hands (i.e. using his fingertips to investigate first). In response to vestibular stimulation, poor head righting was observed. He exhibited definite signs of a sensory integrative dysfunction, particularly in the area of tactile, proprioceptive processing, and auditory sensation. When he was overwhelmed, he would seek proprioceptive and vestibular input to regroup his senses. In summary, the therapist noted significant delays in fine motor and self care skills, with respect to chronological age expectations, are evident. He also demonstrates behaviors indicative of a sensory integrative dysfunction....his play skills are also significantly below his chronological age expectations...his delays are consistent with clinical impression of autism. The therapist recommended speech/language and occupational therapy. The subject received speech/language therapy and occupational therapy. He also attended a structured preschool program. On 11/6/00, the speech pathologist noted that the subject is now able to verbalize some of his wants/desires throughout therapy sessions, eliminating his need to bite and scratch. He will now sit at the table to complete some structured tasks. However, he continues to require moderate assistance to follow directions and to participate in all therapy tasks....his expressive language has improved since the beginning of the treatment period. He is spontaneously producing four to five word utterances during therapy. He repeats phrases, counts to ten, and labels pictures spontaneously. He learns new vocabulary quickly. Although progress has been made, his expressive language still falls severely below that of average age-matched peers. He does not spontaneously tell about remote events or ask simple questions. He does not use whole sentences to request wants/desires. His receptive language skills have also improved. He is able to identify some colors and some simple body parts....he has made significant process since the beginning of the treatment period. From 7/17/00 until 10/27/02, the subject was under the care of a doctor specializing in the treatment of autism. The physician made diagnosis of Nutritional deficiency, mineral deficiency, irritable bowel syndrome, malabsorption. During this time, laboratory analysys revealed abnormalities in plasma amino acid concentrations, urine organix profile, stool organisms, platelet count, serum copper concentration, and hair concentrations of heavy metals. Please see the lab data section. On 8/28/00, the physician made a list of problem areas: heavy metals (elevated levels of heavy metals in hair, scattered pattern hair essential elements, high hair selenium, increased SGOT, low taurine, uncoupling of oxidative phosphorylation, increased VMA, impaired detoxification, sulfate-wasting, dysbiosis, gut bugs, iron deficiency, needs taurine, carnitine, glycine, functional deficiencies in B1, B2, B3, biotin, magnesium, needs sulfate. During this time, the physician prescribed methylphenidate, dimercaptosuccinic acid, lipoic acid, proprietary amino acid blend with selenium, lactic-acid producing organisms, nystatin, vitamin C, neomycin bismuth subsalicylate, co-enzyme Q10, B complex, Citramin II, zinc, chewable multivitamin, L-carnitine, glycine, vitamin E, Gla Forte, eicosapentaenoic acid/docosahexaenoic acid, magnesium, taurine, oral and IV glutathione, IV secretin, epsom salt baths, cranberry concentrate, melatonin, vitamin B6, P5P, and manganese. On 6/28/02, in response to an electronic mail message from the subject's mother, the physician wrote, realistically, the subject is essentially normal right now except for not having a great attention span. On 10/27/02, the physician referred the subject to an integrative medicine specialist to continue therapy. The subject remained under the care of this physician until at least 12/26/02. On 12/14/00, the subject's parents were notified that the subject met the state health department's criteria for mentally retarded or developmentally disabled. The subject underwent a second occupational therapy evaluation with a private therapist on 5/5/02. The subject had been referred by his current pediatrician. During the evaluation, the therapist noted, he is a very emotional little boy whose emotions can vary from one extreme to the other in a matter of a few minutes. During auditory and visual examination, the therapist noted, eye contact is inappropriate. The subject demonstrated a moderate eye jerk at midline when tracking in a horizontal plane. There was an eye jerk noted in the vertical plane. During a gross evaluation of convergence, there was a delay of the right eye. His deficits in tracking can lead to difficulty communicating with written speech and visual motor activities. During the proprioception testing, the following observations were noted: clumsy and awkward movements, poor bilateral integration skills and pushes or leans on objects. Using the Peabody Developmental Motor Scales, his overall age equivalent score in fine motor was 42 to 47 months. He was able to perform all activities through the 47 month level and no activities past the 59 month level. Using the Earhardt Developmental Prehension Assessment, the subject exhibited a immature tripod grasp which is age equivalent to 3 to 4 years. The therapist recommended occupational therapy. The subject underwent a second speech and language evaluation with a private speech pathologist on 5/28/02. The subject had been referred by his current pediatrician. The pathologist noted that the subject was able to write his name, recite his ABC's, colors and count to 20. He is an outgoing little boy with a funny sense of humor and other children seem to like him. He received special education services. He will be mainstreamed into a regular kindergarten classroom next year. Using the Oral and Written Language Scales, the subject's listening comprehension was rated at an age equivalency of 1 year, 9 months. Oral expression was rated at an age equivalency of 1 year, 11 months and oral composite score was 1 year, 10 months. Using the Goldman Frisco Test of Articulation, the subject scored an age equivalency of 2 years, 11 months. The pathologist's clinical impression was based on formal and informal assessment, clinical observations and parent interview, the subject displayed a severe expressive/receptive language disorder characterized by a profound pragmatic deficit secondary to a diagnosis of Autism. He also exhibited a severe articulation disorder characterized by substitutions, distortions, and omissions. Voice, fluency and hearing were judged to be within functional limits. The pathologist recommended speech/language therapy and occupational therapy.