Posttraumatic Stress Disorder in a Child with Autism Spectrum Disorder: Challenges in Management.

[Author Affiliation]Maria del Pilar Trelles Thorne. 1 Mount Sinai Saint Luke's Hospital, Division of Child and Adolescent Psychiatry, Department of Psychiatry, New York, New York. 2 Seaver Autism Center, Icahn School of Medicine at Mount Sinai, New York, New York.Navjot Khinda. 1 Mount Sinai Saint Luke's Hospital, Division of Child and Adolescent Psychiatry, Department of Psychiatry, New York, New York.Barbara J. Coffey. 3 Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief ComplaintM. was a nine-year-old Mexican-American boy, bilingual (English dominant language) and recently promoted to the third grade in a special education setting (12:1:1) in a regular public school. M. lived with his 28-year-old mother and six-year-old sister. He had been diagnosed with autism spectrum disorder (ASD), borderline intellectual functioning, and attention-deficit/hyperactivity disorder (ADHD). M. was referred for worsening aggressive and self-injurious behavior, as well as multiple behavioral problems at home and school, following physical and emotional abuse and exposure to domestic violence 15 months prior.History of Present IllnessM. was initially referred after he presented to the emergency department with suicidal thoughts in the context of bullying at school. He also presented with self-harm behaviors consisting of picking his hand with a pencil repeatedly and expressing no pain. M. had expressed feeling sad on various occasions. His mother had noticed a lack of interest in activities he once enjoyed, and he appeared to be more withdrawn from the family. His performance at school had also progressively worsened over the past six months.Mother reported a history of multiple developmental delays. M. didn't babble until approximately 10 or 11 months and made little eye contact. He was diagnosed with pervasive developmental disorder, not otherwise specified at 18 months, and was immediately referred for early intervention. He was placed in an applied behavioral analysis (ABA) program with intensive in-home speech therapy, occupational therapy, behavioral therapy, and parent education and support from 18 months to three years of age. He was subsequently referred to a specialized center for children with developmental disabilities, where he attended school from pre-kindergarten to first grade. He was in a classroom with eight students, one teacher, and one para-professional with daily speech therapy, twice a week occupational therapy, and daily behavioral treatment. He did not speak his first words until age two. M. began speaking in phrases around age four, and spoke in full sentences at age five. M.'s speech improved significantly with early intervention; however prosody and pragmatic use of language had remained a problem. Mother also reports a history of echolalia that resolved approximately three years ago.Despite treatment, M. continued to show little interest in others and made fleeting eye contact unless prompted. In his early years, M. engaged in neither functional nor symbolic play. He was now able to follow play if invited, but only marginally, and did not participate in imaginative play. There was little shared enjoyment in activities. M. had a history of unusual sensitivities (he could not tolerate washing his hair, certain clothing materials, and some food textures) and high pain threshold. During play he showed unusual sensory interests such as feeling textures repetitively and prolonged visual examination of toys. He had a low frustration tolerance and difficulty with transitions. M. demonstrated stereotyped movements in early childhood, such as hand flapping and rocking, which had resolved. …