Case Report

Sofie Widdershoven
I6215632
Name: Sam
Gender: Male
Age: 8
Referrer: Mother

Diagnostic question

Do the social and behavioural problems Sam is suffering from refer to a neurodevelopmental
disorder/autism spectrum disorder (ASD)?

Developmental history

 Reason for referral: Sam’s mother signed Sam up for neuropsychological

assessment, after the recommendation of Sam’s school teacher. Sam’s teacher
noticed communication problems, anger outbursts and bad relationships with
classmates. These problems have a negative influence on the functioning of himself
and other children in the classroom. The mother agreed with the school teacher to
sign him up for neuropsychological assessment, because she also recognizes the
problems in Sam’s behaviour at home. Both Sam’s mother and teacher think Sam
may suffer from autism spectrum disorder (ASD).

 Development profile: Delivery: 36 weeks after gestation. Sam’s birth weight was too
low, so he had to spend 5 days in an incubator. Language development began later
than normal. At the age of 3 Sam started saying a few words to express his needs,
but barely full sentences. He didn’t respond when his parents called his name and
also didn’t use gestures to communicate. His parents indicated that the anger
outbursts started when they got a divorce nearly 1 years ago, when Sam was 7 years
old. They say it’s very hard for Sam to cope with the divorce, because it changed a
lot. The parents decided that Sam would stay with his mother during the schooldays
and with his father during the weekends, so he wouldn’t have to change schools. The
mother knew it would be a problem for Sam to change schools, because he has
difficulties coping with change.

 School career: Group 1, 2, 3, 4 (Dutch school system) without duplication, despite his
poor communication skills and clumsiness. His clumsiness was and is still observable
as he often stumble to his own feet and he often accidentally drops an object out of
his hands. He also didn’t play with his classmates when they pretend played with toys
in kindergarten (group 1 & 2). Sam got special help at school to improve social
interaction with his classmates. His verbal communication went somewhat better, but
still declined later on. Sam successfully learned to read and write in group 3, but he
stayed significantly behind with social interaction and communication skills in
comparison to his classmates. He can’t get along with his classmates and he doesn’t
 show any interest in them. When his parents got a divorce and his anger outbursts
started he also often got and still get very angry with his classmates. Sam’s parents
think the crowded classrooms at school also contribute in his anger. In the school
breaks Sam often stands alone, because he doesn’t have any friends. Now Sam is in
group 5 of primary school. His academic performance is average, although he doesn’t
perform well at PE (physical education) because of his clumsiness.

 Present functioning: Sam is often very tense when he comes home from school. His
mother tries to talk with him about this, but he doesn’t want to. He also gets frustrated
when things doesn’t go as he anticipated. For example when dinner is ready at 6.30
PM instead of 6 PM. Sam hates to stay at his father’s house at the weekends. His
father implements different house rules than his mother and it really confuses him. He
often gets very frustrated with him and his anger outbursts are at worse when he is at
his father’s house. According to the parents he gets calm by ‘playing’ with his little
dinosaur toys. Sam seems very interested in dinosaurs as he knows a lot about the
different kinds. He often lines up these dinosaur toys in a specific order and
repetitively say the names of these dinosaurs in this order. Therefore his parents
don’t call it playing, because he doesn’t pretend play with his toys, but instead
organises them for hours.

 Previous psychological assessment: no psychological assessment has previously

been conducted. In group 1 and 2 (kindergarten) the parents were told by the school
that Sam just needed more time to develop his communication skills. Therefore they
didn’t think Sam needed psychological assessment at that time. They started
worrying when his anger outbursts started one year ago. These worries slowly got
worse this year. The mother signed Sam up for neuropsychological assessment when
she knew the school teacher shares these worries about Sam.

The findings of the neuropsychological assessment

Observation

Sam makes a young impression for his chronological age. He is relatively small and thin and
his posture is awkward. He doesn’t speak a lot and doesn’t make any eye contact at all.
Instead he stares to the ground most of the time. During the first task, the emotion
recognition task (ERT), Sam seemed confused most of the time. He even showed frustration
at some moments during the test when he didn’t know the answer. When Sam’s motor skills
were assessed Sam showed signs of clumsiness. Especially during the Florida Apraxia
Battery when using a tool. He accidentally dropped the tool several times. During the twenty
questions task Sam asked very specific questions. When the psychologist revealed that the
mystery object is an animal, Sam immediately asked whether it’s a velociraptor.
Test results

During the neuropsychological assessment, several tests have been administered. These
tests include face/emotion perception, motor skills and problem solving. The symptoms that
Sam shows suggest that he may have autism spectrum disorder (Psychiatric Association,
2013)

 Face/emotion perception: Sam shows verbal and non-verbal communication

problems. The emotion recognition task (ERT) was used to test Sam’s ability to
recognise faces and emotions. Deficits in the recognition of face and emotion
perception could explain Sam’s communication difficulties and it’s a common
symptom in children with autism spectrum disorder (Kessels, 2013; Yeates 2020).
Researchers conducting different studies collectively found an impairment in affective
matching tasks (such as the ERT) in individuals with ASD, while they perform
average at nonaffective matching tasks (Yeates, 2020). Besides, several eye-tracking
and behavioural studies show that individuals diagnosed with ASD have a
disorganized approach when viewing faces. This disorganized approach includes an
unusual focus on specific areas of the face such as the mouth, instead of the usual
focus of the eyes (Yeates, 2020).
In this task Sam was instructed to look at a photograph of a face on a screen that
gradually expresses an emotion. Sam’s task was to select the appropriate emotion
from the labels: surprise, happiness, sadness, fear, disgust.

Sam scored an ERT total score of 40.2

on this task, which is low (z-score=-1.61).
The ERT total mean for age group 8 is
54.5 with a standard deviation of 8.9
(See figure 2) (N=31 for age group 8)
(Kessels, 2013).
Figure Emotion Recognition Task (ERT)
  Motor skills: Sam seems to have difficulties with the use of gestures for non-verbal
communication
erview of mean performance and with gross and fine motor skills. His parents indicated that he can
per ERT variable
be quite clumsy. Therefore three tests were administered for assessing Sam’s motor
skills.
Children diagnosed with autism spectrum disorder typically experience difficulties in
basic motor control and in praxis performance. The latter refers to developmental
dyspraxia, which entails impairment in the performance of skilled limb movements.
These skilled limb movements can be categorized as transitive movements or
intransitive movements. Transitive movements involves demonstration of tool use and
intransitive movements includes symbolic and communicative gestures (Dowell,
2009). Impairments in the use of gestures is also a common symptom in children with
autism spectrum disorder. This impairment correlates with the social, communication,
and behavioural deficits seen in autism (Dowell, 2009).
Sam’s basic motor skills such as gait, balance, coordination, and aim were assessed
using the PANESS test. The test measures Sam’s ability to perform repetitive
movements of the hands. He was instructed to repeat each movement 20 times. The
time he needed for each set of repetitive movements was recorded and summed up
to provide a ‘total timed repetitive movements’ score. His total timed repetitive
movements score is 38.6, which is below average (z-score=-1.07) within the typically
developing group (M=32.4, SD=5.80). Looking at the autism group (M=37.7,
SD=8.07) Sam’s performance is average (z-score=-0.11). (See figure 3)
A postural knowledge test (PKT) assessed Sam’s recognition of skilled gestures. This
test consists of three sections. In the first section Sam was presented with a picture of
a person holding a tool with a missing hand (transitive movement). After that he was
asked to indicate from three options which hand demonstrated best how the tool
should be held. The second section involved the same procedure as explained, but
then the person in the picture is performing a gesture without a tool (intransitive
movement, such as waving). In the third section Sam was presented with three
different pictures of hands holding a tool and he was asked to indicate which of the
pictures best depicted how the tool should be held. The numbers of Sam’s correct
responses were added together, resulting in a ‘transitive gestures score’ of 27.5. This
score is again below average within the TD group (z-score=-0.80), but average within
the autism group (z-score=-0.29). (See figure 3)
Lastly, a version of the Florida Apraxia Battery (modified for children) was used to test
Sam’s praxis performance. He was instructed to perform a variety of skilled gestures
in three ways: responding to a verbal command, imitating the examiner, using an
actual tool when applicable (transitive movements). Sam’s average total errors score
on this task was 26.3, which is very low (z-score=-3.03) within the TD group. Within
the autism group Sam scored average (z-score=0.00). (See figure 3)

Figure Analysis of variance of group performance on motor assessments

 There are no age effects seen in the autism and control groups in the sample that
was used (ages range from 8 to 13 years, N=87)
 Problem solving: The “twenty Questions” task was used to assess Sam’s problem
solving skills. He was instructed to identify an object the psychologist had in mind by
asking the psychologist yes or no questions. At the start of the trial the psychologist
only reveals whether the object is an animal, vegetable or mineral. The trial is
completed when Sam figured out what the object is by the twentieth question.
Children with autism spectrum disorder typically ask more specific and detailed
questions focused on smaller categories compared to children without ASD who ask
broad questions (Lezak, 2012). This is in line with the central coherence theory
predicting that people with autism spectrum disorder are more detail-focused and will
perform better at tasks demanding a focus on detail-oriented or local processing
(Yeates, 2010). Sam didn’t complete many trials as he asked very specific and
detailed questions. Therefore he scored low on this task (z-score=-1.87).

Conclusion and recommendation

The results of this set of tests suggest that Sam may suffer from an autism spectrum
disorder. Sam also shows symptoms of autism spectrum disorder including communication
problems, motor problems and fixated interests (dinosaurs) (American Psychiatric
Association, 2013). However, An autism spectrum disorder or other neurodevelopmental
disorder cannot be concluded based on the results of this set of tests. To diagnose Sam,
more tests and interviews have to be administered, including an IQ test to test whether Sam
has an accompanying intellectual impairment (American Psychiatric Association, 2013). An
IQ test was not included in this set of tests, because Sam’s academic performance seems
normal. The anger outbursts Sam experiences seem to be related to his difficulties with
change. The outbursts started when his parents got a divorce, which is a situation with many
changes. Suitable treatment can take place when further assessment is conducted and when
Sam is gets the right diagnosis.
At this moment the people in Sam’s surroundings such as the parents and teachers can help
Sam by providing a safe environment for him. At school it would be helpful to place Sam in a
smaller classroom with less children. Sam may be less tense when the classrooms are less
crowded. At home Sam needs structure and routine. The parents could discuss their house
rules come to an agreement with each other to make it easier for Sam to adapt at his father’s
house. The relationship between Sam and his father could become better too.
References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental

Disorders. American Psychiatric Association.
Dowell, L. R., Mahone, E. M., & Mostofsky, S. H. (2009). Associations of postural knowledge
and basic motor skill with dyspraxia in autism: Implication for abnormalities in distributed
connectivity and motor learning. Neuropsychology, 23(5), 563–570.
https://doi.org/10.1037/a0015640
Kessels, R. P., Montagne, B., Hendriks, A. W., Perrett, D. I., & De Haan, E. H. (2013).
Assessment of perception of morphed facial expressions using the Emotion Recognition
Task: Normative data from healthy participants aged 8–75. Journal of Neuropsychology,
8(1), 75–93. https://doi.org/10.1111/jnp.12009
Lezak, M. D., & Howieson, D. B. (2012). Neuropsychological Assessment (5th Revised
edition). Oxford University Press.
Yeates, K. O. (2009). Pediatric Neuropsychology (2nd New edition). Guilford Publications.