Candidate’s instructions
Where are you:
You are an FY2 in GP.Who the patient is:
Graham Smith, 3 year old boy has come for follow up.Other information you have about the patient:
3 weeks ago he had presented to your GP surgery with speech and learning difficulties. He was referred to the autism team and a diagnosis of autistic spectrum disorder has now been confirmed. He has been referred back to your practice for follow up.What you must do:
Talk to the mother and address her concerns.
Patient Information
- You have come to the GP today because your 3 year old child, Carl, has not been able to speak until now.
- He likes playing by himself only.
- He is your only child so you do not know at what age a child should be able to speak.
- He has a habit of playing with the same toys every time.
- He does not like to change the toys.
- He is not able to speak any words but sometimes he makes some screaming sounds.
- You have no problem with other milestones.
- He is able to walk, sit, and he can eat and drink ok.
- He does not smile much to others either.
- Recently you and your partner took him to the daycare and that is when you notice that other children of his age are able to talk.
- The daycare teacher also mentioned that he does not like to play with other children and he prefers being alone playing with his toys.
- At the age of 12 months he had MMR vaccination and he is up to date with all other vaccinations.
Patient Concerns:
What will happen now?
Is there anything else I need to do for my baby?
Is it because of the MMR vaccine?
Should I give MMR vaccination to my baby?
Approach
GRIPS
Paraphrase:
Paraphrase the scenario about them being referred to the autism team and them coming for follow up.
History
- Symptoms of autism (speech, smiling, interaction with others, responding to his own name, learning abilities)
- Other milestones (walking, responding to surrounding, vision)
- Vaccination history
- Birth history
- PMAFTOSA
- Social history
- Who is at home?
- Do you have anyone else helping you to look after the child?
Ask and explain what autistic spectrum disorder is.
- It is a lifelong condition that affects how people interact and communicate with others.
- Explain that the cause of austism disorder is not known.
- Prognosis: It is a life long disorder and child may have learning difficulties, language impairment and may have mental health problems.
Perform the assessment
-
Functional Assessment
A. Behaviour: What type of behaviour do you find most challenging with Graham? (no smiling, playing alone, screaming episode, speech difficulties, learning difficulties-building towers and playing with blocks)
– Frequency: How frequently does that happen?
– Duration: When he starts doing that, how long does he continue doing that?
– Severity: How does that affect anyone around?B. Sleeping
– Any problem with sleeping?C. Eating
– Does he eat well?
– Can he say when he wants to eat?D. Vision
– Is he able to see properly?E. Hearing
– Is he able to hear properly? -
Expressive communication
– Is he able to tell you if he wants something e.g. food or drink.
– How does he behave if he wants something for example if he wants to eat or drink?
– Speech: Can he say ‘mama’, ‘dada’ or ‘papa’? -
Receptive communication
– If you talk to him, does he understand?
– Does he know his name?
– Does he respond to your smile or hug? -
Self Harm
– Does he have any sort of self harm behaviour such as repeatedly scratching himself? -
Stereotype
– Does he have any stereotype behaviour such as rocking back and forth or flipping of hands?
– Is there anything that stimulates this type of behaviour?
Management
Explain how the child may be affected. Child may have:
- Learning difficulties – we need to refer to occupational therapist
- Speech difficulties - we need to refer to speech and language therapist
- Understanding difficulties – needs to go to special school where there are other children with autism. Normal daycare might not be appropriate for Graham, he needs to go to a school where there is support for autism.
- Behaviour problems – we need to refer to behaviour therapist.
- Home adaptation. Advise parent to make resonable adaptation to the personal space of the child.
- We might need to create a friendly and safe environment at home for your child. His room should have certain types of colours like cream colours and not colours like yellow or white, no harsh lights, noise environment is not good for the child.
- Mental health problems such as anxiety - we need to refer to psychologist
- Explain that he will need support in education and health services.
Explain what support and benefit is available for the child.
- There are organisations that can support: These organisation can help with the learning environment of the child as well as offer financial support.
- Autism Alliance Charity
- Ambitious about Autism Charity
- The National Autistic Society Charity
- Offer leaflets about Autism and where they can get care and financial support.
- Explain that they can get support workers to help look after the child.
Note:
- The first dose is usually 12-13 months.
- Booster dose 3 yrs 4 months to 5 years.
1. Contraindications:
- Acute illness – Postponed until the condition has resolved.
- Severe local generalised reaction to previous dose of MMR.
- Allergic to neomycin or gelatin
- Untreated malignant disease or impaired immunity – e.g. immunosupression, steroids, radiotherapy or cytotoxic drugs.
2. Adverse reaction
- Common
- Fever or rash may occur one week after immunisation.
- Parotid swelling in 1% of children.
- Rare
- Febrile convulsion. The incidence is 1 in 1000.
3. Autism
- A lot of research has been conduction and no link has been proven between MMR vaccination and any bowel disease.
- Some private clinics offer single vaccines but the Department of Health recommends that parents be discouraged from using them.
- MMR is safe and the information which was published in the past has now been discredited.