Pediatric New Consult (ASD)

Referred by: 

PARENTAL CONCERNS:
Parents expressed concerns regarding behavioral issues and sensory regulation issues. Initial concerns included difficulties with self-regulation, which began in early childhood. Additional concerns included behavioral dysregulation triggered by sensory stimuli and selective eating behaviors. Patient was seen at Regional Pediatric Clinic for assessment and is awaiting reassessment.

DEVELOPMENTAL HISTORY:
Language:
Patient demonstrated early advanced speech development with no reported articulation difficulties or motor speech concerns. Patient follows commands and is described as intellectually advanced, with a particular affinity for puzzles, chess, and mathematics, which are calming activities. Patient is exposed to English at home.

Social/Emotional:
Patient gains attention through behavioral outbursts and initiates play through engagement in preferred activities such as hockey and puzzles. Patient interacts socially and is described as having achieved early social smiling. Displays a range of emotions, including frustration, calmness during preferred activities, and dysregulation in overstimulating environments. Tantrums and outbursts are typically triggered by sensory overload, particularly in public or school settings.

Restricted and Repetitive Behaviors (RRBs):
Patient does not require strict routines but demonstrates a strong preference for regular participation in hockey, which has a calming effect. No stereotyped use of objects or insistence on sameness reported. Patient enjoys puzzles, chess, and mathematics, and has specific interests in these activities. Feeding difficulties are related to sensory issues, including preferences for certain textures and abrupt refusal of foods, particularly meats.

Activities of Daily Living (ADL):
Patient is able to self-feed but demonstrates selective eating behaviors. No concerns regarding self-dressing or toileting were reported.

Gross Motor (GM):
No abnormalities noted, including tone or gait.

Fine Motor (FM):
No concerns reported.

Cognitive:
Patient is described as intellectually advanced, with strong skills in puzzles, chess, and mathematics, and demonstrates good attention during calming activities.

Childcare/School History:
Patient has attended school since junior kindergarten. Behavioral dysregulation has intensified in the school environment, particularly in grades one and two.

Services:
No current services reported.

Funding:

Activities in the Community:
Patient participates in hockey, which has a significant calming effect.

PRE/POST-NATAL HISTORY & INFANCY:
Feeding history includes mixed breastfeeding and formula due to insufficient maternal milk supply. Breastfeeding and expressed breast milk were provided until approximately three to four months of age, after which formula feeding was continued.

PAST MEDICAL HISTORY:
Generally healthy. No history of hospitalizations or major health issues. Growth has been slow, and patient is described as small in stature. No ongoing symptoms reported.

Medications:
No current medications.

Immunizations:

Allergies:
No known allergies.

FAMILY AND SOCIAL HISTORY:
Patient has strong social supports at home. Family history not reported.

PHYSICAL EXAM:
Observations: Not available.
Interaction with parents noted, including engagement in calming activities.

Vitals:

General: 
HEENT: 
Lungs: 
Cardiovascular: 
Abdomen: 
Skin: 
CNS: 
MSK: 

ASSESSMENT AND PLAN:
Patient is a child with behavioral and sensory regulation issues, selective eating, and a history of early developmental milestones and advanced cognitive skills. Recommend proceeding with further assessment and consideration of occupational therapy for sensory regulation and feeding concerns. Patient will benefit from continued participation in calming activities such as hockey and puzzles. A follow-up session will be scheduled after further assessment. Thank you for the opportunity to participate in the care of this patient. Please feel free to contact me with any questions.

Arjun Patel, MD
Pediatrics
Regional Pediatric Clinic