An oversight

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.

After reading the Child Psychiatry Consult column “Aggression and angry outbursts” by Dr. Robert R. Althoff in the September 2014 issue of Pediatric News, I was disappointed that the differential diagnosis did not include an autism spectrum disorder such as DSM-IV Asperger syndrome.

The complex of symptoms described almost perfectly reflects the history of a child with autism. Typical autism spectrum disorder (ASD) issues of needing to direct the play, playing by their rules, and being adamant that things must be the way they see it are noted in the patient’s history. Aggression and outbursts also are typical of a patient with ASD.

Even though autistic behavior is typically predictable, parents are not always alert to the triggers. Most meltdowns are over transitions and denials. Parents of patients with autism often complain that they “walk on eggshells.”

Edward B. Aull, M.D.

Behavioral Pediatrics

St. Vincent Carmel Hospital

Carmel, Ind.

Dr. Althoff responds: I’d like to thank Dr. Aull for pointing out an oversight in my article. Certainly, children on the autistic spectrum can exhibit aggression, although it is not part of the diagnostic criteria for DSM-5 ASD, which include deficits in social interaction and communication, and restricted, repetitive patterns of behavior, interests, or activities. I was not intending for the case to give the impression that this child had difficulty with social communication and restricted interests, but the diagnosis of ASD should be considered on the differential. Similar to the situation in obsessive compulsive disorder or other anxiety disorders, when either the need for social communication becomes exceptionally high or the restricted behavior or interests are challenged, these children can become aggressive, although most do not. Interestingly enough, children with DSM-IV Asperger syndrome and high-functioning autism have co-occurring disorders up to 74% of the time, with the highest percentages in the disorders on the differential that I listed in the original article: behavior disorders, anxiety disorders, and mood disorders (J. Autism Dev. Disord. 2010;40:1080-93). Given these findings, one might consider that, while the diagnosis of an ASD should be considered in the differential, the aggressive behavior may not be associated with the autism symptoms, per se, but rather may be co-occurring symptoms.