A 4-year-old boy accompanies his mother into your exam room.  He holds a piece of string and sits on the floor without looking at you.  He makes forced exhalations that result in a low-pitched repetitive vocalization. He begins moving a toy car back and forth repeatedly; he lowers his head to be on level with the car and stares at the wheels. After taking history from the mother and giving the child some time to warm up to you, he still does not initiate any eye contact or social interaction.  You attempt a game of peek-a-boo, which evokes very brief eye contact and a social smile.   You ask the child to show you where his mommy is and he doesn’t respond.  You point to the toy closet and say:  “Look at all those toys!”  The child follows your point and looks at the toys. The mother reports that he can use 5-10 single words although he uses none during the exam.  There is no immediate or delayed echolalia.  He eats only one type of chicken and one shape of pasta; he recently had a severe tantrum when his mother gave him an unfamiliar shape of pasta. Throughout the exam, the child holds his piece of string up close in his peripheral visual field and flicks it between his fingers.  At times the flicking generalizes to his whole hand, which he then rapidly flaps.  His mother reports that he often puts his face up close to the television.  There is no report of heightened sensitivity to any stimuli.  During the exam, he accidently hits his head on the side of your desk but he does not appear to register any discomfort.

Please note:  Pragmatics is automatically scored a 0 (Not applicable) because the patient's Language consists of only single words.  Other points:  encompassing preoccupation with string is observed (remember:  reported encompassing interests must be in past 2 weeks).  High pain threshold is observed.



Eye contact is marked as "None" and scored 2 even though we cannot be sure due to the camera angle.  Pragmatic language difficulties are clearly observed throughout the exam as the patient cannot manage turns in the conversations and also speaks with an odd intonation.  The mother reports hand flapping and finger flicking (motor stereotypy) even though we observe only repetitive finger movements.  We also observed delayed type echolalia.

Eye contact is tricky to gauge here because we cannot be sure if he looks directly at the examiner.  The item is scored as a 2.  When you are with patients it will be more clear.  Pragmatics are impaired in both managing turns/topics as well as with unvaried intonation.


A 36-month-old boy is brought to your office by his mother who reports concerns that her son speaks using only single words.  For example, he can say "Juice" when he wants juice.  She also tells you that he can point to desired objects with good eye contact.  There is no report of echolalia or other repetitive or overly formal use of language.  You begin your physical exam and as you ask him to say "Ah" he opens his mouth wide, smiles, and laughs.  He sustains direct eye contact for about 2 seconds.  You ask him to show you where his mommy is and he points to his mother, looks back at you, and begins to laugh again.  He tries to grab your stethoscope and looks at your eyes as he awaits your response.  When you say, "Oh no you don't!" he laughs and flaps both arms for a few seconds.  His mother adds that he is an "easy child" and at school his play consists of lining up of blocks and other toys but when prompted he exhibits the capacity for symbolic play.  There are no reported or observed preoccupations and no reported or observed sensory symptoms.

Since this child uses only single words and gets a score of 1 for the LANGUAGE item, he automatically gets "Not applicable" and a 0 for the  PRAGMATICS item.  He also has a reported history of repetitive play and observed motor stereotypy--anything checked in the stereotypy/echolalia/stereotyped speech box gives you an item score of 2.



Pragmatics of Language:  the patient reports that he cannot manage conversations with peers (small talk) at work.  There is also observed odd intonation, which makes the item score a 2.

Repetitive Behaviors:  He reports some compulsive-like behaviors but no motor stereotypy so this item gets a 1.  He does exhibit some facial grimacing, which is a sign of an unrelated neurological condition.

Preoccupations:  There is observation of the patient's unusual preoccupation with noble gases.  Because this preoccupation spontaneously encroaches into the clinical exam it is marked as observed and the item score is 2.

This patient has encompassing preoccupations.



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