Training vignettes
A four-year-old boy…
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 child’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. Total AMSE score is 10.
A 36-month-old boy…
A 36-month-old boy is brought to your office by his mother who reports concerns that her child 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.
Please note: 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. Total AMSE score is 4.
An 8-year-old girl…
An eight-year-old girl, accompanied by her mother, sits down in your office. She immediately stands up to get a closer look at a small clock on your desk. She looks at you and then, as she points to the clock, asks you if the clock comes with roman numerals. Her mother tells you that she is very interested in numbers on clocks, calendars and roman numerals. She makes sustained eye contact with you for more than 3 seconds; she tells you about her school, how many children are in her classroom, and what she likes to do during recess. She speaks using an unvaried and odd intonation, yet takes her turn and stays on topic in your conversation with her about her school. At the end of the conversation she starts talking about roman numerals again. Her mother tells you that she cannot tolerate labels on her clothing and only wears soft undershirts. She has no compulsive-like repetitive behaviors and no insistence on routines. There is no report of motor stereotypy or delayed/immediate echolalia but her mother reports that she sometimes uses overly formal language (stereotyped speech) such as “Oh dear me!” or “Indeed”. You don’t observe the overly formal language during the exam. There is no report of high pain threshold.
