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When
play gets serious
by Ann Lacy
Special to The Catalyst
Alan, Brett, and Billy had fun playing with Ernie and Elmo, but the
real hit of the day for them was the gun that blew bubbles.
While first-year pediatric residents Alan Anderson and Brett MacLean
were enjoying interacting with Billy, they also were engaged in a much
more serious task, evaluating the little boy for autism.
 Charles
reviews a patient evaluation with pediatric residents Alan Anderson and
Brett McLean.
Autism is a neurological disorder characterized by severe communicative,
social, and behavioral problems. It is the third most common childhood
disorder after mental retardation and cerebral palsy, and four times more
prevalent in boys than in girls. While there is no cure for autism, early
diagnosis of the disorder is crucial to maximize the future development
of the autistic child.
In the brain of an autistic child, cells in selected circuits are “younger”
than the cells in the rest of the brain and younger than the chronological
age of the child. Neurologists have found that these cells can continue
to develop, provided that the young child receives the appropriate stimulation
from professionals and trained caregivers.
The younger the child, the greater the neuroplasticity of the brain.
While some improvement is possible at any age, an autistic child can
be guided toward a significantly brighter future during a unique window
of opportunity before age 3.
Within MUSC’s Division of Genetics and Developmental Pediatrics, under
Division director G. Shashi Pai, M.D., developmental pediatricians Jane
Charles, M.D., Michelle Lally, Michelle Macias, M.D., and Katrina Doig,
M.D., evaluate children for autism and train future pediatricians like
MacLean and Anderson to be alert to the signs of this disorder. The division
houses two clinics and a research project dealing specifically with autism.
In a weekly CHAT (Checklist for Autism in Toddlers) Clinic, the developmental
pediatrician, assisted by one or two first-year pediatric residents, evaluates
at-risk children referred by their pediatricians, schools, or social service
agencies. The clinic was established specifically to teach residents about
autism evaluations.
 Dr.
Jane Charles
“We see children who are not doing what they are supposed to be doing
developmentally. That means we have kids who show up who are not walking
or not talking or not learning. We see people of all ages; some are young
adults,” Charles said. Children also are referred to the clinic who may
be at risk for developmental disorders triggered by premature birth, spina
bifida, or other diseases.
On this occasion, while Charles interviews the child’s mother, residents
MacLean and Anderson engage the child in structured play.
Block play, bubble blowing, and a birthday party for Elmo are activities
that take place in homes, day care centers, and preschools everywhere,
but the residents are trained by Charles to observe and record the young
child’s social, communicative, and motor skills in what are actually very
controlled settings.
Does little Billy “feed” Elmo when Anderson says, “Elmo is hungry?”
Does the at-risk toddler look to see the big ball at which MacLean is pointing?
The child’s reactions reveal as much to these trained researchers as fluorescent
cell counts do to a cell biologist.
What are Charles and her associates looking for?
For a diagnosis of autism to be made, there must be an onset of symptoms
prior to age 3. There are specific signs of the disorder which must
be present:
There will be evidence of delayed and disordered communication: One
toddler will not speak at all; another may have his own language or only
be able to repeat everything he hears (echolalia).
Severely restricted interests such as a fixation on garage door openers,
and repetitive behaviors like pacing back and forth or head-banging may
be present.
Deficits in reciprocal social interaction skills are the most significant
sign of autism. The child may not meet Anderson’s gaze or respond in any
way to his mother’s smile or seek help in opening the bubble jar.
Following their observation of young patients like Billy, Charles and
the two residents next confer privately to reach a diagnosis and then present
their findings to the parent.
This is not the end but the beginning of Charles’ role in Billy’s future.
She may recommend treatment by an occupational therapist, speech pathologist,
psychiatrist, or psychologist. In subsequent visits, she will continue
to monitor Billy’s progress, and she will educate Billy’s caregivers on
the disorder.
Parents who bring their children to the CHAT clinic are motivated by
great love and concern for their little boy or girl. However, for even
the most loving of families, dealing with an autistic child sometimes demands
super-human patience. Charles mentioned that when she recently saw the
movie "Rainman," she was struck by the behavior of the Tom Cruise character,
brother to the autistic adult played by Dustin Hoffman. She remarked that
“it’s just how the parents of my patients act” at times, as the parents
feel so frustrated when they can’t communicate with their child.
Thus, Charles stresses that the parents of an autistic child also need
to know what will happen next as the child matures. They need help with
behavior management and with appropriate medications. And perhaps most
importantly, Charles emphasizes that “the parents need to be educated to
act as advocates for their child” in the complex worlds of education and
medical and social services.
In addition to the CHAT clinic, MUSC is fortunate to have one of the
three CARE (Carolina Autism Resource and Evaluation) clinics in South Carolina.
Located here at MUSC, at the USC School of Medicine, and in the Greenville
Hospital System, these clinics provide the services of a developmental
pediatrician (Charles), a psychologist, an occupational therapist, a speech
pathologist, and an educational specialist.
As opposed to many other evaluation clinics, the CARE clinic’s multidisciplinary
team is able to do the entire evaluation for autism spectrum disorders
and to deliver the diagnosis and feedback/education to the family in one
day. CARE is on the “cutting edge” of the entire nation in terms of using
evaluation tools recommended by the National Institutes of Health for research
on autism spectrum disorders.
Besides her clinical responsibilities, Charles is a recipient of a
five-year grant from the Centers for Disease Control. She and her colleagues
have been funded to do a “Population-Based Surveillance of Autism Spectrum
Disorders and Other Developmental Disabilities.” Researchers in three other
states (New Jersey, West Virginia, and Arizona) have been awarded similar
grants to collect data on the prevalence of autism.
Previously, different and varied criteria were used to diagnose autism,
resulting in uncertainty about which patients are really autistic and how
many people are affected by this disorder. The goal of Charles’ study is
“to determine the prevalence [of autism spectrum disorders] across a population
of children in South Carolina.” The project will also offer training in
diagnosis to pediatricians, family medicine doctors, residents in pediatric
and family medicine, school psychologists, and special education teachers.
There is no cure for autism.
But for the toddler whose face never lights up at the sight of his
mother, for the 3-year-old girl who reads aloud from the Joy of Cooking
cookbook but does not have the words to ask for a glass of juice,
for the little boy with no friends except a mysterious “Rainman,” there
is help.
Early diagnosis and treatment of the disorder by developmental pediatricians
like Jane Charles is definitely providing a brighter future for autistic
children.
Catalyst Online is published weekly, updated as
needed and improved from time to time by the MUSC Office of Public Relations
for the faculty, employees and students of the Medical University of South
Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107
or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst
Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu
or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community
Press at 849-1778.
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