Iatrogenic Trauma Masquerading as Autistic Spectrum Disorder

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A four-year-old child, thought to be autistic, emerged from his illness and returned to normal development via the working-through of his early traumatic medical experience.INTRODUCTIONb. was a four-year-old boy who first became a concern due to difficulties with his gastrointestinal tract. He suffered with pain after ingestion, had a related refusal to eat, and was reluctant to move his bowels. Between the ages of eighteen months and four years, he had undergone many diagnostic procedures with anesthesia, including endoscopies, colonoscopies, barium enemas, barium swallows, and biopsies, with only one positive finding: a mild to moderate allergy to dairy products. He had also begun to restrict his diet, so that by age two and a half he was significantly underweight, and a year later he came close to requiring a feeding tube.B. was referred for psychiatric evaluation however, only after a preschool teacher, finding him atypical in his behavior, had suggested that he suffered from a sensory processing disorder. He would not allow himself to be touched and would cry and lash out in obvious distress if anyone impinged on his space. Intolerant of transitions, he became upset when his control was challenged and was a difficult child to manage in a classroom. He was highly intelligent with good fine-motor skills and a superb memory, but having evidenced awkwardness with his body in space, a lack of handedness, and errors in perception, had started occupational therapy. Remarkably aware of textures, he required soft clothes and bedding (akin to his father's sensitivities in childhood) and was a perfectionist for whom meltdowns were commonplace, triggered either by a mistake he might make or a correction given, however gently. His frustration tolerance was nil. He quickly resigned from any endeavor on encountering obstacles, and as a result he mostly refused to play with other children. His one-year-old sister presented a significant problem for him, in disrupting the orderliness and quiet he required.Managing or modulating B.'s deregulated affect was a challenge for both parents, exacerbated by a trauma his father had experienced in early adolescence and by the emotional abuse his mother had suffered as a child, but this history did not emerge until we neared the end of the treatment. He would urinate in the toilet but would only defecate in a diaper and would not tolerate any attempt to discuss this situation. He experienced headaches almost daily, associated with too much noise, disliked having any nonfamily member enter the house, and would hit and bite his mother when she picked him up or tried to contain him physically. He had many fears: of various shapes, sounds, pretend play, dogs, and being alone. An injury to his body, especially if there was blood, would be met with rage and panic.Although this description readily fits a child with an autistic spectrum disorder,1 it emerged over the course of a two-year, two-to-three-timesa-week intensive psychotherapy that, in fact, he suffered from severe anxiety and posttraumatic reactions secondary to invasive medical experiences. Treated at his parents' request without psychotropic medication, he was nevertheless able to work through his trauma and return to emotional health. His experience thus presents an opportunity to study the impact of a recurrent physical trauma on the development of a child and the process of a psychotherapeutic intervention that supported his recovery. Eluding repression, the memories of his trauma remained vivid and unmetabolized in his consciousness and consequently were the source of continuous anxiety in the present (Fernando, 2009). But this remarkable memory, pathogenic as it was, also allowed him to symbolize, recreate, and overcome the physical and emotional trauma he had endured in his early years of life.UNDERSTANDINGINITIAL ENCOUNTERS: ESTABLISHING A DIALOGUEB. presented as a boy who was tiny for his age, serious, rigidly constricted in his body's movements, and uncomfortable with physical closeness. …