Friday, 12 October 2018

Pervasive refusal syndrome and autism: autistic traits 'speeding up the recovery process'?

Before reading the case report paper by Emily Bond & Rosalind Oliphant [1], I have to admit that I knew next to nothing about the label known as pervasive refusal syndrome (PRS). PRS, a condition manifesting as 'refusal to eat, weight loss, social withdrawal and school refusal', is not currently recognised in any of the major diagnostic manuals (DSM, ICD) but does seem to have a following in certain circles [2].

Bond & Oliphant detail a case report of a 9-year old boy who came to clinical attention "due to concerns regarding minimal dietary intake." He had previously been diagnosed with an autism spectrum disorder (ASD) as well as attention-deficit hyperactivity disorder (ADHD) following a trend these days (see here). He was subsequently detained under the Mental Health Act as a consequence of "his resistance of treatment in the community" and also him "lacking Gillick competence." The authors detail his clinical journey, and how, with the right support and accommodations, he was eventually discharged from hospital care with the expectation for him to "make a full recovery to his premorbid functioning with support in the community."

Among the various issues raised in the Bond/Oliphant paper, one of the most striking points made by the authors was in the sentence: "It is possible that the ASD [autism spectrum disorder] symptoms such as literal thinking and concrete processing have actually aided in speeding up the recovery process." The idea that certain autistic traits might actually have had a positive benefit to getting someone through treatment for PRS...

I'm slightly careful here not to go off on the 'autism is a superpower' tangent that some people have previously spoken about (particularly on social media). For this young man, autism for him included communication issues ("His sole method of communication was typing on an iPad to his mother")  and various other traits (e.g. "struggling with understanding abstract questions, complex reasoning, and problem solving skills") which probably didn't impart any superpower for him. He did have an interest in superheros and dressing up in costumes however...

Authors mention how his recovery from PRS - he was discharged after 4 months - was significantly quicker than is typically expected (around 12 months "from previous literature"). They noted that: "The clinical team working with our case quickly found that he responded very well to rules, boundaries, and clear consequences of behaviour." This is perhaps even more notable in the context of his autism-ADHD diagnostic combination.

It did get me wondering whether further research might be revealing into how autism or specific autistic traits might positively impact on other treatment/management scenarios. I'm specifically thinking about more psychologically-inclined interventions, for example, dealing with something like anxiety (see here) where talking therapy is something that is being particularly pushed forward. Whether or not I agree that such therapy is going to be all that useful in the longer-term if for example, one considers that anxiety might be intricately related to some core functions in relation to autism (see here) is irrelevant. Whether certain autistic traits might be a critical variable in intervention success however requires much further study...

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[1] Bond EC. & Oliphant RYK. Pervasive Refusal Syndrome in Autistic Spectrum Disorder. Case Rep Psychiatry. 2018 Jun 7;2018:5049818.

[2] Nunn KP. et al. Pervasive refusal syndrome (PRS) 21 years on: a re-conceptualisation and a renaming. Eur Child Adolesc Psychiatry. 2014 Mar;23(3):163-72.

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