Gerardo: asthma and cultural beliefs in a Latino family.

CASE: Gerardo is an 8-year-old Latino boy who saw his primary care pediatrician with a second asthma exacerbation this year. His frustration with his illness was immediately apparent when he said, "I hate having to go to the nurse's office to take my albuterol!" His mother expressed concern that her son frequently refused to take his prevention medication for asthma, montelukast, each morning. When questioned about compliance with his inhaled steroid, his mother hesitated and then admitted that she discontinued the controller medication because she is afraid to "poison his body with so many chemicals." She consistently gave her son the inhaled steroid for 12 months, until care by the allergy specialist was unexpectedly transferred to a Spanish-speaking allergist. She complained that the new doctor is "cold and acts like a veterinarian, not a pediatrician." Gerardo is a first generation Mexican-American who was born in the United States to Spanish-speaking parents. There is no family history of asthma, although his mother fears that she may have contributed to Gerardo's condition. She explained that during pregnancy, she worked cleaning houses where she was exposed to many toxic household cleaners. She has always worried that by inhaling these fumes during pregnancy, she induced her son's asthma. Gerardo presented with his first episode of reactive airway disease at 9 months of age. His mother vividly recalled his high temperature, rapid breathing, and their ambulance ride to the hospital. He was hospitalized for 3 days, and he has not been hospitalized since. Allergy testing revealed sensitivity to weed pollen only. Gerardo sleeps with a nonallergenic pillow and bed cover. Gerardo's mother explained that 3 days before his current exacerbation, he was playing at an amusement park with his friends on a hot day. Gerardo and his friends ran through a large fountain. His mother reported that he was soaked in water and stated, "He knows that he will get sick with asthma if he gets wet!" She recalled that 3 years ago at a friend's birthday party, Gerardo abstained from running through the sprinklers with the other children without instruction from his parents. Since that event, she has trusted Gerardo to care for his "weak lungs." She is frustrated now with his regression in self-care.

Late onset autistic symptoms and other fluctuating behaviors.

CASE: Suzanna was born to a 26-year-old woman who used cocaine, alcohol, and cigarettes and experienced domestic violence throughout her pregnancy. Suzanna was placed in foster care with her current adoptive family after her birth. Her initial evaluation at 4 years revealed a global developmental delay (physical: 6 months; social and communication: 12 months). Improvements in development seemed to be in response to subsequent interventions. At 5 years, she had borderline intellectual functioning, an expressive or receptive language disorder, and attention-deficit hyperactivity disorder. Suzanna experienced an abrupt developmental decline at 6 1/2 years old. She lost cognitive abilities, and she no longer carried on conversations. Although she was no longer interactive with most people, she remained affectionate with her parents. Her mother thought that Suzanna had visual and auditory hallucinations. In addition, she developed encopresis and hand flapping. A neurological evaluation, including a test for Rett Syndrome, was negative. Her Full Scale IQ dropped from 73 to 50 with decreased adaptive functioning and clinically significant problems with hyperactivity, attention, and functional communication. Suzanna's development stabilized temporarily during an 18-month period. A second period of declining function included "zombie-like" behavior, anxiety, and hallucinations. Weekly sessions in child psychiatry included treatment with risperidone, methylphenidate, and supportive therapy for mother and child. After some clinical improvements in behavior, attention, and functioning, a psychological assessment confirmed the persistence of moderate mental retardation. A multidisciplinary team considered a diagnosis of childhood disintegrative disorder.

Late onset autistic symptoms and other fluctuating behaviors.

Suzanna was born to a 26-year-old woman who used cocaine, alcohol, and cigarettes and experienced domestic violence throughout her pregnancy. Suzanna was placed in foster care with her current adoptive family after her birth. Her initial evaluation at 4 years revealed a global developmental delay (physical: 6 months; social and communication: 12 months). Improvements in development seemed to be in response to subsequent interventions. At 5 years, she had borderline intellectual functioning, an expressive or receptive language disorder, and attention-deficit hyperactivity disorder.Suzanna experienced an abrupt developmental decline at 6 1/2 years old. She lost cognitive abilities, and she no longer carried on conversations. Although she was no longer interactive with most people, she remained affectionate with her parents. Her mother thought that Suzanna had visual and auditory hallucinations. In addition, she developed encopresis and hand flapping. A neurological evaluation, including a test for Rett Syndrome, was negative. Her Full Scale IQ dropped from 73 to 50 with decreased adaptive functioning and clinically significant problems with hyperactivity, attention, and functional communication.Suzanna's development stabilized temporarily during an 18-month period. A second period of declining function included "zombie-like" behavior, anxiety, and hallucinations. Weekly sessions in child psychiatry included treatment with risperidone, methylphenidate, and supportive therapy for mother and child. After some clinical improvements in behavior, attention, and functioning, a psychological assessment confirmed the persistence of moderate mental retardation. A multidisciplinary team considered a diagnosis of childhood disintegrative disorder.