Adult Autism and ADHD Case Study: Dora

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This case study aims to understand “Dora” and her psychological profile to provide diagnostic clarity and appropriate recommendations. The client’s name has been changed to “Dora” to protect her confidentiality and identifying information.

Client Overview
1. Dora is a 23-year-old female college student
2. Interests include snowboarding, reading fantasy books, sewing, and music; when not engaged in these activities, she is often thinking about them.
Background Information
1. Developmental History:
  1. Had delays in receptive language and social skills during her early childhood.
2. Educational & Work History:
  1. Attended multiple schools, both in-person and virtually
  2. Currently a part-time student with a 3.5 GPA
  3. Longstanding struggles with attention, organization, and sensory sensitivities
  4. Described school as “incredibly overwhelming”
  5. Works full-time, loves her job, and only has difficulty with unexpected changes
3. Family and Social History:
  1. Raised by her parents and has one brother
  2. Positive relationships with her family and three close friends
  3. Enjoys quality time but often needs alone time
  4. Trouble understanding jokes, fitting into social groups, and prefers shorter interactions
  5. Dislikes crowded settings
  6. Sit in the back of rooms where no one would notice her, wears headphones often, and interacts very minimally
4. Medical and Psychiatric History:
  1. History of depression, anxiety, borderline personality disorder, and social phobia
  2. Diagnosed with Dyslexia
  3. family history of mental health issues
  4. Currently prescribed Cymbalta and Wellbutrin
  5. History of trauma
  6. In counseling for over 10 years
  7. Previous psychiatric hospitalizations
  8. History of suicidal ideation, a suicide attempt, and self-harm
5. Legal and Substance Use History:
  1. Tickets for speeding and frequently hitting parking garages
  2. Consumes coffee and energy drinks daily
  3. Alcohol consumption about 3 times weekly
  4. History of recreational substance use (in multiple categories)
Presenting Problem
1. Description of Symptoms:
  1. Dora experiences difficulties with school and learning, attention, emotional regulation, and executive functioning. She has been struggling with these issues since childhood.
2. Impact on Functioning (self-report):
  1. These symptoms affect her daily life, academic performance, and social interactions. Dora often feels overwhelmed and has trouble completing most tasks on a daily basis, especially those related to school.
Assessment Procedures
1. Behavioral Observations:
  1. Friendly, talkative, and maintained good eye contact
  2. Arrived late for her appointments and was flustered about being late
  3. Easily distracted and had trouble sitting still
  4. Interacted well socially
  5. Worked quickly such that she forgot certain test items and made mistakes
2. Psychological Testing:
  1. Various tests were administered for IQ, academics, memory, executive functioning, personality, and adaptive behavior
  2. Specific measures used for autism (MIGDAS-2, SRS-2, Sensory Processing, CAT-Q for masking behaviors) and for ADHD (CAARS)
Test Results
1. Summary of Strengths:
  1. Strong verbal skills, reading, and reading comprehension
  2. Good visual scanning, motor speed, and switching with verbal information
  3. Average nonverbal skills, processing speed, math skills, and quick verbal recall
2. Summary of Vulnerabilities:
  1. Struggles with spelling, visual recall, and visual reproduction
  2. Difficulties with executive functioning such as focusing, processing information, cognitive flexibility, memory, time management, impulsivity, monitoring her performance on tasks, self-regulation, shifting between tasks, planning, and organization
  3. Struggles with emotion regulation
  4. Struggles in nuanced social interaction and sensory processing
  5. High masking behaviors
Diagnostic Impressions
1. Dora was diagnosed with Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Major Depressive Disorder, and Generalized Anxiety Disorder.
Case Conceptualization
1. Dora has more challenges with being aware of and interacting with others socially and appropriately interpreting and responding to social cues.
2. While her communication style helps her interact well with others, she may struggle at times with understanding others’ tone, use of phrases, and delivery.
3. Dora may feel unmotivated to interact with others, valuing her alone time more than social connections. On the other hand, she may force herself to engage and feel exhausted as a result, needing a significant amount of time to regulate and recharge.
4. Dora may spend large amounts of time interacting with things that interest her, prefer consistency and routine, and respond more intensely to sensory overstimulation. It is also common for autistic individuals to struggle with emotion regulation and need help from trusted support to cope with distress.
5. Dora uses a high number of social “masking” strategies in order to compensate and function relatively well. She described several behaviors and reactions consistent with masking that have allowed her to navigate her life, but it may often take a significant toll on her to uphold this system and leaves her feeling exhausted, dissatisfied, and sometimes overwhelmed.
  1. Masking (also known as camouflaging) is a common technique for autistic people who may want to hide their difficulties, internalize their emotional reactions, avoid being socially ostracized, and/or be accepted in an otherwise neurotypical world.
  2. However, frequent and consistent camouflaging often results in autistic burnout, which happens when they have exceeded their resources and can lead to increases in depression, anxiety, and other emotional stress responses.
6. Dora has more challenges with attention, impulse control, and hyperactivity than others her age.
  1. While some of these difficulties can be explained by anxiety, depression, and emotional distress, her symptoms appear above and beyond what you would typically see from these diagnoses alone.
  2. People with ADHD may also experience emotions more intensely than others, with their feelings showing more frequently, lasting longer, hitting them more easily, and completely overwhelming them, which may result in more exaggerated overreactions to seemingly small triggers.
  3. People with ADHD may also have a tough time soothing themselves and need additional time, and sometimes help, to calm down.
7. Emotional & Personality Features:
  1. React intensely to distress, be easily overwhelmed by social and sensorial challenges, and struggle to apply learned coping strategies in high-stress situations
  2. May be self-critical and self-doubting with a self-esteem that is vulnerable to slights and oversights from others
  3. Longstanding difficulties with anxiety and depression that have been previously diagnosed
8. Impact on Functioning (from test results):
  1. Daily issues with communicating effectively, completing basic home and school-based tasks, and maintaining confidence and self-esteem
Treatment Recommendations
1. Ongoing counseling with cognitive-behavioral and dialectical-behavioral techniques for emotion regulation, distress tolerance skills, managing inattention and executive dysfunction, and enhancing coping strategies
2. Medication management for ADHD
3. Group counseling for executive dysfunction/ADHD and Autism
4. Academic support and accommodations through the Office of Disability Services at her school
  1. Utilization of campus services such as tutoring and counseling
5. Self-help tips for improving focus and managing tasks, such as setting specific times for work and using reminders.

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