Autism Case Studies

CHILD ASD/ADHD EVALUATION

REFERRAL INFORMATION

Client is a 15 year old African American male referred for executive functioning difficulties including inattention, planning and organization, time management, and distractibility.  Also difficulties with irritability and anxiety.

Client has a history of fine motor deficit in childhood but otherwise no developmental delays.  He maintains a small group of friends of similar interests but exhibits less “maturity” than his peers and has a sarcastic attitude that can be “off-putting.”  Academic performance was good.  However, he struggles turning in assignments, remaining organized, and participating in class, which led to failing grades and overall poor performance.  He was enrolled in accelerated courses and worked much harder than his peers to maintain grades.  He experienced panic attacks when his parents attempted to speak with him about grades and became angry when his mother met with teachers.

Client’s previous counselor suggested ruling out Asperger’s Disorder.  He continues struggling with task completion, needing reminders, planning ahead, and poor self-care/hygiene due to inadequate time management.  He often leaves chores incomplete, takes longer to finish tasks, and sometimes is dishonest about his sleep habits and whether school assignments were submitted.  Client struggles with coping and high anxiety under pressure, becoming easily irritated and scratching himself.  He has also experienced moderate depression and anxiety symptoms related to grades and school performance, along with feelings of hopelessness, loneliness, and grief, headaches, and low energy.

DIAGNOSES

• Autism Spectrum Disorder, Level 1 (High Functioning)
• ADHD, predominantly inattentive presentation
• Other Specified Anxiety & Depressive Disorders (secondary to primary dx of ASD & ADHD)

- This means that symptoms do not qualify as a general anxiety or major depressive episode and are instead caused or influenced by difficulties created within the primary diagnoses.  For example, “I’m anxious/sad because I can’t focus.”

WHAT ARE CLIENT’S STRENGTHS?

• Cognitive Skills

Client has an estimated intelligence in the Superior range of ability with very good verbal and reasoning abilities.  This suggests that he uses and understands language well, is able to express himself and his thoughts adequately, and can incorporate  previously learned knowledge into problem solving strategies very well.  His spatial skills and memory were all developing adequately.

• Academics

Client has reading abilities that are in the Very Superior range, suggesting significantly well developed word reading skills.  He comprehends reading materials exceptionally well and spells sight words at a rate higher than his same-age peers.  Though his math skills were lower than these other areas, this skillset is also developing comparable to his peers.

WHAT ARE CLIENT’S VULNERABILITIES?

• Executive Functioning

Client showed deficits in several areas of executive functioning including visual scanning and attention, cognitive flexibility, and set switching (involves the ability to unconsciously shift attention between one task and another).  His overall attention capacity was much lower than his other abilities (verbal, memory, skills, etc), making it a relative weakness for him.

His processing speed was also significantly lower than expectations.  This means that he processes information slower than his peers.  Attempts to inhibit (stop) himself from responding to certain stimuli may slow down his cognitive processing speed.  His cognitive processing may also be slowed by switching demands.  There were several self-reported executive functioning issues including poor initiation, self-monitoring, emotion regulation, and organizational skills.

All of these areas may result in this client struggling with working quickly and efficiently, understanding long instructions and/or lectures, and completing tasks and assignments in a timely fashion or under timed conditions.

• Emotional Functioning

In addition to issues of hyperactivity, attention, problems, and executive dysfunction, rating forms also indicate difficulties with anxiety, depression, adapting to changes, managing everyday chores and tasks, controlling anger and emotions, exhibiting physical complaints, withdrawal, learning problems, and resilience.  These areas will further impact executive functioning and can result in feeling overwhelmed and unable to manage daily stressors.

• Social Functioning

Assessment results and ratings indicated difficulties comprehending perspectives, experiences, and beliefs of others and matching appropriate emotion to contextual cues.  This may impact his ability to show empathy and sympathy for others, notice and make sense of emotional undertones in conversation such as humor and sarcasm, and respond appropriately to others.  He also had trouble describing his own internal emotional experience, usually relating his emotions to physical responses in his body.

Client was very concrete, spoke flatly in a straightforward manner, and rarely offered information about himself.  He had trouble sustaining and initiating conversations, did not make eye contact often, and showed a very limited span of facial expressions.  He was able to describe social situations and his relationships adequately.  He has a very straightforward method for determining his friends and acquaintances that was typically based on the amount of personal information he shares.  While this won’t necessarily create problems for him, this rigid determination system may isolate him from others in some ways.  This rigid behavior was also endorsed on rating forms along with unusual behaviors and sensory sensitivities to sound, touch, body awareness, and balance and motion.

HOW CAN THIS CLIENT BEST BE SUPPORTED?

High Functioning Autism can often be difficult to detect because clients may not struggle significantly in the social domain or with repetitive behaviors or restricted interests as much or as often.  They may often be able to maintain friendships and interact with others well.  Those with higher functioning ADHD are similar in that they may have average to above average academic performance and show exceptional cognitive skills but may struggle to complete work, chores, etc.  

For profiles like these, the following is needed:

• Counseling, specifically cognitive behavioral techniques,  to address concerns related to executive functioning and mood
• Medication for ADHD and anxiety and depressive symptoms
• Social support - social skills groups and extracurricular activities
• Sleep schedule (can be addressed in counseling and with medication if necessary)
• Academic accommodations including preferential seating, frequent breaks, extended time, separate testing space, extensions for assignments, and substitution assignments
• Disenroll from AP classes

Reducing academic load may reduce current struggles - current demands may be exceeding his capacity right now

• Standardized testing accommodations
• Transition to college & continued academic accommodations

ADULT ASD/ADHD EVALUATION

REFERRAL INFORMATION

Client is a 22 year old transgender female referred for ADHD, social difficulties, and mood concerns.  She has trouble with focusing when not immediately interested in the subject matter, staying organized, forgetfulness, blurting out answers, and interrupting others in addition to significant anxiety and depression.

Client has a history of problems with coordination and gait as a child.  She began speaking but stopped suddenly, resulting in speech therapy when she was 3 years old.  She has strained relationships with her father and brother.  While her relationship with her mother has improved, they are also not very close.  Client has difficulty maintaining friendships due to anxiety and forgets to speak to others when not around friends.  She has also always struggled to get along with peers.  This client is currently a junior in college with good academic standing but has trouble focusing on schoolwork.  She has a history of behavioral difficulties in school including fighting and suspension, gifted program participation in 3rd grade, and failing one course in high school.

Medically, Client has conductive hearing loss in her right ear and suffered a head injury at age 5.  She has completed hormone replacement therapy for the past 2 years and is prescribed Vyvanse and Lexapro.  She also has occasional difficulties with sleep and abnormal appetite when medication compliant.  While this client is not currently in counseling, she previously completed play therapy for ADHD, anxiety, and depression.  She was also evaluated when younger and diagnosed with ADHD with “Asperger tendencies.”

Client has trouble with prioritizing work, sitting still, and paying attention in addition to identifying emotions and the emotions of others, understanding other people, initiating and maintaining conversations, making eye contact, speaking in monotone, and feeling upset at changes in routine.  She also tends to hyperfocus on certain things, exhibits mild sensory aversions to noise, touch, and food textures, and engages in unusual and repetitive movements when younger..  All of these have been present since childhood.  Depression has been present for years and includes passive suicidal ideation.  Client also has social anxiety, fears embarrassing herself, worries if interactions do not go smoothly, and experiences anxiety when distracted, inattentive, and not meeting responsibilities.

There is a family history of ADHD, depression, anxiety, social difficulties as well as learning problems, bipolar disorder, and schizophrenia.  During testing, the client showed mild difficulties with social discourse, had variable eye contact, and was observed staring blankly at examiner such that instructions/questions were occasionally repeated.  She spoke quickly and with poorly modulated volume.  She had a flat affect with a depressed mood.  She was very fidgety and distractible throughout the administration and showed increased inattention on orally administered subtests or when speaking directly to her.  She also showed low frustration tolerance at times.

DIAGNOSES

• Autism Spectrum Disorder, Level 1 (High Functioning)
• ADHD, combined presentation
• Major Depressive Disorder
• Other Specified Anxiety Disorder (general and social anxiety secondary to primary diagnoses; test taking situations)

- This means that symptoms do not meet full criteria for generalized anxiety or social anxiety disorder and are instead caused or influenced by difficulties created within the primary diagnoses.  For example, “I’m anxious because I can’t focus.” “I’m afraid when I have to speak to people.”

- There is no diagnosis for test anxiety such that it must be specified by an “other” diagnosis.

WHAT ARE THE CLIENT’S STRENGTHS?

• Nonverbal Skills

Client has significant strengths in nonverbal skills, which indicates the ability to reason through available information to improve problems solving and to process visual information.

• Verbal Skills

Client has very well developed verbal skills.. She is able to use and understand language well and is able to express herself and her thoughts adequately.

• Academic Skills

Client displayed academic skills that were developing nicely including expressive and receptive language, written expression, reading, comprehension, and fluency, mathematics, and math fluency.

WHAT ARE THE CLIENT’S VULNERABILITIES?

• Attention and Executive Functioning

Client has less developed processing speed, which may make it challenging for her to complete tasks as quickly and efficiently as her same-aged peers.  This may result in her needing more time to complete tasks, even more when there are timed conditions.

She had compromised verbal learning and memory, showing deficits in immediate recall, short and long term delayed free and cued recall, and recognition.  This means that Client struggled with recalling information immediately and after a short and longer delay even when provided memory cues and was unable to recognize information that was previously provided when in multiple choice format.

Client also has trouble with inhibition and switching, which means problems with stopping initial behavior and the ability to unconsciously shift attention between one task and another.  

She also has a significant issue with verbal fluency and rapid retrieval.  This is involved in quickly sifting through essential and nonessential information in memory and “retrieving” what is needed for a given task or question.  People who struggle in this area often need more time to read, answer questions, and perform quick math calculations when there are timed conditions.

• Emotional Functioning

Client has significant difficulties with depression and generalized, social, and test  anxiety that has been present for several years.  Rating forms indicated high levels of social stress, feeling out of control, and feeling inadequate.  She has difficult relationships with her parents and others, struggles with self-esteem, self-reliance, and heightened energy.  

The combination of emotional disturbance and dysregulation further contributes to executive dysfunction and will impact the ability to pay attention and manage self appropriately.

• Social Functioning

Client was very insightful into typical social situations and was able to describe her own internal emotional experience well.  She also demonstrated the ability to understand the emotions of others.  However, she had some difficulty displaying empathic behaviors, sustaining and initiating conversations, inquiring about others’ thoughts, beliefs, and feelings, and making eye contact.  Client was very detailed in her speech and often spoke in a straightforward manner.  She displayed a limited range of facial expressions and made occasional references to highly specific topics.  

Additionally, Client may attend to irrelevant stimuli that interferes with focus, notices things less often than others, and finds her environment too intense or variable to support her sustained performance.  Rating forms also endorsed significant problems across the social domains including picking up on and interpreting social cues, communicating, and being motivated to engage with others.

Deficits in social functioning contribute to unsatisfying social relationships, trouble engaging with others in a productive and social manner, understanding and communicating with others, and maintaining healthy friendships.  Feeling isolated from others in a social manner can lead to increases in depression, anxiety, and other emotional disturbances.

• Adaptive Functioning

Adaptive functioning refers to those skills that are necessary for us to effectively navigate through the demands that are placed on us by our environments and others.  These types of skills include communicating with others, independence, expressing yourself, hygiene, and completing other home-based tasks to name a few.  Specifically, this client struggles with navigating the community, academic functioning, basic home care living, maintaining health and safety, recreational skills, handling independent responsibility, and maintaining self-care.  This is indicative of clinical impairment as a direct or indirect result of overall struggles.

HOW CAN THE CLIENT BEST BE SUPPORTED?

High Functioning Autism can often be difficult to detect because people may not struggle significantly in the social domain or with repetitive behaviors or restricted interests as much or as often.  They may often be able to maintain friendships and interact with others well.  Those with higher functioning ADHD are similar in that they may have average to above average academic performance and show exceptional cognitive skills but may struggle to complete work, chores, etc.  Further difficulties with emotional functioning and dysregulation have also impacted overall functioning such that a multi-tiered approach is necessary for improvement.

For profiles like these, the following is needed:

• Counseling, specifically cognitive behavioral and dialectical behavioral techniques,  to address concerns related to executive functioning, social difficulties, and mood.  Having a clinician who is familiar with or trained in working with ASD is an asset.
• Ongoing medication consultation for ADHD and anxiety and depressive symptoms
• Social support and skills groups for adults diagnosed with ASD
• Psychoeducation and resources for ASD, ADHD, sleep issues, anxiety, and depression.
• Academic accommodations and resources including but not limited to tutoring, reduced course load, extended time, distraction-reduced testing environment, recording lectures, obtaining lecture notes in advance, and modified deadlines for assignments.