Question 1

A 7-year-old boy is brought in by his parents because he has difficulty making friends. He plays alone at recess, preferring to read about dinosaurs. He has memorized the classification and characteristics of over 200 dinosaur species. He avoids group activities but his mother says it is not because he is scared - he says other kids' games "don't make sense" and are "too loud." He makes limited eye contact, speaks in a formal, adult-like manner, and interprets idioms literally (when his teacher said it was "raining cats and dogs," he looked out the window and was confused). He becomes very distressed when his after-school schedule changes unexpectedly. His pediatrician suggested he might have social anxiety disorder. Which feature most strongly suggests ASD rather than social anxiety disorder in this child?

Accepted Answer

The core distinction between ASD and social anxiety disorder is the reason for social difficulty. Social anxiety involves intact social cognition with fear of negative evaluation - the child knows the rules but is afraid of breaking them. ASD involves deficits in social cognition - the child genuinely does not understand the unwritten rules. This child's statement that other kids' games 'don't make sense,' his literal interpretation of idioms, and his formal speech pattern indicate deficits in social understanding and pragmatic language, not fear of judgment. His restricted interest (dinosaur taxonomy), sensory sensitivity (noise), and inflexibility (distress at schedule changes) meet Domain B criteria. Avoiding group activities and having difficulty making friends occur in both conditions and do not distinguish between them.

Question 2

A 10-year-old boy with ASD (Level 2) and moderate intellectual disability is brought to the outpatient clinic because of increasing aggression at school - hitting peers and staff, biting himself when frustrated, and frequent severe tantrums. The behaviors have intensified over the past 6 months despite behavioral interventions. The aggression is putting him at risk of being removed from his school placement. His parents are exhausted. A medical workup including dental evaluation and abdominal exam is unremarkable. What is the most appropriate pharmacological intervention?

Accepted Answer

Risperidone (FDA-approved ages 5-16) and aripiprazole (FDA-approved ages 6-17) are the only medications with FDA approval for irritability associated with ASD, which includes aggression, self-injury, and severe tantrums. They should be considered when behavioral interventions alone are insufficient and the behaviors are causing significant harm or functional impairment - both conditions are met in this case. SSRIs may help comorbid anxiety but are not first-line for aggression and self-injury. Stimulants can sometimes worsen irritability in ASD. Benzodiazepines are not appropriate for ongoing behavioral management and can cause paradoxical disinhibition in this population. A thorough medical workup to rule out pain as a driver of behavioral change (dental problems, GI distress, ear infections) was appropriately completed. The correct approach is to start an atypical antipsychotic with careful metabolic monitoring while continuing behavioral interventions.

Question 3

A 29-year-old woman presents requesting evaluation for ASD. She is a graduate student in biology with a 4.0 GPA. She has been treated for generalized anxiety disorder and recurrent major depressive disorder since age 16 with partial response to multiple SSRIs. She describes social interactions as "performances" that leave her exhausted. She has two close friends but says maintaining the friendships feels like a second job. She unconsciously mirrors the accents and mannerisms of whoever she is speaking with. She has organized her apartment with color-coded systems for everything and becomes intensely distressed if her roommate moves anything. She has been passionate about marine invertebrates since age 8 and can lecture for hours on cephalopod neurobiology. She cuts all tags out of her clothing, cannot tolerate fluorescent lighting, and wears earplugs in the grocery store. Her previous psychiatrist told her she "couldn't be autistic" because she makes eye contact and has friends. Which of the following best explains why her previous clinician's reasoning was flawed?

Accepted Answer

This question tests understanding of ASD presentation in women and the concept of camouflaging. The previous clinician applied a clinical prototype (no eye contact, no friends) that reflects only one end of the autism spectrum and was developed primarily from male presentations. The DSM-5 explicitly acknowledges that learned strategies can mask ASD symptoms. This patient demonstrates multiple features of ASD: social communication as effortful performance rather than intuitive process, conscious mirroring (a camouflaging strategy), intense circumscribed interest since childhood, rigid need for environmental order, and pronounced sensory sensitivities. Her eye contact may be learned rather than natural - many autistic adults describe training themselves to look at the bridge of the nose or making eye contact that feels performative rather than communicative. Having two close friendships does not rule out ASD; it is the quality and effort of social interaction, not the mere presence of relationships, that is diagnostically relevant. Her partial SSRI response and chronic treatment-resistant anxiety are consistent with an unidentified primary condition driving secondary anxiety and depression.

Autism Spectrum Disorder

Red Flags & Key Clinical Considerations

Late-Diagnosed Adults Presenting with Treatment-Resistant Anxiety or Depression

Missed Diagnosis in Women and Girls

Assuming Medication Will Treat Core ASD

Behavioral Escalation as Communication of Pain or Distress

Confusing Social Avoidance with Social Cognitive Deficit

Related Medications

References & Further Reading