Confusion Between Depression and Autism in a High Functioning Child

Clinical Case Studieshttp://ccs.sagepub.com Confusion Between Depression and Autism in a High Functioning Child Kristina L. Cooper and Tanya L. Hanstock Clinical Case Studies 2009; 8; 59 DOI: 10.1177/1534650108327012 The online version of this article can be found at: http://ccs.sagepub.com/cgi/content/abstract/8/1/59 Published by: http://www.sagepublications.com Additional services and information for Clinical Case Studies can be found at: Email Alerts: http://ccs.sagepub.com/cgi/alerts Subscriptions: http://ccs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations http://ccs.sagepub.com/cgi/content/refs/8/1/59 Downloaded from http://ccs.sagepub.com by sorina constandache on April 23, 2009 Community Mental Health Service. the average age of diagnosis is around 5.com Kristina L. University of New England. Onset of autism occurs before the age of 3. there can be delays in identification.1177/1534650108327012 http://ccs. 2004). treatment 1 Theoretical and Research Basis Autism is diagnosed when a person has impaired social interaction.sagepub. e-mail: Tanya . Australia. Australia Autism is a diagnosis characterized by social and communication impairments. and treatment. Clinicians commonly consider autism as occurring on a continuum termed autistic spectrum disorders (ASD). 1999).Confusion Between Depression and Autism in a High Functioning Child Clinical Case Studies Volume 8 Number 1 February 2009 59-71 © 2009 Sage Publications 10. The following case highlights how a high-functioning female child with autism was misdiagnosed as having depression at a relatively late age. Clinicians with high-functioning child clients. Box 159.. Female children may be harder to diagnose because they tend to camouflage their social skill difficulties by watching and then imitating other socially competent peers (Attwood.sagepub.5 years (Howlin & Asgharian. along with assessment and treatment of this particular case. depression. Hanstock The Bipolar Program. who appear to have a flat affect and social isolation. NSW. Wagga Wagga. and School of Psychology. abnormal communication skills and a restrictive range of interests occurring since a young age (Sadock & Sadock. Senior Clinical Psychologist. diagnosis. 2000) is between 2 and 20 per 10. children. Edward Clayton for proof reading the manuscript. however.Hanstock@gsahs. are advised to be aware of the possibility of autism in such presentations. P. Correspondence concerning this article should be addressed to Tanya Hanstock. The reported prevalence of autism in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 2006a). Autism occurs four times more frequently in male.nsw. Approximately 70% of children with autism also have an Intelligence Quotient (IQ) falling in the intellectually impaired range (<70). Australia Tanya L. Authors’ Note: The authors would like to thank Dr.compared to female population.com by sorina constandache on April 23.sagepub. diagnosis.com hosted at http://online. 2650. Australia. Hunter New England Area Health Service. A number of symptoms of autism overlap with other childhood mental health disorders. 2009 . Onset of autism occurs before the age of 3. 59 Downloaded from http://ccs.health. Armidale.O.000 individuals. often accounting for a delay in correct diagnosis. Keywords: autism. However. Armidale. Issues around differentiating the diagnosis between depression and autism in children will be discussed.gov. text revision [DSM-IVTR].au. American Psychiatric Association [APA]. Newcastle. Cooper University of New England. and a disinterest in relationships (Fitzgerald & Corvin. Asperger’s disorder. attributing symptoms such as difficulties with social skills to other reasons such as shyness. Prevalence of childhood depression is 1% to 2% (Martin. Schluter. 2000) is depression. in common clinical practice. particularly depression. Depression is diagnosed in children when their mood is persistently low as expressed by marked sadness or irritability with this mood causing distinct impairment in their usual level of functioning. with similar symptomatology. Children with autism who have IQs above 70 and who can use communicative language by the age of 5 to 7 years appear to have the best prognosis (Sadock & Sadock. Autism is a lifelong disorder. mental retardation. On the contrary. some critics suggest that clinicians have become too liberal in giving the diagnosis of autism. Attwood. Second. and McDowell (2005) suggested that liberality in diagnosing autism may be due to two reasons. In such cases. overdiagnosis can be due to the ambiguities intrinsic in the interpretation of the behaviors that are used in providing the diagnosis of autism. 1996. people can still improve to some extent in areas of socializing. and adaptive skills (Attwood. there still appears to be many children who meet the diagnostic criteria of autism but who have either remain undiagnosed or have been given an alternative diagnosis.60 Clinical Case Studies Children who are diagnosed with high functioning autism (HFA) show signs of autism when they are young. The lack of correct diagnosis of autism is often the result of parents. communicating and self-care ability. Then from adolescence females are three times more likely to suffer from depression when compared to males. expressive language disorder. Some researchers have attempted to distinguish HFA from Asperger’s syndrome (Ghaziuddin & Gerstein. childhood disintegrative disorder. and the term HFA is used interchangeably with Asperger’s syndrome in the DSM-IV-TR (APA. First. Autism has some symptom overlap with mood disorders. Early diagnosis and intervention are regarded as important for all childhood psychological disorders.com by sorina constandache on April 23. 2004). Skellern. there is a large potential for clinicians to misdiagnose autism as either a false positive or a false negative. These include other pervasive developmental disorders.sagepub. when they are older. lack of emotional response. However. Ozonoff. One main feature differentiating depression from autism is that depression is diagnosed following a marked change in the child’s previous level of functioning. schizophrenia with childhood onset. It is well Downloaded from http://ccs. and this is especially true for autism. However. however. 2004). Rett’s disorder. The DSM-IV-TR (APA. selective mutism. including social withdrawal. the practice of intentionally upgrading a child’s symptoms to a diagnosis of autism may be a response to the pressure to provide a diagnosis that meets criteria for external funding. they have a greater degree of intellectual. stereotypic movement disorder. 2000) outlines several disorders that need to be considered in the differential diagnosis of autism. Thus. 2000. & Pennington. As a result of this awareness. 2009 . for example. 1991). Therefore. further assessment may be required to provide a differential diagnosis. 2001). and attentiondeficit/hyperactivity disorder. mixed receptive–expressive language disorder. 2006b). 2006). clinicians should consider the possibility of misdiagnosing either depression or autism when similar symptoms present. social. and health professionals not being aware of the main features of the diagnosis. school staff. HFA is a diagnosis given to children who fall at the less severe end of the ASD continuum. There is an equal female to male ratio of cases until puberty. Rogers. One diagnosis that is not considered as a differential diagnosis for autism in the DSMIV-TR (APA. she thought Jane may fit the diagnostic criteria for BD. following an episode of unusual behavior. Jane reported sleep difficulties. there appears to be a lack of literature and research dedicated to the similar symptomatology of depression and autism and to the possibility of confusion between these two disorders as a primary diagnosis in children. She found it difficult to identify her moods as she often did not know whether she was happy. 2009 . social problems (playing alone or with younger children). or angry. Jane had a few friends at school. 3 Presenting Complaints As there were a number of significant people involved in Jane’s care. sad. & Wilson. She reported having a varied appetite and her energy level alternated from being lethargic to not being able to keep still. but that Jane often became angry (especially toward her younger sister). First. Jane’s classroom teacher reported concerns about Jane’s lack of emotion. there were several presenting concerns by different parties. However.sagepub. Jane had become so upset about going to school one day that she had scratched and bruised her grandmother. Jane’s mother was concerned about Jane’s school difficulties. her mother concluded that Jane was upset. She also said she had problems expressing her emotions. However. Jane’s mother was also worried about Jane’s lack of speech and her unwillingness to engage in conversation. on many occasions. such as having problems going to sleep. Streiner. She said that Jane refused to attend school on a regular basis. when Jane hid in her room and refused to come out. a problem that was ongoing since Grade 2 (for 4 years).” She said Jane gave her minimal eye contact and that her speech was monotone in nature. 2000). but they were mostly younger. Jane’s mother could sometimes determine how Jane was feeling by observing Jane’s behavior: for example. and sometimes waking very early.Cooper. Jane’s mother thought Jane experienced everyday happiness more often than sadness. no facial animation (blank looks). The referring clinician had originally diagnosed Jane with depression. lack of communication (grunting rather than speaking). Jane’s mother found it difficult to know how Jane was feeling because she demonstrated minimal facial expression and did not talk about her feelings.com by sorina constandache on April 23. Hanstock / Confusion Between Depression and Autism 61 recognized that there is a high rate of comorbidity between depression and autism (Kim. Bryson. Jane was defiant and when she arrived at school on the mornings of school refusal she would stand with her arms folded and refuse to do any schoolwork. Szatmari. Downloaded from http://ccs. She had never seen Jane “have a good laugh” or seem happy. However. and “flatness. awakening in the night. Jane had been exposed to a lot of bullying and teasing over her primary school years. 2 Case Introduction Jane1 was an 11-year-old female who was referred to a community bipolar disorder (BD) clinic by her treating therapist for a thorough clinical psychology assessment. The case presented in this article is an example of how a child with HFA can be mistakenly diagnosed as suffering from a mood disorder. and younger sister (8 years) in a large rural town in Australia. which was conducted in the following order. which was in contrast to her usual flat affect. biting other children. Both Jane’s mother and teacher reported her to be academically performing well in school. At this time. putting soap in water bottles during the night. She also appeared to be full of energy. Jane achieved her milestones on target. Shortly after commencement of the SSRI. 5 Assessment Jane underwent a comprehensive clinical psychology assessment. and she demonstrated very little facial expression. but said that her own mother had experienced a “breakdown” a few years earlier. and during the initial consultation the family announced that they had plans to move interstate within four months. but this had declined rapidly by the age of 3 and she now only engaged in minimal speech.62 Clinical Case Studies 4 History Jane’s mother reported no family history of mental illness. Her speech was slow and of a monotone nature. the medication was ceased. Jane lived with her mother. The initial assessment commenced with a clinical interview to gather information as to presenting complaints and Jane’s history. Jane had been angry at home and she did not verbally express any of her feelings. She had been a very good talker when she was very young. stealing. where she was seen by an occupational therapist. for example. Jane’s mother was a homemaker and her father was in a government position that required him to engage in regular travel away from home. Jane’s younger sister was very bright and sociable. 2009 . The family had moved towns several times in Jane’s life. Jane appeared very flat during the interview. At the time of assessment. father. Jane was left out of social interactions during Grade 5 and she had appeared sad. The SC suspected Jane was depressed and referred her to a child and adolescent mental health service. and telling stories. Fluoxetine (10 mg daily for the first week with an increase to 20 mg daily from the second week). Jane’s mother also reported some anxiety in her maternal grandmother and paternal grandfather. Jane’s parents noticed Jane engaging in unusual behavior. Jane had outbursts of laughter that did not appear to relate to stimuli in her external environment. and this was unusual for Jane who previously seldom laughed. she was still referred to a specialist BD service for more intense clinical psychology assessment to assess for a mood disorder. she had been having social problems at school that had first become apparent when she was in Grade 4. Jane’s behavior improved and her difficulties stabilized. There was only minimal interaction between Jane and her mother as well as between Jane and the clinician. when questioned about her mood. However. Jane spent the majority of the interview looking down and had very limited eye contact. She reported a normal pregnancy and birth with Jane but noted that she had experienced some reflux when she was an infant. Jane had seldom smiled or laughed and she was. Following medication cessation. However. referred to the school counselor (SC). Downloaded from http://ccs. Jane was also seen by a senior psychiatry registrar who prescribed the selective serotonin reuptake inhibitor (SSRI).sagepub. therefore. However. Jane was in Grade 6 at a large public primary school.com by sorina constandache on April 23. she said she was happy. Due to the unusual behaviors demonstrated by Jane while on the SSRI. & Calabrese. The clinician conducted a Washington University in St. In comparison to the parent CBCL. and she did not rate herself on the sad or angry scales. used no gestures to communicate and did not initiate any play with the toys. Jane did not meet the DSM-IV-TR criteria for a mood disorder but did meet the criteria for Autism (APA. the teacher CBCL indicated Jane to be in the clinical range for the withdrawn/depressed scale. 1994) was then administered to Jane’s parents and revealed abnormal reciprocal social interaction occurring since age 2. and making up words. Hunt. The clinician also completed the Young Mania Rating Scale (YMRS. and acceptability as elevated scores in the child domain but health and depression as elevated scores in the parenting domain. 1995). Ziegler. Lord. 2001) and a Tripartite Mood Rating Scale (TMRS. and the parent version of the Young Mania Rating Scale (PYMRS. Information and observations from the clinical interview and questionnaires suggested that Jane did not meet the diagnostic criteria for a mood disorder but that she appeared to have signs of autism. hoarded objects. & Hazell. The PSI indicated adaptability. The clinician’s rating of the YMRS and the HDRS were not in the clinical range. & Kenworthy. Youngstrom. several questionnaires were given to Jane. Jane completed the Beck Youth Inventories (BYI. The TMRS completed by Jane showed that she was quite happy (and this was also stated by her in the interview). However. making noises. During the administration. mood. Hanstock. Results from the parent CBCL indicated that Jane was in the clinical range for withdrawn/depressed. rule-breaking behavior and aggressive behavior and the subclinical range for thought problems and attention problems. Isquith. Biggs. Gracious. A complicating factor in use of these questionnaires is that many of the signs and symptoms that load onto the depression and withdrawn scales are also those seen in children with autism who are not depressed. and was fixated on sharks and dinosaurs. and treatment. Back. Geller. The most useful clinical information from the parent questionnaires was obtained from the CBCL and the PSI. Hanstock / Confusion Between Depression and Autism 63 To assist in conceptualization. 2000). Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-K-SADS. Abdin. Guy. Jane not looking up if a person entered a room where she was and called her name. 2002) as well as the Parenting Stress Inventory (PSI. Jane had no spontaneous speech. 2000) was also administered to Jane. this formal interview provided further evidence that Jane’s current symptoms could not be accounted for by a mood disorder. Jane’s mother completed the parent versions of the Child Behavior Checklist (CBCL. Her abnormalities in communication included grunting. The Autism Diagnostic Interview–Revised (ADI-R. which suggested she may have had some symptoms of depression in the past and that she had experienced an increase in acting out behavior following commencement of SSRI medication. Young. & Le Couteur. for example. She also had a restrictive pattern to her routine and eating. & Meyer. reinforced parent. 2009 . 1978) and the Hamilton Depression Rating Scale (HDRS. diagnosis. the Behavior Rating of Executive Functioning (BRIEF. Rutter. Hamilton. 2001). very limited eye contact. Lord et al. social problems.com by sorina constandache on April 23. Zimerman. Achenbach & Rescorla. Beck. 2000). 2006). & Jolly. Findling. & Frazier. Downloaded from http://ccs. for assessment and posttreatment scores on these questionnaires). The Autism Diagnostic Observation Schedule (ADOS. and her teacher at the time of the initial assessment (refer to Table 1. Williams. her mother. She had a stereotypy of picking at the skin on her hands.Cooper. 1960). Gioia. Clayton.5 years. 1996) with Jane’s mother..sagepub. and two clinical psychologists. fell within in the Superior Range (96th percentile) and her Processing Speed Index. TMRS scores are on a scale of 1 to 5 with 1 = even and 5 = very happy. a measure of working memory. Jane’s score on the Working Memory Index was a significant strength compared to her Verbal Comprehension.sagepub. YMRS = Young Mania Rating Scale. ability to quickly and correctly scan. a senior psychiatry registrar.64 Clinical Case Studies Table 1 Test Scores on a Range of Questionnaires Used in the Assessment of a Child With Autism Prior to and Following 3 Months of Psychological Treatment Measure CBCL-PRa Internalizing Score Externalizing Score Total Score PYMRSb BRIEF-P (GEC) a PSI total stress c TMRSb. b. t score. PYMRS = Parent Version of the Young Mania Rating Scale. For example. The Wechsler Intelligence Scale for Children–Fourth Edition. was in the Average Range (34th percentile). HDRS = Hamilton Depression Rating Scale. and Processing Speed Indices. d. PSI = Parenting Stress Index. BRIEF-P = Behavior Rating of Executive Functioning–Preschool. was also in the Average Range (61st percentile). verbal reasoning and knowledge acquired from the environment. was in the Average Range (55th percentile). TMRS = Tripartite Mood Rating Scale. Her Full Scale IQ fell within the Average Range (70th percentile). very sad or very angry. GEC = Global Executive Composite. Jane did her work but would not ask for help when she needed it. Jane’s Working Memory Index.d YMRSb HDRSb Pretreatment Score 72 74 77 8 79 90 Happy = 1 (even) Sad = 2 (slightly sad) Angry = 2 (slightly angry) 2 5 Posttreatment Score 66 60 67 8 69 90 Happy = 1 (even) Sad = 1 (even) Angry = 1 (even) 0 1 Note: CBCL-PR = Child Behavior Check List–Parent Report.com by sorina constandache on April 23. 2003) was used to assess Jane’s overall intelligence. a school observation was conducted to view Jane in the classroom setting. further multidisciplinary assessments may have been beneficial. Perceptual Reasoning. 2009 . or discriminate simple visual information. One limitation of the assessment process outlined above was that although the client was assessed by an occupational therapist. c. a. sequence. At recess. Her Perceptual Reasoning Index. she ran out of the classroom and hid until the break ended. Raw score. Finally. a measure of perceptual and fluid reasoning. She was noticeably different from the other students in her class as she did not interact in class activity or with her peers. Percentile. which represents a measure of verbal concept formation. spatial processing and visual–motor integration. She sat very quietly picking at the skin on her hands. Downloaded from http://ccs. Australian Adaptation (Wechsler. Her Verbal Comprehension Index. as this therapy model has been useful for treating children with autism and Asperger’s disorder (Attwood. such as neurological or genetic assessment. lack of understanding social cues and situations. she did not have the main depressive symptom of feeling sad or having somatic complaints. and it appeared to be reinforced by the teasing and bullying she was receiving from other students. behavior and anxieties as she had good intellectual skills and was able to work well with the clinicians.com by sorina constandache on April 23. 6 Case Conceptualization Jane was diagnosed as having HFA. therefore. assessment and treatment occurred simultaneously. SSRI medication. she was not depressed. This would have assisted in ruling out any speech.Cooper. Jane’s poor social and communication skills appeared to have been quite consistent from a young age. did not attract attention until she started to refuse to go to school. Jane’s social impairments were also becoming more noticeable as she grew older. Jane was believed to have a good prognosis of improving her social skills. and a normal developmental fear of the dark. Downloaded from http://ccs. Hanstock / Confusion Between Depression and Autism 65 the client could have been assessed by a speech therapist as well as undergoing further medical tests. However. which her family and teachers had previously attributed to causing her social impairments. She appeared to have been misdiagnosed due to a number of school changes. There were 6 assessment and 10 treatment sessions that were conducted over a 3-month period. as there was no change in her previous level of functioning. as her anxieties were considered to be better explained by her autism. Jane was brought to the attention of mental health services when she started to display acting out behavior. A cognitive behavioral therapy intervention was offered to help her with her difficulties. 2006b). Jane’s school refusal was conceptualized as a response to her anxiety and her peer relationships. language. Jane’s behavior returned to as it had been following cessation of the medication. Jane did not express anxieties about a large number of areas of her life. Jane’s HFA diagnosis was also differentiated from generalized anxiety disorder. 7 Course of Treatment and Assessment of Progress Owing to severity of Jane’s difficulties and the family’s plan to move to a different city in the near future. although her impaired social and communication skills gave her a physical appearance of being depressed. or medical reasons for her difficulties. Jane’s diagnosis of HFA was differentiated from a diagnosis of depression. She was generally well behaved and quiet and. Jane had been upset about the bullying. 2009 . She also had a very close and supportive family. who functioned better both cognitively and socially and who was at times too overwhelming for Jane. She also had some atypical features of autism. and the school staff were very helpful. with deviance from her peers becoming much more obvious. appeared to cause an increase in irritability and aggression. She was then referred to a specialist mental health service when her acting out behavior significantly increased after commencement of SSRI medication.sagepub. she said she felt happy. Furthermore. Jane’s anger was most often directed toward her younger sister. therefore. such as a normal IQ and language. Jane’s number of school refusals was assessed throughout her treatment via school records (refer to Figure 1).sagepub.0 Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Note: Treatment began in late September. Jane’s mother reported an improvement in her behavior. her parents. Jane’s school refusal was the predominant difficulty for Jane. so this was the focus of the early treatment sessions.0 4. Anxiety Reduction The anxiety reduction intervention began by providing Jane and her parents with psychoeducation.0 0.66 Clinical Case Studies Figure 1 Pattern of School Refusal (Number of Episodes per Month) Before and After Treatment Episodes of School Refusal 5. Jane was given a star every day she went to school. Because Jane’s school refusal had been conceptualized as a response to her anxiety and her poor peer relationships. and after five straight successes she was able to choose a reward from a menu of rewards she had created in collaboration with her parents.0 1.0 3. Jane was happier. and she school refused only one day following treatment. In the fifth session. she was not getting as angry as previously. and her classroom teacher. these issues were addressed concurrently. Reward Chart for School Refusal To directly address Jane’s school refusal. and she was better able to control her anger. a star chart was created to reward her for going to school.0 2.com by sorina constandache on April 23. Jane’s good behavior continued over the following weeks. 2009 . she was going to school. The clinician normalized anxiety and discussed examples of Downloaded from http://ccs. most sessions consisted of a combination of anxiety reduction and social skills training. Her teacher had also noticed an improvement in Jane and had sent a letter home stating that she was doing much better at school. Thus. her night-light on (main bathroom light off. Step 2: Going to sleep with her main bedroom light off. but bathroom night-light on) Step 3: Removing toys from her bed Step 4: Going to sleep with all the lights and night-lights off Step 5: Going to sleep after her parents (with all lights off) Jane’s parents were concerned that Jane was not able to communicate her emotions. and a headache. It should be noted that some of Jane’s fears are common for her chronological age (e. Jane often felt anxious at night.com by sorina constandache on April 23. Baillie & Rapee. drawing. With some encouragement. 2000). The clinician discussed relaxation techniques with the family and gave them a relaxation script to use with Jane at home. but that it would pass. The clinician discussed with Jane alternative ways for her to express her anxiety. The clinician also discussed with Jane the importance of using eye contact during conversations (Hwang & Hughes. and other emotions. She also stated that she was worried that there was a dead body buried underneath her room. these being facial expressions and eye contact. Jane elaborated on her fear of the dark by stating that she did not like being awake when the rest of her family had gone to sleep and that she was scared of spiders. Jane was able to provide an acceptable emotion to the majority of the faces. Jane chose to work on her fear of the dark because this was the situation that worried her the most. She was able to identify that when she was anxious she had symptoms of tight lungs. The clinician discussed with Jane the importance of facial expressions including the link between facial expressions and feelings. whereas others are usually seen in younger children (e. a pounding heart. Hanstock / Confusion Between Depression and Autism 67 situations in which some people become anxious as well as common symptoms of anxiety. 2009 . monsters).sagepub. Jane drew a picture of herself on a wave to hang up at home to remind her that she can ride the anxiety wave (a technique known as panic surfing. writing. snakes.g.g. she was asked to draw on a picture of a body where her body felt different when she was anxious. 1998). Jane’s hierarchy for her fear of the dark was as follows: Step 1: Going to sleep with the main bathroom light and her bedroom night-light on. and dying. She was encouraged to think about her anxiety as a wave that would come and increase in intensity. and this was related to her fear of the dark and her nightmares. Once Jane’s fear of the dark had been identified. Jane completed a short exercise in which she named the emotion that pictures of faces were feeling... especially of a night time. These included playing with play-doh. 2003). teacher. To assist Jane in recognizing the impact of anxiety on her body. anger..Cooper. Downloaded from http://ccs. Jane reported enjoying the relaxation script and stated that it helped her anxiety and that she wanted to practice it more often. 2004a). the clinician discussed use of an anxiety ladder (Andrews et al. Social Skills Training Two main social skills were targeted during the treatment period. and painting (Attwood. monsters. Her attempts to use eye contact in various social settings were reinforced by her parents. and the clinicians. snakes). use of facial expression in conversations and the skill of reading others’ expressions. Consistent with her autism diagnosis. and the relevant school staff. There was also pressure for Jane to be discharged from the specialized BD clinic to a general child psychiatry service. However. Jane’s case was prioritized for assessment and treatment due to the obvious lag in detection and early intervention. A consistent approach to understanding Jane’s difficulties and her management led to a better outcome for Jane. one clinician was able to focus on the continued assessment. bodily. ripping up paper) and also ways to calm down when she was at school. 9 Managed Care Considerations To assess and treat Jane with maximum benefit. 2004b). 10 Follow-Up Jane was referred to child health services in her new local town.68 Clinical Case Studies Anger Management Jane was taught how to identify thinking. think of consequences. Fortunately. such as walking away from the anger trigger and asking for help from the teacher (Attwood.com by sorina constandache on April 23. the initial plan was for her to be assessed by a pediatrician. Jane was enrolled in a school that had a special program for children with autism and at an initial meeting they reinforced her diagnosis of autism. and to ensure continuity of care. Jane and her family were well engaged with the two clinicians. there was strong communication and involvement between the mental health services. and then perform her action.sagepub. She became much better at not acting out instantly when upset and was able to instead make good decisions on how best to react. her new town had many services for children with autism. Jane attended her assessment and therapy sessions with her mother. There was also limited time to assess and treat Jane’s difficulties due to the family’s plan to move interstate. She learned ways to physically release her anger (e. 2009 . Therefore. A limitation to this case Downloaded from http://ccs. 8 Complicating Factors Jane’s assessment was complicated as the school staff had not identified autism as a potential diagnosis and they were reluctant to accept this diagnosis because they felt that Jane was “putting on” some of her behaviors. The school staff and clinicians were in regular contact via telephone and meetings at the school. with further plans to refer her and the family to a psychologist to continue to assist them in managing Jane’s new diagnosis. Jane also learned how to stop.. and behavioral changes that occurred when she became angry. As there were two clinicians caring for Jane and her family. whereas the other was able to commence treatment concurrently.g. She practiced checking on an increasing scale (an anger thermometer) what level of anger she was experiencing to help determine what she needed to do to calm down. and her father also attended when he was at home. Jane’s parents. assessment and treatment co-occurred for a period of time after the diagnosis of autism appeared relatively clear. Rowlett. & Kamran. such clients may be incorrectly diagnosed and given antidepressant medication unnecessarily. 1998). children who act out come to the attention of schools (and subsequently. aggression. & Stein. and agitation are reported adverse effects of fluoxetine in children with autism and are often the main reason why fluoxetine is ceased in such cases (Cook. 2004). & Leventhal. Jane became more irritable and aggressive when commenced on fluoxetine. Downloaded from http://ccs. Teague. Jaselskis. In the above case. hyperactivity in particular. Children who have HFA (such as those with average IQs. Stein. can be easily mistaken as being depressed. 2004). Children with autism. Misdiagnosing a primary diagnosis of autism for depression appears to be a relatively simple consideration. flat intonation in speech. Behavioral activation. 1992. and social isolation are all signs that could be associated with a diagnosis of autism or a diagnosis of depression. who have language and also have little or no acting out behavior) may miss correct diagnosis. minimal facial expressions (especially lack of smiles and laughter). 2000). This can interfere with the early diagnosis of autism and result in missed opportunities that early intervention can provide. The school staff were also happier as Jane was less aggressive toward her peers. mental health services) more often and earlier than children with internalizing behavior (Chavira. Jane has a good prognosis due to her average IQ and language (Sadock & Sadock. who are female. irritability. however. depression is not considered as a differential diagnosis for autism in the DSM-IV-TR (APA. 12 Recommendations to Clinicians and Students There are a number of symptoms of ASD that can be mistaken for depression in children. DeLong. she showed a good improvement in her behavior. Furthermore.sagepub. However.com by sorina constandache on April 23.Cooper. there is limited literature and research dedicated to this phenomenon. autism occurs much more frequently in boys. Children with autism are at risk of being diagnosed as depressed and hence likely to commence SSRI medication. Unfortunately. She had only one further episode of school refusal (refer to Figure 1). Bailey. Jane and her family were much happier. and most scores on the posttreatment questionnaires (administered after the final treatment session) improved (refer to Table 1). have a normal IQ and have language skills. Female children may be more likely considered for a diagnosis of depression rather than autism as there is a same sex ratio for boys and girls having depression. Their understanding of Jane’s behavior had improved and they were active in learning about ways to manage her difficult behaviors. 11 Treatment Implications After correct diagnosis and treatment of Jane’s autism. 2009 . Flat affect. Hanstock / Confusion Between Depression and Autism 69 study was that the clinicians were not able to assess if Jane’s improvement continued post treatment cessation. Furthermore. Autism can be a difficult diagnosis owing to number of symptoms that overlap with other mental health disorders that can occur in childhood. as they tend to fade into the background of a school environment. Exploring feelings: Cognitive behavior therapy to manage anger. Beck Youth Inventories of Emotional and Social Impairment Manual.. (1998). M. (2001). & Leventhal. (2003). Chavira.com by sorina constandache on April 23. & Rescorla. Clinician. (2006b). Advances in Psychiatric Treatment. Developmental Medicine and Child Neurology. T. & Fazier. Arlington. C.. & Kenworthy. A. Gracious.. T. R. Zimerman. J.. & Calabrese. 31. London: Jessica Kingsley. J. The complete guide to Asperger’s syndrome. text revision). Burlington: University of Vermont. References Abidin.. Attwood. Attwood. Gioia.. R. S. D. & Page.. M. 155-164. Journal of Autism and Developmental Disorders. Exploring feelings: Cognitive behavior therapy to manage anxiety. American Psychiatric Association. A. 40. Attwood. Lutz. L. L. 3. (2004). Hunt. Louis Kiddie Schedule for Affective Disorders and Schizophrenia. 20. 35-40.. 310-318. J. Beck. 585-595. Effects of fluoextine treatment in young children with ideopathic autism. 551-562.. FL: Psychological Assessment Resources... Jane is a fictional name used to protect the client and family’s anonymity. M. L. Rowlett. Australia: Macquarie Lighthouse Press. Manual for the ASEBA School-Age Forms & Profiles. L. Journal of American Academy of Child and Adolescent Psychiatry. Isquith. Diagnosis and differential diagnosis of Asperger’s syndrome. L. A. Odessa. Youngstrom. T. (2001). M. B. Cook. M. A. Louis. M. St. FL: PAR. T. Depression and Anxiety. & Jolly. E. T. Jaselskis. Bailey. Washington DC: Author.. (1996). R. A. M. B.). Geller. Pedantic speaking style differentiates Asperger sydrome from highfunctioning autism.. G. R.. Beck. Diagnostic and statistical manual of manual of mental disorders (4th ed. A. Journal of American Academy of Child Adolescent Psychiatry. K. Sydney. TX: Future Horizons. (1995).. & Gerstein. A. (2001). B. 2009 . G. Andrews. B. 1350-1359.. L. (2000). San Antonio. J. Creamer. 41. T. Arlington. K. & Stein. DeLong. Lampe. Fitzgerald. TX: Psychological Corporation. C.. Ghaziuddin.70 Clinical Case Studies Clinicians need to be aware of the differences and similarities between depression and autism in children. Baillie. R.. & Corvin. Downloaded from http://ccs. & Rapee. B... Attwood. using multiinformants and conducting naturalistic observations should not be overlooked when diagnosing children with a mental health disorder to ensure correct primary diagnosis and treatment. E. The importance of a thorough clinical assessment. Fluoxetine treatment of children and adults with autistic disorder and mental retardation. Parenting Stress Index: Professional manual (3rd ed. (2002). (2000). Guy. Discriminative validity of a parent version of the Young Mania Rating Scale.sagepub.. Crinco. Note 1. G. (1998).. Achenbach. TX: Future Horizons. with an emphasis on establishing a level of premorbid functioning. UK: Cambridge University Press.. & Kamran. Child anxiety in primary care: prevalent but untreated. Findling. M. Williams. L.. R. R. (1996).. Cambridge.. M. Washington University in St.. (2006a). What doctors never tell you and what parents need to know: Asperger’s Syndrome. Panic surfing: A self treatment workbook for panic disorder. C. The Treatment of Anxiety Disorders: Clinician Guides to Patient Manuals (2nd ed. 7. Behavior Rating Inventory of Executive Function Professional Manual. (1992). (2004a).. L. P. A. Teague. Stein. A. G. R. 26. 739-745. H. (2004b).).. MO: Washington University. Childhood depression. Rogers. 429-435... F. & Meyer. Hanstock is a senior clinical psychologist at The Bipolar Program. 205-223.. P. juvenile bipolar disorder. D. 30. B. Australia: Lippincott Williams & Wilkins. et al. A rating scale for mania: reliability. 133. Armidale. (2000). & Hazell.. The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families.. validity and sensitivity. Streiner. Cook. In P. 4. Hamilton. V. L. (2004). Ozonoff. (1960). Autism. (2006). S. & Pennington. & Asgharian A. J. Hwang. Leventhal. Chicago. Developmental Medicine & Child Neurology. C. Australia: The University of New South Wales Press. (1978). P. The effects of social interactive training on early social communicative skills of children with autism. M. 407-412. V. Journal of Autism and Developmental Disorders... Journal of Neurology Neurosurgery & Psychiatry.. Ziegler.sagepub. & Wilson. Lambrecht. Tanya L. P.. C. B. 30.. Lord. Young. 23. M.. A. Journal of Child Psychology and Psychiatry. 24. psychodermatology. L. The Tripartite Mood Rating Scale (TMRS): A new selfreport mood instrument for children and adolescents with bipolar. P. Hunter New England Area Health Service. T. R. S. 659-685.Cooper. C. Manual for the Wechsler Intelligence Scale for Children (4th ed. 41. C. The prevalence of anxiety and mood problems among children with autism and Asperger syndrome. L. 41. Asperger’s syndrome: Evidence of an empirical distinction from high functioning autism. E. The autism diagnostic observations schedule-generic: A standard measure of social and communication deficits associated with the spectrum of autism. Sadock.com by sorina constandache on April 23. From complexity to category: Responding to diagnostic uncertainties of autistic spectrum disorders. A rating scale for depression. Wechsler. A. Journal of Paediatrics and Child Health. psychonutrition. B. H. B. Hanstock. 331-343. D. (2004). Bryson. (2000). E.) Australian Adaptation.. B. S. Newcastle. & Sadock. 117-132. Martin. 32. 56-62. Lord. A. and selective mutism. (2003). Mood disorders: Recognition and treatment (pp. New York: Psychological Corporation.. (2005). Sydney. Kaplan & Sadock’s concise textbook of clinical psychiatry (2nd ed. E. S. (1994). J. Cooper is a clinical psychologist who completed her doctorate of clinical psychology at The University of New England. Hanstock / Confusion Between Depression and Autism 71 Howlin P. Autism Diagnostic Interview–Revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. obsessive-compulsive disorder.. Australia. Biggs. Australia. E. Paper presented at National Mental Health Institute (NIMH) paediatric bipolar disorder conference.. S. Sydney. Rutter. Mitchell (Eds. Her interests and areas of expertise are in juvenile bipolar disorder. (1999).). J. J. G. Journal of Autism and Developmental Disorders. Downloaded from http://ccs.. eating disorders. March 2006. D. and biological psychology. 1107-1122. Szatmari.). Skellern. Kim. A. J. (2000). & McDowell. C.. complex trauma. Schluter. Journal of Autism and Developmental Disorders. Clayton. (1991). & Le Couteur. M... T. Hunt.. & Hughes. Kristina L.. 349-357)... Joyce & P. 2009 . R. Her interests and experience include child and adolescent psychology. C. 834 -9. Risi.. DiLavore. F. She holds clinical academic conjoint positions with the School of Psychology at the University of New England and the University of Newcastle. British Journal of Psychiatry.