Confusion Between Depression and Autism in A High Functioning Child

Clinical Case Studies
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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
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Confusion Between Depression and

Autism in a High Functioning Child

Volume 8 Number 1
February 2009 59-71
2009 Sage Publications
10.1177/1534650108327012
http://ccs.sagepub.com
hosted at
http://online.sagepub.com
Kristina L. Cooper
University of New England, Armidale, Australia
Tanya L. Hanstock
The Bipolar Program, Hunter New England Area Health Service, Newcastle,
Australia, and School of Psychology, University of New England, Armidale, Australia
Autism is a diagnosis characterized by social and communication impairments. Onset of

autism occurs before the age of 3. However, there can be delays in identification, diagnosis,
and treatment. A number of symptoms of autism overlap with other childhood mental health
disorders, often accounting for a delay in correct diagnosis. 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, who appear to have a flat affect
and social isolation, are advised to be aware of the possibility of autism in such presentations.
Issues around differentiating the diagnosis between depression and autism in children will be
discussed, along with assessment and treatment of this particular case.
Keywords:
autism; depression; children; diagnosis; treatment
1 Theoretical and Research Basis

Autism is diagnosed when a person has impaired social interaction, abnormal communication skills and a restrictive range of interests occurring since a young age (Sadock &
Sadock, 2004). Clinicians commonly consider autism as occurring on a continuum termed
autistic spectrum disorders (ASD). The reported prevalence of autism in the latest version of
the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision [DSM-IVTR]; American Psychiatric Association [APA], 2000) is between 2 and 20 per 10,000 individuals. Autism occurs four times more frequently in male- compared to female population.
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, 2006a).
Onset of autism occurs before the age of 3; however, the average age of diagnosis is around
5.5 years (Howlin & Asgharian, 1999). Approximately 70% of children with autism also
have an Intelligence Quotient (IQ) falling in the intellectually impaired range (<70).
Authors Note: The authors would like to thank Dr. Edward Clayton for proof reading the manuscript.
Correspondence concerning this article should be addressed to Tanya Hanstock, Senior Clinical Psychologist,
Community Mental Health Service, P.O. Box 159, Wagga Wagga, NSW, 2650. Australia; e-mail: Tanya
.Hanstock@gsahs.health.nsw.gov.au.
59
60
Children who are diagnosed with high functioning autism (HFA) show signs of autism
when they are young. However, when they are older, they have a greater degree of intellectual, social, and adaptive skills (Attwood, 2006b). Some researchers have attempted to distinguish HFA from Aspergers syndrome (Ghaziuddin & Gerstein, 1996; Ozonoff, Rogers,
& Pennington, 1991). However, in common clinical practice, HFA is a diagnosis given to
children who fall at the less severe end of the ASD continuum, and the term HFA is used
interchangeably with Aspergers syndrome in the DSM-IV-TR (APA, 2000; Attwood,
2006). Autism is a lifelong disorder; however, people can still improve to some extent in
areas of socializing, communicating and self-care ability. 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, 2004).
Early diagnosis and intervention are regarded as important for all childhood psychological
disorders, and this is especially true for autism. As a result of this awareness, some critics suggest that clinicians have become too liberal in giving the diagnosis of autism. Skellern,
Schluter, and McDowell (2005) suggested that liberality in diagnosing autism may be due to
two reasons. First, overdiagnosis can be due to the ambiguities intrinsic in the interpretation
of the behaviors that are used in providing the diagnosis of autism. Second, the practice of
intentionally upgrading a childs symptoms to a diagnosis of autism may be a response to the
pressure to provide a diagnosis that meets criteria for external funding. On the contrary, 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. The lack of correct
diagnosis of autism is often the result of parents, school staff, and health professionals not
being aware of the main features of the diagnosis; for example, attributing symptoms such as
difficulties with social skills to other reasons such as shyness. Thus, there is a large potential
for clinicians to misdiagnose autism as either a false positive or a false negative.
The DSM-IV-TR (APA, 2000) outlines several disorders that need to be considered in the
differential diagnosis of autism. These include other pervasive developmental disorders,
Retts disorder, childhood disintegrative disorder, Aspergers disorder, schizophrenia with
childhood onset, selective mutism, expressive language disorder, mixed receptiveexpressive
language disorder, mental retardation, stereotypic movement disorder, and attentiondeficit/hyperactivity disorder.
One diagnosis that is not considered as a differential diagnosis for autism in the DSMIV-TR (APA, 2000) is 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. Prevalence of childhood depression is
1% to 2% (Martin, 2004). There is an equal female to male ratio of cases until puberty.
Then from adolescence females are three times more likely to suffer from depression when
compared to males.
Autism has some symptom overlap with mood disorders, particularly depression, with
similar symptomatology, including social withdrawal, lack of emotional response, and a
disinterest in relationships (Fitzgerald & Corvin, 2001). One main feature differentiating
depression from autism is that depression is diagnosed following a marked change in the
childs previous level of functioning. Therefore, clinicians should consider the possibility
of misdiagnosing either depression or autism when similar symptoms present. In such
cases, further assessment may be required to provide a differential diagnosis. It is well
Cooper, Hanstock / Confusion Between Depression and Autism
61
recognized that there is a high rate of comorbidity between depression and autism (Kim,
Szatmari, Bryson, Streiner, & Wilson, 2000). However, 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. 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.
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 referring
clinician had originally diagnosed Jane with depression. However, following an episode of
unusual behavior, she thought Jane may fit the diagnostic criteria for BD.
3 Presenting Complaints
As there were a number of significant people involved in Janes care, there were several
presenting concerns by different parties. First, Janes mother was concerned about Janes
school difficulties. She said that Jane refused to attend school on a regular basis, a problem
that was ongoing since Grade 2 (for 4 years). 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. Jane had become so upset about going to school one day that she
had scratched and bruised her grandmother. Jane had a few friends at school, but they were
mostly younger. Jane had been exposed to a lot of bullying and teasing over her primary
school years. Janes mother was also worried about Janes lack of speech and her unwillingness to engage in conversation. Janes mother thought Jane experienced everyday happiness more often than sadness, but that Jane often became angry (especially toward her
younger sister). Janes mother could sometimes determine how Jane was feeling by observing Janes behavior: for example, when Jane hid in her room and refused to come out, her
mother concluded that Jane was upset. However, on many occasions, Janes mother found
it difficult to know how Jane was feeling because she demonstrated minimal facial expression and did not talk about her feelings.
Janes classroom teacher reported concerns about Janes lack of emotion, lack of communication (grunting rather than speaking), social problems (playing alone or with younger
children), no facial animation (blank looks), and flatness. She said Jane gave her minimal eye contact and that her speech was monotone in nature. She had never seen Jane have
a good laugh or seem happy.
Jane reported sleep difficulties, such as having problems going to sleep, awakening in
the night, and sometimes waking very early. She reported having a varied appetite and her
energy level alternated from being lethargic to not being able to keep still. She found it difficult to identify her moods as she often did not know whether she was happy, sad, or angry.
She also said she had problems expressing her emotions.
62
4 History
Janes mother reported no family history of mental illness, but said that her own mother
had experienced a breakdown a few years earlier. Janes mother also reported some anxiety
in her maternal grandmother and paternal grandfather. She reported a normal pregnancy and
birth with Jane but noted that she had experienced some reflux when she was an infant. Jane
achieved her milestones on target. She had been a very good talker when she was very young,
but this had declined rapidly by the age of 3 and she now only engaged in minimal speech.
At the time of assessment, Jane lived with her mother, father, and younger sister (8 years)
in a large rural town in Australia. Janes mother was a homemaker and her father was in a
government position that required him to engage in regular travel away from home. Janes
younger sister was very bright and sociable. The family had moved towns several times in
Janes life, and during the initial consultation the family announced that they had plans to
move interstate within four months.
Jane was in Grade 6 at a large public primary school. Both Janes mother and teacher
reported her to be academically performing well in school. However, she had been having
social problems at school that had first become apparent when she was in Grade 4. Jane was
left out of social interactions during Grade 5 and she had appeared sad. At this time, Jane
had seldom smiled or laughed and she was, therefore, referred to the school counselor (SC).
Jane had been angry at home and she did not verbally express any of her feelings. The SC
suspected Jane was depressed and referred her to a child and adolescent mental health service, where she was seen by an occupational therapist. Jane was also seen by a senior psychiatry registrar who prescribed the selective serotonin reuptake inhibitor (SSRI), Fluoxetine
(10 mg daily for the first week with an increase to 20 mg daily from the second week).
Shortly after commencement of the SSRI, Janes parents noticed Jane engaging in
unusual behavior, for example, stealing, putting soap in water bottles during the night, biting other children, and telling stories. 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 also appeared to be full of energy, which was in contrast to her usual
flat affect. Due to the unusual behaviors demonstrated by Jane while on the SSRI, the medication was ceased. Following medication cessation, Janes behavior improved and her difficulties stabilized. However, she was still referred to a specialist BD service for more
intense clinical psychology assessment to assess for a mood disorder.
5 Assessment
Jane underwent a comprehensive clinical psychology assessment, which was conducted
in the following order. The initial assessment commenced with a clinical interview to gather
information as to presenting complaints and Janes history. Jane appeared very flat during
the interview. However, when questioned about her mood, she said she was happy. Her
speech was slow and of a monotone nature, and she demonstrated very little facial expression. There was only minimal interaction between Jane and her mother as well as between
Jane and the clinician. Jane spent the majority of the interview looking down and had very
limited eye contact.
63
To assist in conceptualization, diagnosis, and treatment, several questionnaires were given

to Jane, her mother, and her teacher at the time of the initial assessment (refer to Table 1, for
assessment and posttreatment scores on these questionnaires). Janes mother completed the
parent versions of the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), the
Behavior Rating of Executive Functioning (BRIEF; Gioia, Isquith, Guy, & Kenworthy,
2000), and the parent version of the Young Mania Rating Scale (PYMRS; Gracious,
Youngstrom, Findling, & Calabrese, 2002) as well as the Parenting Stress Inventory (PSI;
Abdin, 1995). Jane completed the Beck Youth Inventories (BYI; Beck, Back, & Jolly, 2001)
and a Tripartite Mood Rating Scale (TMRS; Hanstock, Clayton, Hunt, & Hazell, 2006). The
clinician also completed the Young Mania Rating Scale (YMRS; Young, Biggs, Ziegler, &
Meyer, 1978) and the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960).
The most useful clinical information from the parent questionnaires was obtained from
the CBCL and the PSI. Results from the parent CBCL indicated that Jane was in the clinical range for withdrawn/depressed, social problems, rule-breaking behavior and aggressive
behavior and the subclinical range for thought problems and attention problems. The PSI
indicated adaptability, reinforced parent, mood, and acceptability as elevated scores in the
child domain but health and depression as elevated scores in the parenting domain. In comparison to the parent CBCL, the teacher CBCL indicated Jane to be in the clinical range for
the withdrawn/depressed scale.
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. The TMRS completed by Jane showed that she was quite
happy (and this was also stated by her in the interview), and she did not rate herself on the
sad or angry scales. The clinicians rating of the YMRS and the HDRS were not in the clinical range. 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. The clinician conducted a Washington University in St.
Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-K-SADS;
Geller, Williams, Zimerman, & Frazier, 1996) with Janes mother, 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. However,
this formal interview provided further evidence that Janes current symptoms could not be
accounted for by a mood disorder.
The Autism Diagnostic InterviewRevised (ADI-R; Lord, Rutter, & Le Couteur, 1994)
was then administered to Janes parents and revealed abnormal reciprocal social interaction
occurring since age 2.5 years, for example, Jane not looking up if a person entered a room
where she was and called her name. Her abnormalities in communication included grunting, making noises, and making up words. She also had a restrictive pattern to her routine
and eating. She had a stereotypy of picking at the skin on her hands, hoarded objects, and
was fixated on sharks and dinosaurs.
The Autism Diagnostic Observation Schedule (ADOS; Lord et al., 2000) was also
administered to Jane. During the administration, Jane had no spontaneous speech, very limited eye contact, 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, 2000).
64
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,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 ListParent Report; PYMRS = Parent Version of the Young Mania
Rating Scale; BRIEF-P = Behavior Rating of Executive FunctioningPreschool; GEC = Global Executive
Composite; PSI = Parenting Stress Index; TMRS = Tripartite Mood Rating Scale; YMRS = Young Mania Rating
Scale; HDRS = Hamilton Depression Rating Scale.
a. t score.
b. Raw score.
c. Percentile.
d. TMRS scores are on a scale of 1 to 5 with 1 = even and 5 = very happy, very sad or very angry.
The Wechsler Intelligence Scale for ChildrenFourth Edition, Australian Adaptation

(Wechsler, 2003) was used to assess Janes overall intelligence. Her Full Scale IQ fell
within the Average Range (70th percentile). Her Verbal Comprehension Index, which represents a measure of verbal concept formation, verbal reasoning and knowledge acquired
from the environment, was in the Average Range (55th percentile). Her Perceptual
Reasoning Index, a measure of perceptual and fluid reasoning, spatial processing and
visualmotor integration, was also in the Average Range (61st percentile). Janes Working
Memory Index, a measure of working memory, fell within in the Superior Range (96th percentile) and her Processing Speed Index, ability to quickly and correctly scan, sequence, or
discriminate simple visual information, was in the Average Range (34th percentile). Janes
score on the Working Memory Index was a significant strength compared to her Verbal
Comprehension, Perceptual Reasoning, and Processing Speed Indices.
Finally, a school observation was conducted to view Jane in the classroom setting. She
was noticeably different from the other students in her class as she did not interact in class
activity or with her peers. She sat very quietly picking at the skin on her hands. Jane did
her work but would not ask for help when she needed it. At recess, she ran out of the classroom and hid until the break ended.
One limitation of the assessment process outlined above was that although the client was
assessed by an occupational therapist, a senior psychiatry registrar, and two clinical psychologists, further multidisciplinary assessments may have been beneficial. For example,
65
the client could have been assessed by a speech therapist as well as undergoing further
medical tests, such as neurological or genetic assessment. This would have assisted in ruling out any speech, language, or medical reasons for her difficulties.
6 Case Conceptualization
Jane was diagnosed as having HFA. She appeared to have been misdiagnosed due to a number of school changes, which her family and teachers had previously attributed to causing her
social impairments. She also had some atypical features of autism, such as a normal IQ and
language. She was generally well behaved and quiet and, therefore, did not attract attention
until she started to refuse to go to school. Janes school refusal was conceptualized as a
response to her anxiety and her peer relationships, and it appeared to be reinforced by the teasing and bullying she was receiving from other students. Janes social impairments were also
becoming more noticeable as she grew older, with deviance from her peers becoming much
more obvious. Janes anger was most often directed toward her younger sister, who functioned
better both cognitively and socially and who was at times too overwhelming for Jane.
Jane was brought to the attention of mental health services when she started to display
acting out behavior. She was then referred to a specialist mental health service when her
acting out behavior significantly increased after commencement of SSRI medication. Jane
had been upset about the bullying. However, she was not depressed. SSRI medication,
therefore, appeared to cause an increase in irritability and aggression. Janes behavior
returned to as it had been following cessation of the medication.
Janes diagnosis of HFA was differentiated from a diagnosis of depression, as there was
no change in her previous level of functioning. Janes poor social and communication skills
appeared to have been quite consistent from a young age. Furthermore, she did not have the
main depressive symptom of feeling sad or having somatic complaints; although her
impaired social and communication skills gave her a physical appearance of being
depressed, she said she felt happy. Janes HFA diagnosis was also differentiated from generalized anxiety disorder, as her anxieties were considered to be better explained by her
autism, lack of understanding social cues and situations, and a normal developmental fear
of the dark. Jane did not express anxieties about a large number of areas of her life.
Jane was believed to have a good prognosis of improving her social skills, behavior and
anxieties as she had good intellectual skills and was able to work well with the clinicians.
She also had a very close and supportive family, and the school staff were very helpful. A
cognitive behavioral therapy intervention was offered to help her with her difficulties, as
this therapy model has been useful for treating children with autism and Aspergers disorder (Attwood, 2006b).
7 Course of Treatment and Assessment of Progress

Owing to severity of Janes difficulties and the familys plan to move to a different
city in the near future, assessment and treatment occurred simultaneously. There were 6
assessment and 10 treatment sessions that were conducted over a 3-month period.
66
Figure 1
Pattern of School Refusal (Number of Episodes per Month)
Before and After Treatment
Episodes of School Refusal
5.0
4.0
3.0
2.0
1.0
0.0
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Note: Treatment began in late September.
Janes school refusal was the predominant difficulty for Jane, her parents, and her classroom teacher, so this was the focus of the early treatment sessions. Because Janes school
refusal had been conceptualized as a response to her anxiety and her poor peer relationships, these issues were addressed concurrently. Thus, most sessions consisted of a combination of anxiety reduction and social skills training. Janes number of school refusals was
assessed throughout her treatment via school records (refer to Figure 1).
Reward Chart for School Refusal

To directly address Janes school refusal, a star chart was created to reward her for going
to school. Jane was given a star every day she went to school, 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. In the fifth session, Janes mother reported an improvement in her
behavior. Jane was happier, she was going to school, she was not getting as angry as previously, and she was better able to control her anger. Her teacher had also noticed an
improvement in Jane and had sent a letter home stating that she was doing much better at
school. Janes good behavior continued over the following weeks, and she school refused
only one day following treatment.
Anxiety Reduction
The anxiety reduction intervention began by providing Jane and her parents
with psychoeducation. The clinician normalized anxiety and discussed examples of
67
situations in which some people become anxious as well as common symptoms of

anxiety. Jane often felt anxious at night, and this was related to her fear of the dark and
her nightmares. 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, snakes, monsters, and dying. She also stated that she was worried that there
was a dead body buried underneath her room. It should be noted that some of Janes
fears are common for her chronological age (e.g., snakes), whereas others are usually
seen in younger children (e.g., monsters).
To assist Jane in recognizing the impact of anxiety on her body, she was asked to draw
on a picture of a body where her body felt different when she was anxious. She was able to
identify that when she was anxious she had symptoms of tight lungs, a pounding heart, and
a headache. She was encouraged to think about her anxiety as a wave that would come and
increase in intensity, but that it would pass. 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, Baillie & Rapee, 1998). The clinician discussed relaxation techniques with the
family and gave them a relaxation script to use with Jane at home, especially of a night
time. Jane reported enjoying the relaxation script and stated that it helped her anxiety and
that she wanted to practice it more often.
Once Janes fear of the dark had been identified, the clinician discussed use of an anxiety
ladder (Andrews et al., 2003). Jane chose to work on her fear of the dark because this was the
situation that worried her the most. Janes 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.
Step 2: Going to sleep with her main bedroom light off, her night-light on (main bathroom 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)
Janes parents were concerned that Jane was not able to communicate her emotions. The
clinician discussed with Jane alternative ways for her to express her anxiety, anger, and
other emotions. These included playing with play-doh, writing, drawing, and painting
(Attwood, 2004a).
Social Skills Training

Two main social skills were targeted during the treatment period, these being facial
expressions and eye contact. The clinician discussed with Jane the importance of facial
expressions including the link between facial expressions and feelings, use of facial expression in conversations and the skill of reading others expressions. Jane completed a short
exercise in which she named the emotion that pictures of faces were feeling. With some
encouragement, Jane was able to provide an acceptable emotion to the majority of the
faces. The clinician also discussed with Jane the importance of using eye contact during
conversations (Hwang & Hughes, 2000). Her attempts to use eye contact in various social
settings were reinforced by her parents, teacher, and the clinicians.
68
Anger Management
Jane was taught how to identify thinking, bodily, and behavioral changes that occurred
when she became angry. 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. Jane also learned how to stop, think of consequences, and then perform her action. She
became much better at not acting out instantly when upset and was able to instead make good
decisions on how best to react. She learned ways to physically release her anger (e.g., ripping
up paper) and also ways to calm down when she was at school, such as walking away from
the anger trigger and asking for help from the teacher (Attwood, 2004b).
8 Complicating Factors
Janes 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. There was also limited time to assess and treat
Janes difficulties due to the familys plan to move interstate. Therefore, assessment and
treatment co-occurred for a period of time after the diagnosis of autism appeared relatively
clear. There was also pressure for Jane to be discharged from the specialized BD clinic to a
general child psychiatry service. However, Jane and her family were well engaged with the
two clinicians, and to ensure continuity of care, Janes case was prioritized for assessment
and treatment due to the obvious lag in detection and early intervention.
9 Managed Care Considerations

To assess and treat Jane with maximum benefit, there was strong communication and
involvement between the mental health services, Janes parents, and the relevant school
staff. Jane attended her assessment and therapy sessions with her mother, and her father
also attended when he was at home. The school staff and clinicians were in regular contact
via telephone and meetings at the school. A consistent approach to understanding Janes
difficulties and her management led to a better outcome for Jane. As there were two clinicians caring for Jane and her family, one clinician was able to focus on the continued
assessment, whereas the other was able to commence treatment concurrently.
10 Follow-Up
Jane was referred to child health services in her new local town. Consistent with her
autism diagnosis, the initial plan was for her to be assessed by a pediatrician, with further
plans to refer her and the family to a psychologist to continue to assist them in managing
Janes new diagnosis. Fortunately, her new town had many services for children with
autism. 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. A limitation to this case
69
study was that the clinicians were not able to assess if Janes improvement continued post
treatment cessation.
11 Treatment Implications
After correct diagnosis and treatment of Janes autism, she showed a good improvement
in her behavior. She had only one further episode of school refusal (refer to Figure 1), and
most scores on the posttreatment questionnaires (administered after the final treatment session) improved (refer to Table 1). Jane and her family were much happier. Their understanding of Janes behavior had improved and they were active in learning about ways to
manage her difficult behaviors. The school staff were also happier as Jane was less aggressive toward her peers. Jane has a good prognosis due to her average IQ and language
(Sadock & Sadock, 2004).
Autism can be a difficult diagnosis owing to number of symptoms that overlap with
other mental health disorders that can occur in childhood. Children with autism are at risk
of being diagnosed as depressed and hence likely to commence SSRI medication. In the
above case, Jane became more irritable and aggressive when commenced on fluoxetine.
Behavioral activation, hyperactivity in particular, aggression, 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, Rowlett, Jaselskis, & Leventhal, 1992; DeLong,
Teague, & Kamran, 1998).
Unfortunately, children who act out come to the attention of schools (and subsequently,
mental health services) more often and earlier than children with internalizing behavior
(Chavira, Stein, Bailey, & Stein, 2004). Children with autism, who are female, have a normal IQ and have language skills, can be easily mistaken as being depressed. This can interfere with the early diagnosis of autism and result in missed opportunities that early
intervention can provide. Furthermore, such clients may be incorrectly diagnosed and given
antidepressant medication unnecessarily. 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; however, autism occurs much more frequently in boys.
Misdiagnosing a primary diagnosis of autism for depression appears to be a relatively
simple consideration. However, there is limited literature and research dedicated to this
phenomenon. Furthermore, depression is not considered as a differential diagnosis for
autism in the DSM-IV-TR (APA, 2000).
12 Recommendations to Clinicians and Students

There are a number of symptoms of ASD that can be mistaken for depression in children.
Flat affect, flat intonation in speech, minimal facial expressions (especially lack of smiles
and laughter), irritability, and social isolation are all signs that could be associated with a
diagnosis of autism or a diagnosis of depression. Children who have HFA (such as those
with average IQs, who have language and also have little or no acting out behavior) may
miss correct diagnosis, as they tend to fade into the background of a school environment.
70
Clinicians need to be aware of the differences and similarities between depression and
autism in children. The importance of a thorough clinical assessment, with an emphasis on
establishing a level of premorbid functioning, 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.
Note
1. Jane is a fictional name used to protect the client and familys anonymity.
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Kristina L. Cooper is a clinical psychologist who completed her doctorate of clinical psychology at The
University of New England, Armidale, Australia. Her interests and experience include child and adolescent psychology, eating disorders, obsessive-compulsive disorder, juvenile bipolar disorder, and selective mutism.
Tanya L. Hanstock is a senior clinical psychologist at The Bipolar Program, Hunter New England Area Health
Service, Newcastle, Australia. She holds clinical academic conjoint positions with the School of Psychology at
the University of New England and the University of Newcastle. Her interests and areas of expertise are in juvenile bipolar disorder, complex trauma, psychodermatology, psychonutrition, and biological psychology.

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