Is My Son Autistic?

You are a psychiatrist in private practice. You receive a phone call from a woman who asks if you can see her son. She tells you he is 22 years old and has a job but suffers from horrible depressive episodes and panic attacks and has not slept in weeks. You explain that her son is old enough to make appointments himself and for legal reasons, should. She responds that she knows that and says he asked her to make an appointment for him. She also says she does a lot of things for him because he needs her help. She asks if she can tell you more about him and that, if you agree to see her son, she would ask him to call for the appointment after he returns from work. You ask who else is in the family, and she says her son has an older sister who lives in New York City and works for a large bank. She says her daughter could likely tell you more about her son if you are interested. The daughter is married to a man who is a youth minister and travels a lot. “We’re not religious,” the mother tells you. “My son used to hear voices that he was convinced were God and the Devil, but I have a suspicion it’s because he went to a Catholic school.” She tells you her mother and father divorced when she was a child because her father had schizophrenia and “he drove her crazy.”

You agree to see the patient.

By what age can you diagnose autism spectrum disorder (ASD)?

When the mother shows up with her son, she hands you a packet of cognitive testing results from when the patient was 7 years old, plus a typewritten family history that includes information about his sister; then his family is divided according to his mother and father and traced back to his grandparents, of whom only his maternal grandfather is still alive. Following this is a genetics report that details how the patient should respond to a variety of medications, also from when the patient was 7 years old.

You notice immediately from the family history that his sister, father, paternal grandfather, and maternal uncle were diagnosed as having conditions related to the present DSM-5 diagnosis of ASD. You read more carefully that different types of mental illness, including anxiety disorders (generalized anxiety disorder, panic disorder, and social anxiety), “odd/inappropriate behavior,” childhood-onset schizophrenia, childhood-onset bipolar disorder, posttraumatic stress disorder, alcoholism, “depression,” and “serious anger problem” were diagnosed among all members of the family on both sides.

After glancing at the patient’s cognitive testing, you note that the patient received very high marks on the Differential Ability Scales (2nd ed.) as well as on the processing speed index from the Wechsler Intelligence Scale for Children (4th ed.; WISC-IV) and that he was in the 91st percentile, or the superior range. You then note that in the area of nonverbal reasoning, he was in the 70th percentile, or the average range. You also note that according to the WISC-IV processing speed index, he was also in the average range.

According to his core language assessment, he was in the average range. Written in boldface print, you note that his “parents both endorsed clinically significant symptoms of hyperactivity and elevated symptoms of problems with attention.”

Given what you know about this patient, how do you diagnose ASD?

At what age does ASD typically remit?

Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).