There Was Something Going on With This Child, But What? A boy was diagnosed with autism, but his behaviors didn’t match up. A speech-language pathologist investigated. Case Puzzler
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Case Puzzler  |   April 01, 2016
There Was Something Going on With This Child, But What?
Author Notes
  • Ken Anderson, MS, CCC-SLP, is a clinician at Walt Whitman High School in the South Huntington Union Free School District in Long Island, New York. The case in this column is from a previous district. kenwanderson87@gmail.com
    Ken Anderson, MS, CCC-SLP, is a clinician at Walt Whitman High School in the South Huntington Union Free School District in Long Island, New York. The case in this column is from a previous district. kenwanderson87@gmail.com×
Article Information
Special Populations / Autism Spectrum / Case Puzzler
Case Puzzler   |   April 01, 2016
There Was Something Going on With This Child, But What?
The ASHA Leader, April 2016, Vol. 21, 38-40. doi:10.1044/leader.CP.21042016.38
The ASHA Leader, April 2016, Vol. 21, 38-40. doi:10.1044/leader.CP.21042016.38
With my caseload high and numerous triennials to prepare for, I suddenly faced a new task: a 30-day review for an incoming student, Manny. The IEP for this 12-year-old seventh-grader stated he had autism spectrum disorder (ASD) with goals targeting social interaction.
I prepared to quickly accept his IEP and place him in a social skills group. But then I read his speech and language report. It didn’t all add up. Manny didn’t have a history of speech services. They had been quickly added by his previous school district after an incident that resulted in Manny missing school due to stress.
I pieced together that Manny’s English grade had drastically dropped when he wasn’t able to turn in a major writing assignment due to illness, even after receiving extra time to complete it. Manny’s mother claimed the combination of stress and difficulty with writing (due to his ASD) made him miss the due date. After his teacher refused to extend the deadline, the school called an IEP meeting to address the problem. Nevertheless, Manny’s mother decided to change school districts.
The results of speech-language assessments indicated Manny had average pragmatic skills and receptive and expressive language abilities. Additionally, he earned good grades, and teachers reported he was cooperative and worked well with peers.
So what was the problem?
The only atypical indicator was a questionnaire filled out by Manny’s mother, which pegged him with high-functioning autism. This, apparently, was the source of his ASD diagnosis and IEP, but I could find no other confirming documentation.
I had to investigate.

Manny earned good grades, and teachers reported he was cooperative and worked well with peers. So what was the problem?

Observation
I met with Manny in my speech room and was fully prepared to start checking off his ASD characteristics. My checklist went unchecked.
Manny demonstrated good eye contact and appropriate body language. He initiated, maintained and smoothly transferred between topics of conversation, and even cracked jokes. Sure, he seemed a little quirky and really liked “Star Wars”—he could tell you everything about it, but then again, so could I.
What struck me was his fixation on the clock. He asked me if he would be docked credit for missing class and when he would be returning. I assured him he would not, and the look of fear disappeared. I thought his distress over missing class was odd. Most students loved missing class.
My classroom observations of him jibed with teacher reports that he participated and interacted well with peers. The school psychologist, after meeting with Manny, also thought he was a fun, normal kid, who was just a little “off.” He also noticed Manny’s initial look of fear at meeting a new person and missing class.
I finally received more insight from questionnaires I sent out to his new teachers. They described him as mostly typical—except for what they called “mini-shutdowns.” These consisted of a quick change in mood, a stone-faced expression and full-body rigidity. Now I had something! Students on the spectrum often present with shutdowns in response to social interaction, environmental stimuli or sensory processing difficulties. However, these shutdowns weren’t related to social interaction, or any of the typical contributors to ASD meltdowns.
I thought, “Could this be anxiety, ASD or both?”
Anxiety versus ASD
I turned to the literature for a review of manifestation of general anxiety, separation anxiety, over-arousal, and social anxiety in children on the spectrum and differentiation of ASD-specific anxiety from more generalized anxiety (see sources). I was reminded that characteristics of anxiety shutdowns can overlap with those of ASD-related anxiety, resulting in confusion between the two.
Teachers indicated that Manny’s shutdowns had a common denominator: He shut down when the classroom routine was altered, especially when related to the date his work was due. He didn’t like when high-priority tests, reports and projects were changed. He would then shut down, cause disruptions and demand to call his mother.

What struck me was his fixation on the clock. He asked me if he would be docked credit for missing class and when he would be returning.

She, in turn, would get the school to give him more time to complete work. This got me thinking. Did Manny have ASD, anxiety or both? Or had he learned that throwing a tantrum would result in him getting what he wanted?
The IEP team and I used a basic breakdown of shutdowns, meltdowns and tantrums to help discover the answer (see chart).
The IEP team examined each of Manny’s reported shutdowns to put together the puzzle. After much debate among the psychologist, teachers, Manny’s counselor, the mental health service representative and me, we concluded that Manny’s primary disability was not ASD, but rather anxiety-related. The characteristics his mother had perceived as ASD were situational. She said he was “a little ‘spectrumy’ once in a while,” but a student with true ASD can’t turn his or her autism on and off.
Manny also wasn’t having meltdowns to get attention—they resulted from his feeling overwhelmed when teachers changed his homework schedule. He felt anxious about how and when he would get it all done.
This anxiety caused temporary antisocial behavior and trouble communicating, resembling characteristics of high-functioning autism. However, when not anxious, Manny could socialize and communicate like any other child.
In the end, the IEP team changed his primary disability to generalized anxiety disorder, allowing the school to provide Manny with the goals and services he really needed: a 504 plan, counseling, support and testing accommodations. Getting to the right diagnosis was a lot of work for our team, but, ultimately, we did the right thing for the student.
Sources
Cholemkery, H., Mojica, L., Rohrmann, S., Gensthaler, A., & Freitag, C. M. (2014). Can autism spectrum disorders and social anxiety disorders be differentiated by the social responsiveness scale in children and adolescents? Journal of Autism and Developmental Disorders, 44(5), 1168–1182. doi:http://dx.doi.org/10.1007/s10803-013-1979-4 [Article] [PubMed]
Cholemkery, H., Mojica, L., Rohrmann, S., Gensthaler, A., & Freitag, C. M. (2014). Can autism spectrum disorders and social anxiety disorders be differentiated by the social responsiveness scale in children and adolescents? Journal of Autism and Developmental Disorders, 44(5), 1168–1182. doi:http://dx.doi.org/10.1007/s10803-013-1979-4 [Article] [PubMed]×
Conner, C. M., Maddox, B. B., & White, S. W. (2013). Parents’ state and trait anxiety: Relationships with anxiety severity and treatment response in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(8), 1811–1818. [Article] [PubMed]
Conner, C. M., Maddox, B. B., & White, S. W. (2013). Parents’ state and trait anxiety: Relationships with anxiety severity and treatment response in adolescents with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(8), 1811–1818. [Article] [PubMed]×
Hallett, V., Lecavalier, L., Sukhodolsky, D. G., Cipriano, N., Aman, M. G., Mccracken, J. T., … Scahill, L. (2013). Exploring the manifestations of anxiety in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(10), 2341–2352. [Article] [PubMed]
Hallett, V., Lecavalier, L., Sukhodolsky, D. G., Cipriano, N., Aman, M. G., Mccracken, J. T., … Scahill, L. (2013). Exploring the manifestations of anxiety in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 43(10), 2341–2352. [Article] [PubMed]×
Kuusikko-Gauffin, S., Pollock-Wurman, R., Mattila, M., Jussila, K., Ebeling, H., Pauls, D., & Moilanen, I. (2013). Social anxiety in parents of high-functioning children with autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 43(3), 521–529. [Article] [PubMed]
Kuusikko-Gauffin, S., Pollock-Wurman, R., Mattila, M., Jussila, K., Ebeling, H., Pauls, D., & Moilanen, I. (2013). Social anxiety in parents of high-functioning children with autism and Asperger syndrome. Journal of Autism and Developmental Disorders, 43(3), 521–529. [Article] [PubMed]×
van Steensel, F. J., Bögels, S. M., & Wood, J. J. (2013). Autism spectrum traits in children with anxiety disorders. Journal of Autism and Developmental Disorders, 43(2), 361–370. [Article] [PubMed]
van Steensel, F. J., Bögels, S. M., & Wood, J. J. (2013). Autism spectrum traits in children with anxiety disorders. Journal of Autism and Developmental Disorders, 43(2), 361–370. [Article] [PubMed]×
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April 2016
Volume 21, Issue 4