Unravelling High Functioning Autism in a Child with Comorbid Psychiatric Manifestations: A Case Report with Review of Literature

Abstract

Background: Autism Spectrum Disorder (ASD) without accompanying language or intellectual impairment, previously termed Asperger syndrome, is characterized by deficits in social communication, restricted interests, and behavioral rigidity. In highly verbal and intellectually gifted children, particularly girls, core autistic traits may be masked, leading to frequent misdiagnosis as primary mood, anxiety, or psychotic disorders. Such diagnostic delays can adversely affect clinical outcomes.

Case Presentation: We report the case of an 8-year-old girl who presented with escalating aggression, obsessive behaviors, social withdrawal, sensory hypersensitivity, and self-injurious behavior. Over a two-year period, she received multiple psychiatric diagnoses, including schizophrenia and bipolar disorder, and was treated with antipsychotics and mood stabilizers, with worsening symptoms. A detailed re-evaluation focusing on early social developmental milestones, sensory profile, and symptom clustering led to the diagnosis of high-functioning ASD with comorbid depression and obsessive-compulsive disorder. Multimodal intervention including pharmacotherapy, cognitive-behavioral therapy, structured environmental modifications at home and school, and parental education resulted in marked clinical improvement. Quality of life improved significantly over one year, as measured using a standardized objective assessment tool.

Conclusion: This case underscores the importance of careful assessment of social developmental milestones and interpretation of behavioral symptoms as an interrelated cluster rather than isolated psychiatric entities. Early recognition of high-functioning ASD, especially in cognitively advanced children, enables appropriate interventions and significantly improves long-term outcomes.

Introduction

Autism Spectrum Disorder (ASD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), encompasses a continuum of neurodevelopmental conditions previously classified separately, including Asperger syndrome. ASD without accompanying intellectual or language impairment-often referred to as high functioning autism-poses unique diagnostic challenges due to preserved or superior cognitive and verbal abilities. In such cases, social communication deficits and behavioral rigidity may be subtle or misattributed to personality traits, emotional disorders, or primary psychiatric illness.

The presence of comorbid psychiatric symptoms such as anxiety, obsessive compulsive behaviors, depression, and self injury further complicates diagnostic clarity. Girls with ASD are particularly vulnerable to delayed or missed diagnosis due to social camouflaging and atypical symptom expression. We present a case illustrating how failure to evaluate social developmental milestones and symptom clustering resulted in repeated misdiagnosis and delayed identification of high functioning ASD.

Case Report

CASE PRESENTATION

An 8 year old girl was brought by her parents with complaints of frequent anger outbursts, aggressive behavior, emotional dysregulation, increasing possessiveness toward her mother, and progressive social withdrawal. Over the preceding year, she had become reluctant to leave home, avoided peer interactions, and preferred to play alone. She exhibited excessive crying spells, marked distress with minor changes in her daily routine and resistance to unfamiliar environments.

She was born to non consanguineous parents following an uneventful term pregnancy and normal vaginal delivery, with a birth weight of 3.1 kg. Antenatal, natal, and postnatal periods were unremarkable. Immunizations were up to date. There was no history of significant medical illness, hospitalizations, seizures, or head injury. Both parents were physicians, and there was no family history of neurodevelopmental or psychiatric disorders.

Early developmental history revealed timely attainment of gross motor, fine motor, and language milestones. However, parents were unable to clearly recall early social milestones, including joint attention behaviors and reciprocal social smiling. Retrospectively, the child had long demonstrated reduced eye contact, limited peer engagement, preference for solitary activities, ritualistic behaviors, and heightened distress when routines were disrupted. These behaviors were initially interpreted as shyness and introversion rather than neurodevelopmental concerns.

On physical examination, the child was conscious and oriented. Anthropometric measurements were appropriate for age (weight 20 kg, height 115 cm). Vital signs were stable. General examination revealed no dysmorphism, pallor, icterus, clubbing, edema, or lymphadenopathy. Cardiovascular, respiratory, and abdominal examinations were normal. Neurological examination showed normal cranial nerve function, tone, power, deep tendon reflexes, coordination, gait, and sensory responses, effectively excluding focal neurological pathology. Baseline laboratory investigations, revealed hemoglobin 12 g/dL, total leukocyte count 5700/cumm, platelets 2.97 lakh/cumm, C-reactive protein- negative, bilirubin 0.5 mg/dL, Alanine Transferase /Aspartate Transferase- 18/20 U/L, serum albumin 2.8 g/dL, Blood Urea Nitrogen /creatinine 10/0.6 mg/dL, Sodium- 140 mEq/L; Potassium- 4 mEq/L; Calcium- 8.8 mg/dL, MRI brain was normal.

Over the next year, her behavioral symptoms worsened significantly. She developed rigid routines, compulsive behaviors, trichotillomania, and severe self injurious behaviors, including repeated cutting of her hands and wrists using sharp household objects. She was referred to a psychiatrist for further evaluation.

Initial Psychiatric Assessments and Diagnostic Reconsideration

The first psychiatrist attributed her symptoms of obsessive behaviors, social withdrawal, affective flattening, and anxiety to a primary psychotic disorder. Psychological assessment using the Rorschach test yielded a score suggestive of severe depression. Based on these findings, she was diagnosed with disorganized type schizophrenia and started on clozapine (25 mg twice daily). Cognitive assessment using the Wechsler Intelligence Scale for Children IV revealed a full scale IQ of 145, indicating superior intellectual functioning.

Despite treatment, the girl self -harm behaviour worsened over 6 months, leading to repeated harming over her hand and wrist as shown in Figure 1, so sought for second opinion with a psychiatrist who diagnosed her as Bipolar disorder(severe depression + self harm) started on Tab. Lithium 300mg twice daily ,Tab.Fluoxetin 10mg once daily in the morning- SSRI(Selective Serotonin Reuptake Inhibitors), Tab.Risperidone 0.5mg a day (minimum dose of antipsychotic), Cognitive Behaviour Therapy session and referred to Child Psychologist. However, her symptoms continued to worsen over the following year.

Figure 1. Repeated self-injurious cutting marks over the child's hand and wrist.

A comprehensive evaluation by a child psychologist focused on behavioral observations, social communication patterns, sensory sensitivities, and rigidity , inclined to revisit the diagnosis . Again , a child psychiatrist, took elaborate history since childhood and asked questions to mother from infancy which helped to clench the diagnosis of Asperger syndrome.In this case, developmental milestones were normal as per the history given by the parents. Previously, only the Gross motor , fine motor skills and language milestone were addressed. But the most important milestones to be assessed for ASD especially when it a high functioning ASD with normal language are the social milestones which was missed due to associated behaviour problem displayed in the child . This child had a history of difficulty in maintaining eye contact when spoken. Parents were not able to recall history regarding joint attention and were not able to recall the social milestones clearly as well. The child always preferred to play alone which was taken as a shy and introverted child, rather than evaluating further. There were several ritualistic behaviors as shown in figure 2 and the child experienced meltdowns when there was a change in the routine. This was interpreted as adamant behavior and aggression. The self injurious behavior in some children is due to alteration in sensory perception. There seemed to be no emotional trigger for self injurious behavior in this girl. The anger outburst and aggressiveness is usually precipitated when there is change in routine of the child. The child always preferred mother over others and gets agitated when the caregiver is changed. The meltdowns, anger outbursts was misdiagnosed as a bipolar disorder previously. A lack of understanding in taking the symptoms as a cluster rather than individual symptoms led to the misdiagnosis.

Figure 2. Ritualistic behaviors observed in the child.

This longitudinal and contextual assessment revealed that her symptoms were best explained by high functioning ASD rather than primary mood or psychotic disorders. The previous diagnoses were reconsidered due to the absence of hallucinations, delusions, mood congruent psychotic features, or episodic mood cycling, and the presence of lifelong social communication deficits, sensory hypersensitivity, insistence on sameness, and poor social reciprocity.

Diagnostic Assessment

Mental status examination revealed a well groomed child with age appropriate attire. Eye contact was fleeting and poorly sustained. Rapport was difficult to establish. Speech was fluent but monotonic, with increased response latency. Affect was blunted, and mood was subjectively neutral. Thought content revealed preoccupation with routines, without delusions or suicidal ideation. Sensory hypersensitivity to sound, touch, and smells were evident. Insight was limited, while cognition and higher mental functions were intact.

Autism Diagnostic Observation Schedule (ADOS 2), Module 3, was administered. The calibrated severity score was 4, indicating mild to moderate autism symptom severity, with elevated social affect scores and restricted, repetitive behaviors as shown in table 1.

Table 1. Standardized Assessment Findings

MANAGEMENT AND OUTCOME

The child was managed using a multidisciplinary approach. Pharmacological treatment included escitalopram (15 mg/day) and quetiapine (50 mg/night). Cognitive behavioral therapy was continued with autism specific adaptations.

At school, an Individualized Education Plan (IEP) was implemented, including seating away from sensory triggers, access to a quiet sensory room, reduced school hours, small group activities, modified assessments, and teacher assisted de escalation during meltdowns. At home, environmental modifications included a dimly lit, predictable setting, visual planners, consistent routines, calming sensory inputs, and pet assisted emotional regulation. Parental education focused on understanding sensory triggers, routine management, and emotional regulation strategies.

Over one year, there was a marked reduction in self injurious behavior,obsessive routines, improved emotional regulation, enhanced academic performance, and better social adaptation. Quality of life improved significantly, as measured using the Pediatric Quality of Life Inventory (PedsQL™ 4.0), summarized in table 2. Written informed consent was obtained from the parents.

Table 2. Objective tool for measuring outcomes

Discussion

High-functioning ASD can present diagnostic challenges due to preserved language and cognitive skills, which often mask deficits in social communication, non-verbal interactions, and behavioral rigidity (2). The removal of Asperger Syndrome as a distinct diagnosis in DSM-5 and its integration into the broader ASD classification underscores the dimensional nature of autism and the continuum of functional impairments (3). High-functioning individuals may be articulate, intellectually advanced, and academically successful.

The presence of comorbid psychiatric conditions such as obsessive-compulsive disorder, generalized anxiety, and depression further obscures the underlying neurodevelopmental disorder, particularly in high-IQ children who are adept at camouflaging or masking symptoms.(4) Camouflaging is especially prevalent in females and contributes to diagnostic delays (5). Self-injurious behaviors, though alarming, are not uncommon in ASD and often stem from sensory processing difficulties, particularly hyperresponsivity to tactile and auditory stimuli. These behaviors are often misinterpreted as signs of mood disorders or psychosis, leading to inappropriate treatment strategies. Psychiatric comorbidities, including anxiety, obsessive compulsive symptoms, depression, and self injurious behavior, frequently coexist with ASD and should be interpreted as part of a symptom cluster rather than isolated psychiatric disorders. Sensory processing abnormalities are strongly associated with emotional dysregulation and self injury in ASD and may mimic affective or psychotic illness (6)

Effective identification hinges on a thorough developmental and behavioral history, detailed observation across contexts, and standardized assessments tailored to autism symptomatology (7). Misdiagnosis can lead to inappropriate pharmacotherapy and delayed implementation of effective, autism specific interventions. Interdisciplinary collaboration among pediatricians, psychologists, occupational therapists, educators, and psychiatrists is vital (8). Quantifiable outcome measures such as the Childhood Depression Inventory (CDI-II) provide objective metrics to monitor the response to interventions and guide clinical decision-making (9).

Recent studies emphasize that early diagnosis and individualized, context-sensitive interventions significantly improve adaptive functioning, reduce psychiatric comorbidities, and enhance quality of life (10). Table 3 outlines contemporary literature that highlights the ongoing issue of misdiagnosis in high-functioning ASD and reinforces the need for heightened clinical vigilance, especially in atypical or ambiguous presentations.

Table 3. Studies Highlighting Misdiagnosis of High-Functioning Autism

Management of Asperger Syndrome involves a multidisciplinary approach tailored to the individual's unique needs. Key strategies include individualized education plans (IEPs), speech and language therapy, occupational therapy, and behavioral interventions such as Applied Behavior Analysis (ABA) (8). Creating a structured, predictable environment at school and home helps reduce anxiety and promote adaptive functioning . Social skills training is particularly valuable for helping children understand and to deal social cues.

Family involvement plays a central role in management. Parent education should focus on understanding the child's unique behavioral profile, recognizing signs of distress, and developing strategies for managing meltdowns, selective eating, or rigid routines (22). Communication with the child should be calm, consistent, and non-authoritarian. Empowering parents with practical tools and knowledge fosters a nurturing and structured home environment that complements formal interventions and supports the child's overall development. (23)

This case reinforces the importance of comprehensive developmental history, standardized autism specific assessment tools, and interdisciplinary collaboration. Early diagnosis and individualized intervention strategies are associated with improved adaptive functioning and quality of life.

Conclusion

Lessons Learnt

1. Careful evaluation of social developmental milestones is essential for diagnosing autism spectrum disorder, particularly in high-functioning children.

2. Psychiatric symptoms such as obsessive-compulsive behaviors, depression, aggression, and self-injury should be interpreted collectively as potential manifestations of ASD.

3. A multidisciplinary approach combining medication, behavioral therapy, environmental modification, educational support, and parental education significantly improves outcomes in ASD.

Cite this article as: Vikram A, Arumugam A, M Nithya. Unravelling high-functioning autism in a child with comorbid psychiatric manifestations: a case report with review of literature. Pediatr Acad Case Rep. 2026;5(3):79-86.

Written informed consent was obtained from the parents of this patient for this study.

Concept: AV,AA; design: AV,NM; supervision: NM; materials: AA,NM; data collection and/or processing: AV,AA; analysis and interpretation: NM,AV; literature review: AV,AA; writing manuscript: AV; critical reviews: NM. All authors contributed to the final version of the manuscript and discussed the results and contributed to the final manuscript.

The authors declared no conflicts of interest with respect to authorship and/or publication of the article.

The authors received no financial support for the research and/or publication of this article.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
2. Huerta M, Bishop SL, Duncan A, Hus V, Lord C. Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders (PDD). Am J Psychiatry. 2012;169(10):1056-64
3. Dr Sensory. Why was Asperger's removed from DSM-5? [Internet]. 2025 [cited 2025 Dec 16]. Available from: https://drsensory.com/why-was-aspergers-removed-from-dsm-5/
4. Behavior Therapy Associates. Comorbid OCD and high functioning autism spectrum disorder [Internet]. 2025 [cited 2025 Dec 16]. Available from: https://behaviortherapyassociates.com/autism-spectrum/comorbid-ocd-and-autism-spectrum-disorder/
5. Livingston LA, Shah P, Antún E, et al. Does camouflaging predict age at autism diagnosis? A comparison of autistic men and women. Autism Res. 2024;17(3):436-45
6. Duerden EG, Oathes DJ, Francis SM, et al. Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders. J Autism Dev Disord. 2012;42(11):2160-70
7. Elder JH, Dawson G, Toth K, et al. Clinical impact of early diagnosis of autism on the prognosis and parent-child interactions. Psychol Res Behav Manag. 2017;10:309-17
8. Magnet ABA. The importance of a multidisciplinary approach in ABA therapy [Internet]. 2025 [cited 2025 Dec 16]. Available from: https://www.magnetaba.com/blog/the-importance-of-a-multidisciplinary-approach-in-aba-therapy.
9. Psychological Assessment Australia. Children's Depression Inventory 2 [Internet]. 2023 [cited 2025 Dec 16]. Available from: https://paa.com.au/product/cdi-2/.
10. Okoye C, Jones E, Smith A. Early diagnosis of autism spectrum disorder: a review. Cureus. 2023;15(8):e43198
11. Taiminen TJ. Schizophrenia or Asperger's disorder? A case report. Eur Psychiatry. 1994;9(4):206-9.
12. Nylander L, Gillberg C. Screening for autism spectrum disorders in adult psychiatric out-patients: A preliminary report. Acta Psychiatr Scand. 2001;103(6):428-34.
13. Raja M, Azzoni A. Autistic spectrum disorders and schizophrenia spectrum disorders in adult psychiatric patients. BMC Psychiatry. 2009;9:28.
14. Lai MC, Baron-Cohen S. Identifying the lost generation of adults with autism spectrum conditions. Lancet Psychiatry. 2015;2(11):1013-1027.
15. Mandy W, Tchanturia K. Do women with eating disorders who have social and flexibility difficulties really have autism? A case series. Mol Autism. 2015;6:6.
16. Wigham S, Rodgers J, South M, McConachie H, Freeston M. The interplay between sensory processing abnormalities, intolerance of uncertainty, anxiety and restricted and repetitive behaviours in autism spectrum disorder. J Autism Dev Disord. 2015;45(4):943-952.
17. Brewer N, Young RL, Barnett E. Measuring theory of mind in children with and without autism spectrum disorder. J Autism Dev Disord. 2016;46(6):2068-2078
18. Ying J, Zhang MW, Sajith SG, Tan GM, Wei KC. Misdiagnosis of Psychosis and Obsessive-Compulsive Disorder in a Young Patient with Autism Spectrum Disorder. Case Rep Psychiatry. 2023 Feb 14;2023:7705913. doi: 10.1155/2023/7705913. PMID: 36824478; PMCID: PMC9943599
19. Iversen S, Kildahl AN. Case report: mechanisms in misdiagnosis of autism as borderline personality disorder. Frontiers in Psychology. 2022 Feb 4;13:735205.
20. Casey MR, Sall S, Parsons G, Raveendran K, Zaheri A. Misdiagnosis in an Autistic Adolescent. Cureus. 2024 Aug 29;16(8):e68129. doi: 10.7759/cureus.68129. PMID: 39347360; PMCID: PMC11438490.
21. Rim SJ, Kwak K, Park S. Risk of psychiatric comorbidity with autism spectrum disorder and its association with diagnosis timing using a nationally representative cohort. Research in Autism Spectrum Disorders. 2023 Jun 1;104:102134.
22. Advanced Autism. Supporting children with autism through parent education and empowerment [Internet]. [cited 2025 Dec 16]. Available from: https://www.advancedautism.com/post/supporting-children-with-autism-through-parent-education-and-empowerment
23. Attwood, T. (2007). The Complete Guide to Asperger's Syndrome. Jessica Kingsley Publishers.