CHIEF COMPLAINT Mother: “Teacher asked him to evaluate as he is not socialising & being isolated” HISTORY OF PRESENT ILLNESS The patient was brought by his mother for psychiatric evaluation due to concerns regarding his learning ability and behavioral changes. According to the mother, she had observed that the patient had become socially withdrawn, preferring to isolate himself from others and experiencing difficulty adapting to new environments. Initially, one of his Eldest brothers noted that patients have difficulty interacting with others but the mother denied that he'll become normal as he grow. At school, he was noted to spend most of his time lying down on his desk and was minimally responsive when approached by teachers or classmates. The mother also reported that the patient had difficulty keeping up with his academic work. She believed that his tendency to converse mostly in English contributed to his social isolation, as he had difficulty interacting with others. The patient had expressed reluctance to attend school, stating that "No one is being friendly with him. His benchmate also reportedly complained that he is breaking her belongings.” In addition, the mother noticed that the patient occasionally talked to himself and cried without any apparent reason. Teachers reported that he had difficulty accepting changes or corrections; whenever his mistakes were pointed out, he would become angry. Due to these persistent concerns regarding his academic performance, social functioning, and behavioral changes, the teachers recommended that the patient undergo a psychiatric evaluation. Consequently, his mother brought him to the VSMMC–CBS OPD for his first psychiatric consultation on July 15, 2026. PAST PSYCHIATRIC HISTORY The patient has no prior psychiatric symptoms observed. Had no psychiatric consultations or hospitalizations. Patient had no history of suicidal or homicidal thoughts process in the past. PAST MEDICAL HISTORY The mother stated that he had received all age appropriate vaccination. The patient had dengue and was admitted to a private clinic for 1 week. Mother denied previous surgeries. The Mother denied any congenital illness or taking maintenance medication. No known allergies noted. FAMILY HISTORY The patient has five siblings, all of whom are brothers. He lives with his mother, father, and four of his brothers, while the eldest brother resides separately. His mother reported that the patient has a good relationship with all family members. The patient stated that he is closer to his father. The patient's father is a known hypertensive but is non-compliant with his medications. His mother has a visual impairment affecting her right eye and is a housewife, while his father works as a human resources (HR) personnel. The eldest brother has a history of hypokalemia. There is a family history of hypertension and diabetes mellitus. No family history of psychiatric illness was reported. DEVELOPMENTAL AND SOCIAL HISTORY Prenatal, Natal, and Postnatal History: The patient was born to a 37 year old G5P5 (4105) mother through normal spontaneous delivery. She had Gestational Diabetes mellitus and was advised for lifestyle modification with no maintenance medication. The patient was breastfed till 4 years. Mother claims she had routine prenatal checkup and took all multivitamins prescribed. There was no reported history of maternal drug or alcohol use during pregnancy. The mother had no history of medical or psychiatric disorders during pregnancy or childbirth. Early Childhood (0–3 years): The Primary Care giver for the patient was his lola till 1 year of his age. The patient had Jaundice a few days after birth but mother didn't want him to get admitted so she discharged him and had been advised to keep the child under sunlight. The patient crawled while 7 months of age. Mother couldn't recall other developmental milestones as she wasn't taking care of him. Joined kindergarten at the age of 3 and was noticed as a well behaved child. Middle Childhood (4 –Present): The patient's mother was his primary caregiver. He was breastfed until the age of 4 years. At the age of 4 years, he began saying "Mama" and "Papa." He also learned to speak English primarily by watching YouTube videos and currently converses predominantly in English, with difficulty speaking Bisaya. At the age of 5 years, the patient was able to feed himself independently and learned to ride a tricycle. At the age of 7 years, he began bathing independently. During the same year, his mother enrolled him in karate classes, which were held for 3 hours on weekends, and football training, where he played as a goalkeeper for 1 hour in the afternoons. Despite participating in these activities, he remained socially withdrawn and interacted minimally with others. He is currently studying at a public elementary school. He prefers to line up his toys and becomes anxious if someone disturbs their arrangement. He spends most of his time playing mobile games, particularly Roblox, and watching cartoon videos. He stated that Science is his favorite subject and enjoys watching videos about trains. He is able to count up to 100, even when asked to start from a number in the middle of the sequence. He can read and write simple words. He tends to isolate himself from others. He has been noted to have difficulty passing examinations, and his mother described him as an average student academically. MENTAL STATUS EXAMINATION The patient was seen awake, cooperative, well-groomed, and appropriately dressed for his age. Speech was non-spontaneous, slow in rate, and low in volume. He was alert and responsive, and oriented to person, place, and time. He maintained poor eye contact and frequently looked away and appeared hesitant to answer questions. Mood appeared euthymic; however, he became tearful during the interview without any apparent external stimulus. He was inattentive and easily distracted. Concentration were adequate for age, as evidenced by his ability to read the words "WORLD" and "CENTER" and perform simple arithmetic calculations (e.g., 9 + 4 and 2 × 4). Immediate memory was intact. No evidence of hallucinations, delusions, or other perceptual disturbances was elicited. Insight was limited. Give primary impression and 3 best differential diagnosis with rule in and rule out
Primary Impression and Differential Diagnoses
PRIMARY CLINICAL IMPRESSION
DIFFERENTIAL DIAGNOSES
1. Intellectual Disability (ID) - Mild Severity
- Delayed language milestones - first words ("Mama," "Papa") at age 4 years, well beyond the expected 12-18 months
- Academic difficulties: described as an "average" student who has difficulty passing examinations, difficulty keeping up with academic work
- Possible delayed motor milestones: bathing independently only at age 7 (typically achieved around age 5-6)
- Prenatal risk factors: gestational diabetes in the mother, neonatal jaundice that was managed sub-optimally (home sunlight only, discharge against advice), and primary caregiving gap (cared for by grandmother, not mother, in the first year of life)
- Cognitive testing in the MSE is limited: he can read simple words, do basic arithmetic (9+4, 2×4), count to 100 - but formal IQ has not yet been assessed
- DSM-5 requires deficits in BOTH intellectual functioning AND adaptive functioning (Kaplan and Sadock's Synopsis of Psychiatry, p. 323): deficits in reasoning, abstraction, judgment, learning, and adaptive behavior arising during development - several of these appear present
- Adaptive functioning may actually be partially preserved: he feeds himself, rides a tricycle, bathes independently, participates in karate and football - these self-care gains, while delayed, suggest he is not profoundly or severely impaired
- Intellectual deficits in this case may be secondary to or comorbid with ASD (approximately one-third of ASD children also have ID), rather than standing alone as the primary diagnosis
- Formal IQ testing (WISC, Stanford-Binet) has not been done - cannot confirm until standardized cognitive evaluation is completed
- His specific interest in Science, ability to count in sequence from mid-range numbers, and learning English primarily through media suggest preserved abilities in certain domains, which is less characteristic of moderate-to-severe ID
2. Social (Pragmatic) Communication Disorder (SPCD)
- Core deficit is in social pragmatic communication: difficulty interacting with classmates, inability to adapt communication to context (he converses in English in a Bisaya-speaking environment and does not adjust this), limited spontaneous speech (non-spontaneous, slow, low volume on MSE)
- Persistent difficulties in social communication across settings (school, extracurriculars, home interactions with peers)
- Academic underachievement attributable to communication deficits
- No gross psychosis or hallucinations present
- DSM-5 distinguishes SPCD from ASD in that SPCD lacks restricted/repetitive behaviors (RRBs) and highly restricted interests; some patients originally diagnosed with Asperger's or PDD-NOS in DSM-IV may now better fit SPCD (Kaplan and Sadock's Synopsis of Psychiatry, p. 390)
- This diagnosis is critically ruled out by the presence of restricted and repetitive behaviors and interests: he lines up toys and becomes anxious if their arrangement is disturbed, has intense focused interest in trains and Roblox, resists correction/change, and showed the same behavioral pattern in karate and football settings
- Per DSM-5 and Kaplan and Sadock: "We should consider social (pragmatic) communication disorder ONLY when the restricted interests and repetitive behaviors have NEVER been present" (p. 390). These ARE present in this case, which pushes the diagnosis decisively toward ASD
- Even if RRBs were minimal now, if they were present earlier in development, ASD remains the correct diagnosis over SPCD
- SPCD thus functions more as a differential to rule out rather than the primary diagnosis
3. Attention-Deficit/Hyperactivity Disorder (ADHD) - Predominantly Inattentive Presentation
- Inattentiveness is prominent: easily distracted during the MSE, difficulty keeping up with academic tasks, spending most of class time lying on his desk and minimally responsive to teachers
- Difficulty adapting to new environments and transitions (which can also be seen in ADHD with executive dysfunction)
- Academic underachievement and difficulty completing schoolwork
- Emotional dysregulation: becomes angry when corrections are pointed out, cries without apparent reason (emotional lability is recognized in ADHD)
- Socially disruptive behavior noted at school (benchmate complaining he breaks her belongings)
- The inattention and social withdrawal pattern here appears more pervasive and qualitatively different from the hyperactive/distractible pattern of classic ADHD - he is not described as hyperactive, impulsive, or restless; rather he is withdrawn, flat, and minimally responsive
- The social withdrawal, poor eye contact, restricted interests, and ritualistic behaviors (toy arrangement) are not explained by ADHD alone
- The MSE shows concentration adequate for age (he read "WORLD" and "CENTER" and performed arithmetic correctly), which is more consistent with intact core attention capacity and less with primary ADHD
- ADHD does not account for the stereotyped interests, communication-specific deficits, and early developmental pattern of social unresponsiveness
- ADHD can be comorbid with ASD (very commonly), but it would be a secondary rather than primary diagnosis in this clinical picture
SUMMARY TABLE
| Feature | ASD (Primary) | Intellectual Disability | ADHD |
|---|---|---|---|
| Social withdrawal | + (core feature) | + (secondary) | +/- (inattention-related) |
| Restricted/repetitive behaviors | + (lining toys, train interest) | - | - |
| Language delay | + (first words at age 4) | + | - |
| Poor eye contact | + (core) | +/- | - |
| Academic difficulty | + | + | + |
| Emotional dysregulation | + | +/- | + |
| Preserved self-care | + (delayed but present) | + (mild ID) | + |
| Formal IQ deficit | ? (not yet tested) | Required | - |
| Explains full picture | YES | Partial (comorbid) | Partial (comorbid) |
CLINICAL NOTE
According to dsm 5 TR 3 differentuals for this diagnosis
DSM-5-TR Differential Diagnoses for Autism Spectrum Disorder
1. Social (Pragmatic) Communication Disorder (SPCD)
- Non-spontaneous, low-volume, slow speech
- Difficulty adjusting language to social context (speaking English in a Bisaya-speaking environment without adapting)
- Minimal responsiveness when approached at school
- Impaired social relationships and academic underachievement secondary to communication deficits
- He lines up toys and becomes anxious when their arrangement is disturbed - this IS a restricted/repetitive behavior
- He has a narrow, intense interest in trains and Roblox
- Restricted and repetitive behaviors (RRBs) are present; per DSM-5-TR, SPCD may only be diagnosed when RRBs have never been present - which is not the case here
- This makes ASD the more appropriate primary diagnosis over SPCD
2. Intellectual Disability (Intellectual Developmental Disorder) with Behavioral Symptoms
- In ID: impairment is global and even across both verbal and nonverbal areas. Children with ID generally relate verbally and socially to adults and peers consistent with their mental age.
- In ASD: impairment is uneven - specifically and disproportionately weak in social interaction and communication relative to other areas of performance. ASD children typically show a higher performance IQ than verbal IQ score pattern.
- First words ("Mama," "Papa") only at age 4 years (expected: 12-18 months) - significant language delay
- Academic difficulty: fails examinations, described as an average student struggling to keep up
- Delayed self-care: independent bathing achieved only at age 7 (expected: ~5-6 years)
- Perinatal risk factors: gestational diabetes, neonatal jaundice managed sub-optimally
- Adaptive functioning delays are present across multiple domains
- His social impairment is disproportionately severe compared to other skills: he can count to 100 from a mid-sequence starting point, do arithmetic, read simple words, and ride a tricycle - suggesting uneven rather than global deficit
- He has intense, specific interests (trains, Science, Roblox) that are qualitatively different from global developmental delay
- His social deficits appear more characteristic of ASD's specific impairment in social relatedness than ID's even limitation across all domains
- Note: ASD and ID are not mutually exclusive - approximately one-third of ASD children have comorbid ID; both can co-exist and formal IQ testing is still required
3. Childhood-Onset Schizophrenia
| Feature | ASD | Childhood-Onset Schizophrenia |
|---|---|---|
| Age of onset | Early developmental period | Rarely under age 5 |
| Incidence | ~1% | <1 in 10,000 |
| Sex ratio (M:F) | 4:1 | ~1.67:1 |
| Hallucinations/delusions | Absent | Present (core feature) |
| Family history (psychiatric) | Not increased | Likely increased |
| Perinatal complications | Increased | Not increased |
| IQ pattern | Performance > Verbal | More even |
| Seizures | 4-32% | Low incidence |
| Adaptive functioning | Impaired (from early on) | Deterioration from baseline |
- He talks to himself (which could superficially appear like responding to internal stimuli)
- Crying without apparent reason (could mimic blunted or inappropriate affect)
- Social withdrawal and functional impairment are present
- No hallucinations, delusions, or perceptual disturbances were elicited on MSE - the MSE explicitly states "no evidence of hallucinations, delusions, or other perceptual disturbances"
- His symptoms have been present from early developmental life, not as a deterioration from a previously normal baseline
- No family history of psychiatric illness is reported
- Childhood-onset schizophrenia almost never presents this young (patient is elementary school age)
- Talking to himself is more consistent with self-stimulatory or echolalic behavior seen in ASD than with command auditory hallucinations
Summary
| Differential | Shares with ASD | Key Feature That Rules It Out |
|---|---|---|
| Social (Pragmatic) Communication Disorder | Social communication deficits, language difficulty | No RRBs - but this patient HAS RRBs (toy lining, restricted interests) |
| Intellectual Disability with Behavioral Symptoms | Language delay, adaptive deficits, behavioral overlap | Global even impairment - but this patient has uneven profile favoring ASD |
| Childhood-Onset Schizophrenia | Social withdrawal, self-talk, affective changes | No hallucinations/delusions on MSE; early developmental onset, not deterioration |