Case Study: Ethan Morales (DSM-5-TR: Autism Spectrum Disorder, Level 2 – Requiring Substantial Support)

Demographics

• Name: Ethan Morales

• Age: 8

• Gender: Male

• Grade: 2nd grade

• Family Background: Lives with both parents and a younger sister (age 5). No significant family psychiatric history.

Clinical Presentation

Course of Symptoms

Ethan’s parents first noticed differences in his development around age two. He rarely responded to his name, did not point to request objects, and preferred to play alone for long periods with toy cars, lining them up meticulously rather than engaging in pretend play.

At school, Ethan struggles with transitions between activities and becomes visibly distressed when routines are disrupted. His teacher describes him as bright, especially in math and memory-related tasks, but socially withdrawn. He often fails to make eye contact, speaks in a flat tone, and talks excessively about one topic, train schedules.

Though academically capable, Ethan’s rigidity, sensory sensitivities, and limited social reciprocity interfere with learning and peer relationships.

DSM-5-TR Diagnostic Features

Criterion A: Persistent deficits in social communication and social interaction across multiple contexts, manifested by all three of the following:

1. Deficits in social-emotional reciprocity

   Ethan rarely initiates or responds to social interactions. When others speak to him, he often turns away or continues focusing on his toys. He does not engage in back-and-forth conversation and has difficulty understanding others’ emotions.

2. Deficits in nonverbal communicative behaviors

   Limited eye contact, few facial expressions, and minimal use of gestures. When excited, he flaps his hands or hums softly but does not use facial or bodily cues typical of social engagement.

3. Deficits in developing, maintaining, and understanding relationships

   Ethan prefers solitary play and struggles to interpret social rules. Peers describe him as “in his own world.” Attempts at group play often lead to frustration or withdrawal.

Criterion B: Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following:

1. Stereotyped or repetitive motor movements, use of objects, or speech

   Repetitively lines up toy cars and insists they face the same direction. Uses echolalia (“train’s coming, train’s coming”) during play.

2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior

   Must eat breakfast from the same blue bowl each morning; becomes inconsolable if it is unavailable. Exhibits distress when daily routines change.

3. Highly restricted, fixated interests that are abnormal in intensity or focus

   Fascination with train timetables and mechanical operations. Can recite departure times from memory and grows anxious when prevented from discussing them.

4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment

   Covers his ears at loud noises and becomes mesmerized by spinning fan blades or flashing lights.

Criterion C:

Symptoms must be present in the early developmental period, though they may not become fully manifest until social demands exceed capacities.

Ethan’s delays were evident by age two.

Criterion D:

Symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning.

Ethan requires classroom accommodations and one-on-one support to complete transitions, group projects, and emotional regulation tasks.

Criterion E:

These disturbances are not better explained by intellectual disability or global developmental delay.

Ethan’s IQ and adaptive functioning are within the average range. His difficulties are specific to social communication and flexibility.

Specifier (DSM-5-TR):

• Severity: Level 2 – Requiring substantial support in both social communication and restricted behaviors.

• With language impairment: Present (delayed pragmatic and conversational speech).

Psychological and Behavioral Features

• Cognitive strengths: Excellent rote memory, pattern recognition, and factual recall.

• Social challenges: Difficulty understanding figurative language and tone. Literal interpretations cause confusion (“Why would someone spill the beans if they’re not cooking?”).

• Emotional regulation: Meltdowns when overstimulated or when routines change unexpectedly.

• Adaptive functioning: Needs reminders for hygiene, organization, and transitions.

• Motor behaviors: Hand-flapping, rocking, and repetitive tapping during stress.

Differential Diagnosis (DSM-5-TR Guidance)

Functional Impairment

• Academic: Excels in structured tasks but struggles with group collaboration and transitions.

• Social: Lacks close friends; peers often exclude him from play.

• Home life: Family limits activities (e.g., noisy restaurants) due to sensory overload.

• Emotional: Increased anxiety when routines change or when sensory thresholds are exceeded.

Treatment Considerations (DSM-5-TR Aligned)

• Applied Behavior Analysis (ABA): Reinforces communication and social skills through structured reinforcement.

• Speech and Language Therapy: Focused on pragmatic and reciprocal conversation skills.

• Occupational Therapy: Addresses sensory sensitivities and fine motor skills.

• Social Skills Groups: Provides guided practice in peer interaction.

• Parent Training: Helps family develop predictable routines and strategies to prevent meltdowns.

• Educational Supports: Individualized Education Plan (IEP) including visual schedules, transition cues, and quiet spaces.

Cultural and Psychosocial Context

• Ethan’s bilingual household (English and Spanish) initially raised concerns that his language delays were due to dual-language exposure; however, deficits persisted across both languages.

• His parents initially faced stigma in their extended family, who viewed his behaviors as “disobedient.”

• Access to services improved once they connected with a school-based psychologist familiar with ASD in bilingual children.