When the shy, dark-haired boy met with clinicians for a full psychiatric evaluation two years ago, almost everything about him pointed to autism. W. had not spoken his first words until age 2. He was at least 4 before he could form sentences. As he got older, he was unable to make friends. He struggled to accept changes to his routine and maintain eye contact. And despite having an average intelligence quotient, he was unusually attached to objects; at age 11, he still lugged a bag of stuffed animals with him everywhere he went.
But something else was clearly at work, too. “He had these things that he would call day dreams,” recalls Jennifer Foss-Feig, assistant professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York. When she evaluated W., she noticed that he would often gaze into an empty corner of the room — particularly when he seemed to suspect that she wasn’t paying attention to him. (For privacy reasons, Foss-Feig declined to reveal anything but the child’s first initial.) Occasionally, he would speak to that space, as though someone else were there.
His parents, she recalls, were worried. They explained to Foss-Feig that their son had what he called an “imaginary family.” But W.’s invisible playmates weren’t of the usual harmless variety that many children have; they seemed to be a dangerous distraction both at home and at school. On one occasion, he wandered through a busy parking lot, seemingly oblivious to the oncoming traffic.
As these frightening episodes grew more frequent, they raised a red flag. Doctors had previously attributed the boy’s difficulties to attention deficit hyperactivity disorder and learning disorders. But now it was unclear if those labels really fit. Perhaps, instead of tuning out from the world, W. was unable to distinguish reality from fantasy and had some form of psychosis.
There was no question W. had autism, according to Foss-Feig. She and several of her colleagues were also confident that he was experiencing hallucinations and delusions. Ultimately, they diagnosed him with autism and psychosis,