The Asperger individual who is a verbal logic thinker uses verbal categories. For example, Dr. Minshew had an Asperger patient who had a bad side effect with a medication. Explaining the science of why he should try a different medication was useless. However, he became willing to try a new medication after he was simply told, the pink pills made you sick and I want you to try the blue pills. He agreed to try the blue pills.
The more I learn, the more I realize more and more that how I think and feel is different. My thinking is different from a normal person, but it is also very different from the verbal logic non-visual person with Asperger's. They create word categories instead of picture categories. The one common denominator of all autistic and Asperger thinking is that details are associated into categories to form a concept. Details are assembled into concepts like putting a jigsaw puzzle together. The picture on the puzzle can be seen when only 20 percent of the puzzle is put together, forming a big picture.
2
THE GREAT CONTINUUM
Diagnosing Autism
THE FIRST SIGN that a baby may be autistic is that it stiffens up and resists being held and cuddled. It may be extremely sensitive to touch and respond by pulling away or screaming. More obvious symptoms of autism usually occur between twelve and twenty-four months of age. I was my mother's first child, and I was like a little wild animal. I struggled to get away when held, but if I was left alone in the big baby carriage I seldom fussed. Mother first realized that something was dreadfully wrong when I failed to start talking like the little girl next door, and it seemed that I might be deaf. Between nonstop tantrums and a penchant for smearing feces, I was a terrible two-year-old.
At that time, I showed the symptoms of classic autism: no speech, poor eye contact, tantrums, appearance of deafness, no interest in people, and constant staring off into space. I was taken to a neurologist, and when a hearing test revealed that I was not deaf, I was given the label “brain-damaged.” Most doctors over forty years ago had never heard of autism. A few years later, when more doctors learned about it, that label was applied.
I can remember the frustration of not being able to talk at age three. This caused me to throw many a tantrum. I could understand what people said to me, but I could not get my words out. It was like a big stutter, and starting words was difficult. My first few words were very difficult to produce and generally had only one syllable, such as “bah” for ball. I can remember logically thinking to myself that I would have to scream because I had no other way to communicate. Tantrums also occurred when I became tired or stressed by too much noise, such as horns going off at a birthday party. My behavior was like a tripping circuit breaker. One minute I was fine, and the next minute I was on the floor kicking and screaming like a crazed wildcat.
I can remember the day I bit my teacher's leg. It was late in the afternoon and I was getting tired. I just lost it. But it was only after I came out of it, when I saw her bleeding leg, that I realized I had bitten her. Tantrums occurred suddenly, like epileptic seizures. Mother figured out that like seizures, they had to run their course. Getting angry once a tantrum started just made it worse. She explained to my elementary school teachers that the best way to handle me if I had a tantrum was not to get angry or excited. She learned that tantrums could be prevented by getting me out of noisy places when I got tired. Privileges such as watching Howdy Doody on TV were withdrawn when I had a bad day at school. She even figured out that I'd sometimes throw a tantrum to avoid going to class.
When left alone, I would often space out and become hypnotized. I could sit for hours on the beach watching sand dribbling through my fingers. I'd study each individual grain of sand as it flowed between my fingers. Each grain was different, and I was like a scientist studying the grains under a microscope. As I scrutinized their shapes and contours, I went into a trance which cut me off from the sights and sounds around me.
Rocking and spinning were other ways to shut out the world when I became overloaded with too much noise. Rocking made me feel calm. It was like taking an addictive drug. The more I did it, the more I wanted to do it. My mother and my teachers would stop me so I would get back in touch with the rest of the world. I also loved to spin, and I seldom got dizzy. When I stopped spinning, I enjoyed the sensation of watching the room spin.
Today, autism is regarded as an early childhood disorder by definition, and it is three times more common in boys than girls. For the diagnosis to be made, autistic symptoms must appear before the age of three. The most common symptoms in young children are no speech or abnormal speech, lack of eye contact, frequent temper tantrums, oversensitivity to touch, the appearance of deafness, a preference for being alone, rocking or other rhythmic stereotypic behavior, aloofness, and lack of social contact with parents and siblings. Another sign is inappropriate play with toys. The child may spend long periods of time spinning the wheel of a toy car instead of driving it around on the floor.
Diagnosing autism is complicated by the fact that the behavioral criteria are constantly being changed. These criteria are listed in the Diagnostic and Statistical Manual published by the American Psychiatric Association. Using those in the third edition of the book, 91 percent of young children displaying autistic symptoms would be labeled autistic. However, using the newest edition of the book, the label would apply to only 59 percent of the cases, because the criteria have been narrowed.
Many parents with an autistic child will go to many different specialists looking for a precise diagnosis. Unfortunately, diagnosing autism is not like diagnosing measles or a specific chromosomal defect such as Down syndrome. Even though autism is a neurological disorder, it is still diagnosed by observing a child's behavior. There is no blood test or brain scan that can give an absolute diagnosis, though brain scans may partially replace observation in the future.
The new diagnostic categories are autism, pervasive developmental disorder (PDD), Asperger's syndrome, and disintegrative disorder, and there is much controversy among professionals about them. Some consider these categories to be true separate entities, and others believe that they lie on an autistic continuum and there is no definite distinction between them.
A three-year-old child would be labeled autistic if he or she lacked both social relatedness and speech or had abnormal speech. This diagnosis is also called classic Kanner's syndrome, after Leo Kanner, the physician who first described this form of autism, in 1943. These individuals usually learn to talk, but they remain very severely handicapped because of extremely rigid thinking, poor ability to generalize, and no common sense. Some of the Kanner people have savant skills, such as calendar calculation. The savant group comprises about 10 percent of the children and adults who are diagnosed.
A child with classic Kanner's syndrome has little or no flexibility of thinking or behavior. Charles Hart describes this rigidity in his autistic brother, Sumner, who had to be constantly coached by his mother. He had to be told each step of getting undressed and going to bed. Hart goes on to describe the behavior of his autistic son, Ted, during a birthday party when ice cream cones were served. The other children immediately began to lick them, but Ted just stared at his and appeared to be afraid of it. He didn't know what to do, because in the past he had eaten ice cream with a spoon.
Another serious problem for people with Kanner's syndrome is lack of common sense. They can easily learn how to get on a bus to go to school, but have no idea what to do if something interrupts the routine. Any disruption of routine causes a panic attack, anxiety, or a flight response, unless the person is taught what to do when something goes wrong. Rigid thinking makes it difficult to teach people with Kanner-type autism the subtleties of socially appropriate behavior. For example, at an autism meeting, a young man with Kanner's syndrome walked up to every person and asked, “Where are your earrings?” Kanner autistics need to be told in a clear simple way what is appropriate and inappropriate social behavior.
Uta Frith, a researcher at the MRC Cognitive Development Unit in
London, has found that some people with Kanner's syndrome are unable to imagine what another person is thinking. She developed a “theory of mind” test to determine the extent of the problem. For example, Joe, Dick, and a person with autism are sitting at a table. Joe places a candy bar in a box and shuts the lid. The telephone rings, and Dick leaves the room to answer the phone. While Dick is gone, Joe eats the candy bar and puts a pen in the box. The autistic person who is watching is asked, “What does Dick think is in the box?” Many people with autism will give the wrong answer and say “a pen.” They are not able to figure out that Dick, who is now outside the room, thinks that the box still contains a candy bar.
People with Asperger's syndrome, who tend to be far less handicapped than people with Kanner-type autism, can usually pass this test and generally perform better on tests of flexible problem-solving than Kanner's syndrome autistics. In fact, many Asperger individuals never get formally diagnosed, and they often hold jobs and live independently. Children with Asperger's syndrome have more normal speech development and much better cognitive skills than those with classic Kanner's. Another label for Asperger's syndrome is “high-functioning autism.” One noticeable difference between Kanner's and Asperger's syndromes is that Asperger children are often clumsy. The diagnosis of Asperger's is often confused with PDD, a label that is applied to children with mild symptoms which are not quite serious enough to call for one of the other labels.
Children diagnosed as having disintegrative disorder start to develop normal speech and social behavior and then regress and lose their speech after age two. Many of them never regain their speech, and they have difficulty learning simple household chores. These individuals are also referred to as having low-functioning autism, and they require supervised living arrangements for their entire lives. Some children with disintegrative disorder improve and become high-functioning, but overall, children in this category are likely to remain low-functioning. There is a large group of children labeled autistic who start to develop normally and then regress and lose their speech before age two. These early regressives sometimes have a better prognosis than late regressives. Those who never learn to talk usually have severe neurological impairments that show up on routine tests. They are also more likely to have epilepsy than Kanner or Asperger children. Individuals who are low-functioning often have very poor ability to understand spoken words. Kanner, Asperger, and PDD children and adults usually have a much better ability to understand speech.
Children in all of the diagnostic categories benefit from placement in a good educational program. Prognosis is improved if intensive education is started before age three. I finally learned to speak at three and a half, after a year of intensive speech therapy. Children who regress at eighteen to twenty-four months of age respond to intensive educational programs when speech loss first occurs, but as they become older they may require calmer, quieter teaching methods to prevent sensory overload. If an educational program is successful, many autistic symptoms become less severe.
The only accurate way to diagnose autism in an adult is to interview the person about his or her early childhood and obtain descriptions of his or her behavior from parents or teachers. Other disorders with autistic symptoms, such as acquired aphasia (loss of speech), disintegrative disorder, and Landau-Kleffner syndrome, occur at an older age. A child may have normal or near-normal speech and then lose it between the ages of two and seven. In some cases disintegrative disorder and Landau-Kleffner syndrome may have similar underlying brain abnormalities. Landau-Kleffner syndrome is a type of epilepsy that often causes a child to lose speech. Small seizures scramble hearing and make it difficult or impossible for the child to understand spoken words. A proper diagnosis requires very sophisticated tests, because the seizures are difficult to detect. They will not show up on a simple brain-wave (EEG) test. These disorders can often be successfully treated with anticonvulsants (epilepsy drugs) or corticosteroids such as prednisone. Anticonvulsant medications may also be helpful to autistic children who have abnormal EEGs or sensory scrambling. Other neurological disorders that have symptoms of autism are Fragile X syndrome, Rhett's syndrome, and tuberous sclerosis. Educational and treatment programs that help autistic children are usually helpful for children with these disorders also.
There is still confusion in diagnosing between autism and schizophrenia. Some professionals claim that children with autism develop schizophrenic characteristics in adulthood. Like autism's, schizophrenia's current diagnostic criteria are purely behavioral, though both are neurological disorders. In the future, brain scans will be sophisticated enough to provide an accurate diagnosis. Thus far, brain research has shown that these conditions have different patterns of abnormalities. By definition, autism starts in early childhood, while the first symptoms of schizophrenia usually occur in adolescence or early adulthood. Schizophrenia has two major components, the positive symptoms, which include full-blown hallucinations and delusions accompanied by incoherent thinking, and the negative symptoms, such as flat, dull affect and monotone speech. These negative symptoms often resemble the lack of affect seen in adults with autism.
In the British Journal of Psychiatry, Dr. P. Liddle and Dr. T. Barnes wrote that schizophrenia may really be two or three separate conditions. The positive symptoms are entirely different from symptoms of autism, but the negative ones may partially overlap with autistic symptoms. Confusion of the two conditions is the reason that some doctors attempt to treat autism with neuroleptic drugs such as Haldol and Mellaril. But neuroleptics should not be the first-choice medications for autism, because other, safer drugs are often more effective. Neuroleptic drugs have very severe side effects and can damage the nervous system.
Over ten years ago, Dr. Peter Tanguay and Rose Mary Edwards, at UCLA, hypothesized that distortion of auditory input during a critical phase in early childhood development may be one cause of handicaps in language and thinking. The exact timing of the sensory processing problems may determine whether a child has Kanner's syndrome or is a nonverbal, low-functioning autistic. I hypothesize that oversensitivity to touch and auditory scrambling prior to age two may cause the rigidity of thinking and lack of emotional development found in Kanner-type autism. These children partially recover the ability to understand speech between the ages of two and a half and three. Disintegrative disorder children, who develop normally up to two years of age, may be more emotionally normal because emotional centers in the brain have had an opportunity to develop before the onset of sensory processing problems. It may be that a simple difference in timing determines which type of autism develops. Early sensory processing problems may prevent development of the emotional centers of the brain in Kanner-type autistics, while the acquisition of language is more disturbed when sensory processing difficulties occur slightly later.
Research has very clearly shown that autism is a neurological disorder that reveals distinct abnormalities in the brain. Brain autopsy research by Dr. Margaret Bauman has shown that those with both autism and disintegrative disorder have immature development of the cerebellum and the limbic system. Indications of a delay in brain maturation can also be seen in autistic children's brain waves. Dr. David Canter and his associates at the University of Maryland found that low-functioning children between the ages of four and twelve have EEG readings that resemble the brain-wave pattern of a two-year-old. The question is what causes these abnormalities. Studies by many researchers are showing that there may be a cluster of genes that can put a person at risk for many disorders, including autism, depression, anxiety, dyslexia, attention deficit disorder, and other problems.
There is no single autism gene, though most cases of autism have a strong genetic basis. If a person is autistic, his or her chances of having an autistic child are greatly increased. There is also a tendency for the siblings of autistic children to have a higher incidence of learning problems than other children. Studies by Susan Folstein and Mark Rutter in London showed that in 42 percent of the families surveyed,
either a sibling or a parent of an autistic child had delayed speech or learning problems.
Genetics, however, does not completely control brain development. Studies of identical twins by Folstein and Rutter show that sometimes one twin is severely autistic and the other has only a few autistic traits. MRI (magnetic resonance imaging) brain scans of identical twin schizophrenics have shown that the more severely afflicted twin has greater brain abnormalities. The brain is so complex that genetics cannot tell every little developing neuron exactly where it should be connected. There is a 10 percent variation in brain anatomical structure that is not controlled by genetics. Brain scans of normal identical twins by Michael Gazzaniga, at the Dartmouth Medical School, showed an easily observable variation in brain structure, but twins' brains are more similar than the brains of unrelated people. Likewise, the personalities of identical twins are similar. Studies at the University of Minnesota by Thomas Bouchard and his colleagues of twins reared in different families show that basic traits such as mathematical ability, athletic ability, and temperament are highly inheritable. A summary of these studies concluded that roughly half of what a person becomes is determined by genetics and the other half is determined by environment and upbringing.
Other theories suggest that if a fetus is exposed to certain toxins and viruses, these may interact with genes to cause the abnormal brain development typical of autism. If either parent is exposed to chemical toxins that slightly damage his or her genetic material, that could increase the likelihood of autism or some other developmental disorder. Some parents suspect that an allergic reaction to early childhood vaccinations triggers autistic regression. If this is true it is likely that the vaccine interacts with genetic factors. Another possibility is immune system abnormalities which interfere with brain development. However, there is still too much that is not known, and neither parent should be held responsible for an autistic child. Scientific studies and interviews with families indicate that both the father's and the mother's side contribute genetically to autism.
Thinking in Pictures: My Life with Autism Page 5
