David M. Callahan, Ph.D.
Providing Psychological Services to
Cape Cod and Southeastern Massachusetts
Over the last decade there has been a tremendous upsurge in the diagnosis of a disorder now known as Autistic Spectrum Disorders, formerly known as Autism or Pervasive Development Disorders. The vast majority of this change in diagnosis relates to the extent to which we have expanded the diagnosis to include individuals with far less severe difficulties than previously. Some of this is due to increased awareness of these disorders and their impact within the field in general, allowing a greater number of individuals to be identified as in need of the assistance that can be provided to address these issues.
There is tremendous variability in the functional levels of individuals with Autistic Spectrum Disorders (ASD). At the higher levels of functioning, there are many persons identified as rather brilliant and among the giants of our science who are suspected to have possibly had ASD, including individuals such as Isaac Newton, Albert Einstein and perhaps even Bill Gates. In contrast, at the lowest level of functioning, persons with severe ASD will be nonverbal, and largely unable to respond beyond very basic levels in interactions with others. Thus, we see a vast array of functional capacities falling into a very broad-based rubric, with the majority of people functioning at the higher ends of that spectrum. In the past, only the lower functioning individuals would have been identified with any reliability. At this point, however, increased awareness has indeed greatly increased the number of persons carrying ASD diagnoses.
The fundamental areas of difficulties for persons with ASD include some complex of interpersonal difficulties, specific cognitive difficulties and sensory processing difficulties. Each of those will be discussed below.
Interpersonal Difficulties:
Persons with ASD often suffer from difficulties forming close and mutual relationships with others. Many persons with ASD have difficulty reading basic social cues, with reading of facial expressions often difficult. There tends to be difficulty with understanding subtleties in behavior and communication, with difficulty reading nonverbal cues especially. Persons with ASD are sometimes described as “inner focused,” more likely to be aware of their own internal states than the states of those around them. It is often difficult for persons with ASD to understand the emotions of others. Much of their life is spent in essence “lost in their own thoughts,” focused on their own basic needs, but having difficulty recognizing the emotions and needs of others. It is typical that individuals with ASD have difficulty forming close and intimate relationships. At the higher levels of functioning, we often see relationships formulated around mutually enjoyable activities, with gaming a very common behavior at this time, but true intimacy and reciprocity is often difficult for such persons to develop. Relationships will often be somewhat superficial and activity-based rather than based on mutual emotional exchanges.
Atypical Cognitive Processes:
Persons with Autism show several cognitive symptoms that relate to somewhat atypical and idiosyncratic thinking on their part. Often, persons with ASD have difficulty understanding humor. They may make some attempts at their own expressions of humor, but often these are somewhat quirky and unusual. It is frequently difficult for such persons to understand the jokes of others, often taking them somewhat literally. There is often difficulty understanding sarcasm or tolerating teasing, as attempts of humor by others are misread as being expressions of genuine intent. This can create reactivity and tension in relationships. There is also a tendency for many persons with ASD to become obsessionally preoccupied with a single topic, to the extent that they can appear to be quite “an expert” around that topic. Often this exceeds simple heightened interest, as the obsessional focus will result in frequent discussion of the topic, even when such discussions are unwelcome or ignored. It is not unusual of persons with ASD to talk incessantly about a single idea or concept, regardless of the level of interest of the audience. All of this seems to coalesce around a sense of inflexibility often found with ASD, as they are very rigid in their approach to life and have difficulty accepting changes in schedule, preferring a very structured and predictable day. Unexpected surprises can be quite disconcerting; it often proves very challenging for persons with ASD to approach their life in a flexible fashion. Thus, moments of turmoil are frequent as the normal fluctuations of life intrude on a desire for a clearly defined and predictable progression through ones’ day. Anxiety is the most common expression of these struggles, but some individuals become sufficiently agitated that they resort to more aggressive, acting out behavior.
Sensory Processing Difficulties:
One of the hallmark symptoms of ASD is the presence of difficulty with the processing and toleration of sensory input. This can vary dramatically from person to person, affecting many different senses in many different ways. Some individuals are hypersensitive and thus overreactive to stimulation; others are hyposensitive and are underreactive to sensory stimulation. Other persons vary within those two states. Typically sensory processing difficulties present inconsistently across time, but are fairly persistent over the long-term. There is a tendency for these symptoms to become less intense as individuals age into adolescence, but there tends to be at least some persistent difficulties in these areas as well.
Areas of vulnerability can affect all senses. Thus, difficulties with managing sound can be problematic, with many individuals particularly sensitive to loud noises. Thus, children can be very disconcerted by fire alarms, fireworks and other loud noises; some children have difficulty tolerating parents vacuuming their home. Other children seem to be somewhat unaware of noise and sound. We see individuals with both hyper- and hypo-sensitivity to light as well. Some children will pull down the shades in the room and turn off all the lights as soon as they return home from school. Others seem to have tremendous difficulty tolerating darkness. The most noticeable symptoms are often around difficulties with touch. Many ASD children have difficulty being held, finding being held gently especially uncomfortable. Such youngsters will be difficult to cuddle when they are infants, likely at times interrupting the bonding process between parent and child. This can carry over into other areas of aversion to touch. Many children are bothered by the feel of clothing, including clothing tags and specific fabrics that they find itchy, scratchy or otherwise uncomfortable. Notably, many children with ASD will respond better to very strong pressure touch, preferring to be squeezed tightly rather than to be held gently. Problems with food texture are quite common as well, with particular difficulty often in tolerating mushier foods, but other issues such as crunchiness can be problematic. Many children also show what are called vestibular difficulties, essentially needing to engage in atypical movements. Thus, we see individuals who will rock repeatedly and sharply, spin, swing, intentionally run into walls, flap their hands oddly, and engage in odd looking clapping behaviors. It is believed that these behaviors help to soothe and calm the sensory processing difficulties that such individuals experience. The problematic element of sensory processing difficulties is that they ultimately create a frequent or chronic sense of internal discomfort, making it very challenging for persons with ASD to “feel comfortable in their own skin.” Instead, frequent feelings of discomfort and anxiety fuel difficulties managing daily events. This preoccupation with internal states again makes it difficult for a person with ASD to focus on others, as their own physiological states dominate their perceptual experience.
Interventions:
There are several forms of interventions that can be helpful to individuals with Autistic Spectrum Disorders, but none would be expected to fully eliminate this condition. These difficulties tend to be chronic and ongoing, but individuals with these struggles can show improvement in a variety of areas of functioning with some assistance.
In terms of social functioning, the intervention most often advocated is that of the training of “pivotal behaviors,” generally defined as a single behavior that it is felt that it would be beneficial in improving an individual’s functioning. For example, a child who has limited ability to form connections could be taught very specifically how to engage in more appropriate eye contact, a common area of vulnerability in a person with ASD. The learning curves for such behaviors are often problematic, however, as the person with ASD will require far more trials than the typical individual to learn new behaviors and often have difficulty understanding when the behavior should be applied. This is described as a problem with generalization of learning, as ASD people, due to inflexibility, have difficulty recognizing that a behavior applicable in one setting is applicable in another. Thus, it is most often recommended that individuals be taught the same behavior across different settings, preferably by different individuals training the behavior. Thus, coordination between school, home and a therapist can be very beneficial in enhancing the generalization of a specific behavior. It is often necessary to work on these behaviors for far more repetitions than one would anticipate based on an individual’s intellectual capacities, as the learning curves are again far more protracted than one would expect. Similarly, very specific coping skills can be taught in that same way. Often, utilizing the individual’s tendency of rigidity to one’s advantage in an intervention proves helpful. Thus, teaching very specific protocol of behaviors in response to upset could be worthwhile. For example, a child prone to escalations into panic could be taught to first identify the internal, physiological states associated with anxiety, and then immediately initiate specific behaviors to reduce that anxiety, such as routinized deep breathing exercises. Again, the learning curves of these coping behaviors can be quite lengthy as well, but once more improvements can be gained.
Cognitive rigidity can be addressed in a similar fashion, but again this is often very challenging. Specifically for focusing on behaviors that create difficulties for a child can be worthwhile, however. Thus, a child who obsessionally focuses on single topic, to the consternation of the persons around them, can be taught to set limits on the amount of time they spend talking about the subject day-to-day. Fostering greater awareness of when those behaviors are engaged in can be helpful in reducing those trends as well. Once more, however, this will likely need to be done over an extended period of time in order for significant impact to be found.
Sensory processing difficulties can often be worked on with the assistance of an Occupational Therapist. There are a variety of sensory interventions used to assist persons with sensory processing difficulties, many related to vestibular soothing or tactile issues. Thus, use of weighted blankets or vests to increase a sense of pressure, brushing techniques and a variety of movement-based interventions are all used. Again, many of these interventions can be helpful in reducing the person’s sense of discomfort, allowing them to more consistently focus on others and/or the tasks before them.
Again, the variability in the intensity of these symptoms is tremendous. Many very high functioning, successful people are diagnosed with ASD, but there are typically some lingering issues related to this diagnosis that are lifelong. The best recommendation that this psychologist can offer is that when working with someone with ASD one should “play to his strengths.” Thus, finding areas of competence and happiness that can be a focus of structure in a person’s life is often the most useful approach. ASD individuals are far more content when they find a comfortable niche in which they can comfortably express their true interest. Often such an activity fosters a greater sense of contentment, and is where their relationships are found.
Understanding Autistic Spectrum Disorders
