50 shades of grey: Parenting is not all black & white
One of my bug-bears regarding mainstream advice for parents is the extreme focus on “Dos and Don’ts”. Having been asked to write a few articles for mainstream media, I often sigh when I am asked to produce a list of my top ‘dos and don’ts of parenting’.
Incidentally, it would be the following:
- Use sunscreen on your children
- Vaccinate your children
- Sexually abuse your children
- Physically abuse your children
- Emotionally abuse your children
- Physically or emotionally neglect your children
But this isn’t usually what people are after.
I know what people are after: Don’t allow your children on social media/ Don’t allow your children to watch TV/ Don’t tell your daughters that they are beautiful/ Don’t praise your children for being intelligent/ Do praise your children for effort/ Do encourage exercise/ Do read with your children/ Don’t push your children to achieve/ Do push your children to achieve.
The advice may be catchy and ‘sound’ sensible and I could even throw in a few science sounding sound bites to support my case, but really – it is meaningless and often based on fluff and anecdote rather than hard science. The reality is that in the words of Ben Goldacre: “I think you’ll find it’s a bit more complicated than that” and like most things, parenting does not exist in the black and white, but 50 shades of grey.
“Black and white thinking” is often an undesirable symptom of conditions such as depression, personality disorder and autism spectrum disorder. In depression for example people can feel that making a small mistake is a disaster because in the binary world of ‘black and white’ or ‘perfection and imperfection’, small mistakes necessitate categorisation in the ‘imperfect’ pile. People with personality disorder may tend to classify people as “good or bad”, those who are good are put on a pedestal, but if they cause even minor offence, they then become enemy number 1 – because there are no in-between options. In autism spectrum disorder, there is much frustration, anger and a sense of injustice with queue-jumpers and rule infringers, because often there is only “right and wrong”. In all cases, black and white thinking is a negative: it does not reflect reality, discourages adaptability and perceptions of nuance and as such causes unnecessary distress.
So why does the media wish to encourage its audience to think in such maladaptive ways? And how can we protect ourselves from binary thinking?
In cognitive behavioural therapy for children with black and white thinking, one of the purposes of therapy is to challenge black and white thinking: to map out every shade of grey and to consider every caveat.
I think we parents could also do with some of this in our lives to stop our own binary thinking regarding how we parent:
Mapping out Shades of Grey:
(If black is no and white is yes)
Does looking like a hot mess mean I am a bad parent? Black
Does having a messy house mean I am a bad parent? Slate
Does doing the school run in my PJs mean I’m a bad parent? Ash
Does shouting at my child in anger mean I am a bad parent? Pigeon
Does physically abusing my child mean I am a bad parent? Snow
If I give my children ready meals am I a bad parent?
- What if it is not every night?
- What if I am a time poor working parent?
- What if I am a time poor single parent?
- What if it allows me to spend more quality time with my child?
- What if it allows me to help my child with their homework?
- What if I have 4 children?
- What if I have a new baby?
- What if it is a hipster vegan and gluten free ready-meal?
I know that binary parenting advice is an easy-to-understand way of delivering information, but I think that it is about time that we trusted the intelligence and judgement of parents a little more. The focus should be on providing good quality information and education and not on sound bites to be dogmatically followed. I hope that my blogs and book reflect this ethos. I don’t want people to ‘do as I do’ or ‘do as I say’ but to reflect on their own parenting and find their own path with a clear understanding of the implications of compromises that we must all make. And to embrace grey in their lives like they would Jamie Dornan if they got the chance…!
Managing your child’s behaviour: Can’t behave, Won’t behave?
Over the last few weeks I have been asked by a few people to write something on managing behaviour of children. This is one of the biggest challenges for parents, and yet I had put off writing about this as it is not as easy to give advice on this as it sounds. The “tips” that friends were asking for basically amount to what we in the industry call “behavioural management”. Ways in which parents can magically “change” or “manage” their children’s behaviour. Sadly, there is no magic tip, only all the things that you have already heard of and tried. Behavioural management tries to spell out what is and is not desirable behaviour and strategies try to tip the balance of choice towards behaviours that are desirable. Well known strategies include “the naughty mat” or “time out”, “ignoring” your child’s mild bad behaviour and also the blessed “reward chart”. If you want to read up on behavioural management an excellent book is “The Incredible Years” by Webster-Stratton. I won’t précis what I feel is a thorough account of good behavioural management, but instead ask:
Does behavioural management work?
The answer in theory is unequivocally “yes”.
But, so often in practice is “no”.
This is because behavioural management is easiest to implement when your child is “typical” and has no other problems, and you (the parent) are brilliant, have no problems and are super consistent in everything you do both with your co-parent and school.
Which basically means “no” or only “a bit”– as when does the above situation ever happen?
Here are two reasons why your child may not be “typical”:
Neurodevelopmental problems, in particular learning difficulty can heavily impact behaviour. In young children, aggression and temper tantrums are typical responses to frustration, but by school age, some control should have been gained over these behaviours. If a child is developmentally delayed, then their ability to behave should be compared to their developmental age rather than chronological age. A 16 year old boy with the developmental level of a 4 year old; can be expected to behave in line with a 4 year old. For a four year old, temper tantrums and hitting out are common responses to frustration, the trouble is that being hit by a 16 year old boy in a temper tantrum has very different consequences to being hit by a 4 year old, and yet, the child “can’t” help responding in this way. These children are often clients in child mental health services as parenting children with severe learning difficulties can be extremely challenging. Other neurodevelopmental disorders also cause behavioural problems. In ADHD children with problems with attention cannot listen to or follow instructions as well as other children. They will tend to act without thinking and may do things that they regret later because they acted without thinking. Children with Autistic Spectrum Disorder may have behavioural problems as they are having difficulty in understanding what is being expected of them and poor social understanding can lead to many more frustrations on a daily basis. Standard behavioural management may not work in these groups of children and behavioural management needs to be adapted to the child’s difficulties. In general it is harder to implement and with more varied results than in children without neurodevelopmental difficulties.
Children who are having emotional problems may have difficulties in behaviour. Emotions and behaviour are inextricably linked. When we feel down or stressed out, our behaviour changes. Some of us reach for chocolate, some for alcohol, some people become withdrawn and unsociable, other people become irritable and angry. It is important to assess emotional aspects of your child’s life if their behaviour changes or deteriorates. Children may not always volunteer their states of mind to you. They may not be able to label their emotions, or to express themselves. They may be afraid to talk about these things. Their unhappiness and frustrations are displayed in their behaviour rather than in words. It is your responsibility as a parent to notice, to ask, to label for them, to give them words, to give them permission to talk about their difficulties. To guess and to investigate from asking teachers and friends if nothing is forthcoming. It may be that they are being bullied at school, it may be that they are picking up on the stress in your marriage, it may be something trivial, but if you don’t notice/ enquire, you won’t know and their change in behaviour will just be called “bad behaviour” or “acting out”. In these cases, behavioural management will not work well. Rewards will feel irrelevant, ignoring and punishment will feel like persecution, negative attention will be better than no attention and rejection is a welcome confirmation of their own self-loathing. Finding out what is wrong, offering security will work better here. Unattended emotional problems in children can impact personality and aid development of long-lasting traits that can lead to “bad behaviour” becoming habitual and “part of” a person’s personality that can no longer be easily mended.
In children without these additional problems, the limiting factor to good behaviour is usually the parent not the child.
Lack of sustained motivation:
In the defining clinical trial for children with ADHD where they compared medication to behavioural management (The MTA Study), behavioural management achieved equal outcomes compared to medication. But wait, here the behavioural management programme used highly trained psychologists to work with highly motivated parents and teachers to obtain this outcome. Real-life trials (what we call pragmatic trials) using existing services, which tend not to heavily involve the schools (as the Department of Education is separate from the Department of Health), and non-selected patient groups, that have looked at the efficacy of community parenting and behavioural management programmes have netted unimpressive results. It is not that children’s behaviour cannot be managed; it is that the will of society and parents, is insufficient.
I know this all too well. Big Sis has a weekly spelling test. On the weeks where I have my act together, we sit and learn the words and I test her on the words each day to make sure that at the end of the week, she gets full marks and I reward her for this attainment. This is basically behavioural management in action: co-working towards a set goal that is achievable, achieved and rewarded. This works fantastically well, thumbs up and smiles all around. Once she has done this for a few weeks, I get complacent and I think, well now – maybe I can just give it a skip this week, she and I can both have a relax and we’ll just have a quick look at the words the night before. She gets a couple of mistakes. That’s basically my anecdote for behavioural management. It genuinely works until one day, you can’t be bothered and it all goes a bit wobbly again. The limiting factor is me, not Big Sis.
Wobbles in my behavioural management can also be seen when I am stressed or distracted. One time when I was very stressed waiting for a phone call regarding a job offer; the children were extremely badly behaved – “for no reason”. I was snappy and shouted at them and they just wouldn’t do what they were told – “it was as if they knew exactly when to wind me up”. Eventually, the phone call came, and I had got the job. That afternoon, they were very well behaved. The change had been in me, and their behaviour merely reflected my state and parenting capability, not something innate in them.
Unrealistic parental expectation:
When we talk about “bad behaviour” we all mean different things and we all have different thresholds as to what is meant by “bad”. Some friends and relatives come by our house and make “tutting” sounds when they see our kids glued to the TV, leave the table at meal times on a whim to dance around the kitchen, bonk each other on the head with cushions and generally shout at each other and at us. To me, this is not bad behaviour – this is just life in our household! Equally, I raise a brow when I see children that never say “please” or “thank you” and run away from their parents on the street, while this is not something that bothers them. When parents complain that their children “Will not do as they are told”, the severity of the issue rather depends on what they are being told to do. If they will not do 60 minutes of piano practice every night, that is rather different from refusing to do their homework, or refusing to stop watching TV; and “good” and “bad” behaviour is sooo dependent on what the parental and school expectation is. Often there are cultural and generational expectations of how children should behave. A normal child in a school with high behavioural expectations may be deemed to have “bad behaviour”, a normal child in one culture may be deemed badly behaved in another. The behaviour is relative and in order to assess behaviour properly, it is important to first evaluate that the expectations are reasonable. There is a limit to how much a child can “change” and they will not bother to attempt to change behaviour if they feel that the bar is being set too high.
One of the main saboteurs of a good behavioural management programme is “other people”. The well-intentioned/ or not so well-intentioned other half who disagrees with what you are doing. By not supporting you, they are de facto sabotaging the behavioural management plan because children are such buggers that they can spot disagreement a mile off and work it to their advantage. Much like MPs claiming expenses and benefit fraudsters, they are not averse to trying to get away with as much as they can. Playing one parent off the other must be a favourite game for children. In my opinion parents who want to succeed at behavioural management need to get on board together, or not bother. A similar conundrum exists with the school. If children are told one thing at home and another at school, the “authority” of “the rules” is undermined. It is a good idea when implementing behavioural management to discuss plans with the child’s school so that the same message is delivered to the child.
So in summary, if emotional problems are excluded, behavioural management delivered consistently and well will definitely improve your child’s behaviour, even if they have additional difficulties; but it is by no means a magic wand. It takes hard toil, stamina, guts, persistence and tears, but can reward you with likeable human beings. Isn’t that the essence of parenting?
If you want to know more about behavioural management please buy/ beg/ steal/ borrow: The Incredible Years, by Carolyn Webster-Stratton. This is the programme recommended by my colleague Professor Stephen Scott OBE of the UK’s National Parenting Academy. I have read it cover to cover and it’s good common sense.
Carolyn Webster-Stratton. The Incredible Years. ISBN 978-1-892222-04-06. http://www.incredibleyears.com
The MTA Cooperative Group (1999) A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry. 56:1073-1086
Assess your child’s mental health and other great resources for parents
This week I have been working on a resources page for the site as there are some great, free resources out there that I think are unknown to parents and under-utilised. The resources page will permanently feature on this site now, so please let other people know about it. I hope to continue to populate this resource page with new and wonderful things so do check back occasionally to the resource page.
FREE Child Psychiatry Textbook
Youth in Mind is a great resource from Professor Robert Goodman a fantastic researcher in epidemiology in children’s mental health who has taught and helped me with research in the past. The website is a bit basic, but don’t let this fool you into thinking it is not legitimate; it’s just that high-flying academics have more time for research than prettying-up a website. On the bottom of the home page, you can access a download of Goodman and Scott’s textbook on Child & Adolescent Psychiatry. All psychiatrists read this book for the Membership exams for the Royal College of Psychiatrists so if you digest this book, it is probably as much as most generic psychiatrists know. Unless you are a budding psychiatrist, I am not recommending you read this cover to cover, but if you want an authoritative and comprehensive view of a particular issue, it’s a really useful reference. And FREE. Robert is a truly generous academic and I know that he negotiated with the publishers for this content to be made free particularly for colleagues practicing in the developing countries, but it does mean that this resource is now available for everyone.
Assess you child’s strengths and difficulties
Also from Youth in Mind, you can navigate in your own language to an on-line questionnaire, the Strengths and Difficulties Questionnaire (SDQ) which you can complete on-line for your child. The SDQ is one of the most frequently used screens for mental health problems worldwide and will help highlight your child’s strengths and difficulties in key domains. The web-site will give you specific instructions and will also give you a feedback report about your child’s strengths and difficulties. A teacher version is also available, and the combination of both parent and teacher reports will give a more accurate summary. For teenagers there is also a child self-report version. Of course, no on-line questionnaire can replace a medical assessment if you are worried about your child, but it can prompt you to think about your child broadly and to consider if there are any concerns that warrant further exploration.
Learn how to help a child you work with
For teachers, social workers, youth group leaders and anyone working with children MindED is a great e-learning resource that will undoubtedly help you help the children you are working with. It was set up as a collaboration between the Department of Health and the Royal College of Psychiatrists as well as Paediatrics, so is a good resource.
For Young People
This is a website targeted at young people so that they can get informed about the medications that they may be being prescribed. It is funded by the charity Young Minds and is also very good.
The National Autistic Society Website
Still the go-to site for autism information for parents. There are regional branches of the NAS and they will give you information about resources, services and support groups locally.
What would I do without the brilliant Book People? The majority of presents that we give to other children for their birthdays come from here (Sssshh – they are so cheap – don’t tell). Books make great presents, and the Book People even do cheap but beautiful birthday cards. I hate cheap plastic tat, and so we always give a book as the party-bag present at parties too. At a pound-or-so a book (including greats such as Roald Dahl and Diary of a Wimpy Kid), it beats plastic tat and a glow-stick any day. The full Roald Dahl collection (15 books, potentially a year’s worth of reading) can be purchased for the price of two cinema tickets, and the full set of David Walliams audio-books kept the kids quiet on many a long drive. Great adult and cookery books too!
Why there is no autism epidemic
Strictly speaking, the term “epidemic” should be reserved for infectious diseases. I realise that the term has now bled into everyday language to mean a large rise in prevalence rates for anything (e.g. obesity epidemic), but the original clinical definition was to describe the spread of infectious diseases (e.g. ebola epidemic). I’m a clinical terminology pedant; I lose sleep over people that call a “fascination” an “obsession”, so you can imagine my loathing of the headlines of “autism epidemic” to describe the increased numbers of people being given a diagnosis of autism. The reported autism prevalence rates have increased from around 1/100 to 1/68 (that’s about one child in every 2 state school classrooms). However, even if the lay terminology is accepted, the rise in numbers of people diagnosed with autism has more to do with changing diagnostic classifications and awareness than an environmental hazard that shock-headlines would like us to anticipate. There are many press and internet articles that discuss this, but I didn’t feel that they fully explored the territory, so here is a researcher and clinician’s view of the reasons for increased rates of autism.
Why do boundaries in classification change?
Autism is primarily a genetic disorder and the genetic basis of autism is pretty much undisputed now. Although environmental hazards may play a role, these are generally on the basis of a pre-existing genetic vulnerability. There are several known genetic disorders already identified that highly predispose to autism (e.g. Fragile X, tuberous sclerosis, neurofibromatosis), but these disorders account for only a small proportion of the total incidence of autism. The bulk of people with autism have what is called “idiopathic autism” the genes for which have yet to be identified (although several genes are suspected and are undergoing rigorous going over by scientists, none have been conclusively proved).
The identification of genes for autism is a tricky problem, as it is not a single gene that is wonky in autism. If it were, then it would have been identified long ago, like other single gene defects (cystic fibrosis, tuberous sclerosis) and we would be able to test for it readily with a genetic test. It is likely that there are multiple genes, say 6 (this is an educated guess), that are all required in order to generate the disorder. These genes are common, and both you and I are probably carrying several of these genes right now and have already handed them over to our children. Like in the National Lottery though, it is quite common for individuals to have a few of the numbers that come up, but it is much rarer to have all 6 numbers together. In the case of autism, only the people with all 6 genes get autism. Also like in the National Lottery where 5 numbers will get a small pay-out, people with 5 genes may get a watered down version of autism.
Scientists have been using all the tricks available to them to try and elucidate the precise gene combination. A few years ago, the computer capability to do Genome Wide Association Studies (GWAS) (where you sequence the entire genome of subjects with autism and the entire genome of subjects without autism, bung the lot in a very big computer and get it to output the combinations of genes that are common to people with autism but not present in the people without) was supposed to lead to a major breakthrough in autism research. It didn’t. The reason being that as all scientists know; if you put sh*t data in, you get sh*t data out. The conclusion amongst researchers was this: the people that we are defining as “autistic” and “not autistic” are wrong. If there are non-autistic people in the “autistic” group; or more likely, autistic people in the “not autistic group”, this will mess up the results.
How are we currently diagnosing autism and is it correct?
The current classification manuals for diagnosing autism (and other mental health problems) are the DSM (used in the USA) and ICD (used in Europe) manuals. My husband has a similar book for “diagnosing” if a mushroom that he finds on the heath is poisonous or not. There is no blood test or scan, only the basic science of observation and interrogation. You might, (and some do) dispute the validity of such classification manuals, but it has thus far served my husband, who has a penchant for putting foraged fungi into his mouth, well (i.e. he has correctly been able to avoid the death cap by consulting his book). A hundred or so years ago, manuals like these were used to diagnose everything from brain tumour to Down’s syndrome (doctors of old diagnosed brain tumours from symptom check-lists including things such as headaches and vision problems, and having round faces and “Mongolian eyes” suggested Down’s syndrome). By fine tuning the classification and studying the people identified, it has become possible to find causes and cures. If classification had not initially taken place, cures would not have been found. This is where we are currently at with autism, fine-tuning the classifications based on new research findings, the precursor to elucidating cause and generating treatments and cures.
The by-product of fine-tuning the classification manuals is a change in disorder prevalence rates. Old classification manuals stated that all children with autism had a learning difficulty, this was found not to be true and newer classifications reflect this. Older classifications state that autism is largely a disorder that only affects boys; newer classifications describe what symptoms may look like in girls. In previous classification manuals, it was stated that if a child had ADHD, they could not have autism, this is now known not to be the case and indeed 30%-50% or so of children with autism have ADHD. New classifications allow this diagnosis to be made. Thus, over the years, with increased research pointing to a wider distribution of the core symptoms of what “we” scientists and clinicians see as autism, and with each revision of the classification manuals, the description of “an autistic child/ person” has changed vastly. An intelligent, inattentive girl with core features of autism, diagnosed with autism today would not have received a diagnosis even 50 years ago, and I am pretty sure that our current classification will not be the last revision.
Some might call this changing boundary of diagnosis pharma and clinical collusion to “medicalise natural variation”; but as I mentioned previously, I prefer to see it as a scientific journey we are halfway/ dare-I-even-believe three quarters of the way through, towards an understanding of aetiology and generation of treatment and cure. Who knows, when aetiology is found, the boundaries may yet shrink back.
The conclusion to the journey may not be far off. Whilst geneticists are relying on better patient classifications to do genetic studies on, neurophysicists are relying on better patient classifications to do neuroimaging and functional neuroimaging studies on. We are already almost at the stage where a computer can accurately predict if a person has autism or not based on their brain scan (Ecker 2010). It may be within my life-time (my grandpa lived to 104 years so I have an optimistic life-expectancy) that the diagnostic classification manuals can be ditched for a brain scan or set of genetic tests; just as has already happened in the case of brain tumour or Down’s syndrome.
Raising awareness of health conditions is a great thing. Many people have benefitted from the increased awareness of autism over the last 10 – 20 years. Autism is a condition that babies are born with and that they will grow and live with life-long. There is no current treatment for the core symptoms, let alone a cure, but the correct support for the child, family and school, can have a significant impact on outcomes. Improving awareness encourages people to come forward for assessment and diagnosis and access support; improving awareness leads to requests for more and better services; improving awareness leads to higher profile and political will to spend on autism; improving awareness leads to better acceptance and understanding of people with autism. I can say nothing but good things about raising the profile and awareness of autism. In 1988 when Rainman was first released, I had never heard of autism. I think if a film about autism was released now, the majority of people would have heard of the condition. Without a doubt, the number of families seeking autism assessments for their children has increased, and this can only mean increases in diagnostic rates.
An epiphenomenon to improving awareness that has also contributed to increased prevalence rates is due to what can be discretely called “diagnostic inflation”; or what can be better understood as “overdiagnosis” or “misdiagnosis”. It is an unpopular but real notion. It is one thing to “raise awareness” of autism, but it is another to educate about autism. I think if I surveyed a group of 100 parents, they would all have heard of autism but I think that only a handful of the 100 parents surveyed would be able to give a passable definition of the core symptoms of autism.
Why stop at parents? Teachers, GPs, paediatricians, child psychologists and child psychiatrists, especially those that trained ten or twenty years ago when autism was relatively unknown and unsexy may not be up-to-date on autism and certainly many fewer will have completed and maintained specialist training on autism diagnosis. Couple this with the improved awareness from parents of the diagnosis and the political will to allow access to substantial resources (welfare and educational) only for a diagnosis of autism and you have a system that will favour increased diagnosis.
I think that now that the job on awareness has been done, we need to work harder on the education front.
Has there been any real increase in autism at all?
This was the topic of discussion at the last Royal College of Psychiatry conference I went to. The consensus was that there was, but that this real increase was much less dramatic than the increase accounted for by classification changes and increased awareness. Many studies have focused on insults in pregnancy and environmental toxins. The research on these has yielded minor or inconsistent results, certainly nothing that alone would account for the real rise seen. The only factor that was given significant credibility was that of the increased age of the mother AND FATHER of autistic children.
Whilst awareness of the effects of maternal age on children’s outcome has been well-publicised (increased risk of Down’s syndrome as one well-known example), the risks of older dads has been less so. Yet, paternal age has long been established as a risk factor for schizophrenia (Malaspina 2001), and there is now emerging evidence for association of paternal as well as maternal age with autism (Reichenberg 2006; Durkin 2008; Sandin 2012).
It is ironic that many people sought to blame a vaccine for increasing levels of autism, in some instances sparking fears of a real epidemic (of measles), when in fact, like so many other health problems, the cause may prove to be within our own life-styles.
Ecker C, Marquand A, Mourão-Miranda J, Johnston P, Daly EM, Brammer MJ, Maltezos S, Murphy CM, Robertson D, Williams SC, Murphy DG. (2010 ) Describing the brain in autism in five dimensions–magnetic resonance imaging-assisted diagnosis of autism spectrum disorder using a multiparameter classification approach. Journal of Neuroscience. 11;30(32):10612-23.
Malaspina D, Harlap S, Fennig S, Heiman D, Nahon D, Feldman D, Susser ES. (2001) Advancing paternal age and the risk of schizophrenia. Archives of General Psychiatry, 58(4):361-7.
Reichenberg A, Gross R, Weiser M, Bresnahan M, Silverman J, Harlap S, Rabinowitz J, Shulman C, Malaspina D, Lubin G, Knobler HY, Davidson M, Susser E. (2006) Advancing paternal age and autism. Archives of General Psychiatry. 63(9):1026-32.
Sandin S, Hultman CM, Kolevzon A, Gross R, MacCabe JH, Reichenberg A. (2012) Advancing maternal age is associated with increasing risk for autism: a review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry. 51(5):477-486.
Durkin MS, Maenner MJ, Newschaffer CJ, Lee LC, Cunniff CM, Daniels JL, Kirby RS, Leavitt L, Miller L, Zahorodny W, Schieve LA. (2008) Advanced parental age and the risk of autism spectrum disorder. American Journal of Epidemiology. 168(11):1268-76.
Social hierarchy in 4 year olds
This is part of the infant 360 degree appraisal series on social ability. This post follows on from previous posts on basic,and higher level social ability and will give you information about social hierarchy in 4 year olds. I am not an expert in social anthropology and so the following is just a précis of my own observations using my knowledge of human behaviour and social science that are part and parcel of psychological and psychiatric training.
One of the best places I have found to observe social skill in my children is at a kid’s birthday party, particularly at age 4 years where the tendency is to invite the whole class. Unlike a classroom environment where structure is ever present, and authority stems from the teacher, a birthday party is like the school playground where it is a social free-for-all. In any school assessment we professionals conduct, we always observe the child in the playground as well as in the classroom because, here, and only here, children are left to fend for themselves without adult intervention, it is quite literally a different world.
For a child, the birthday party scenario is one of the most challenging of their social skill. Hell, even as an adult, who does not occasionally quiver in fear at the prospect of having to make small talk with numerable new people at a work do or colleague’s birthday party? Observing how your child copes with this situation is a real test of their social skill in the most difficult of social situations. I had stumbled on this quite by chance by attending numerous kids’ parties, but then my instincts were ratified when I found out that Professor Dale Hay, Professor of Psychology at Cardiff University uses the “Birthday Party Scenario” to assess social skills in children. Her team at the Cardiff Child Development Study, have been hosting mock children’s birthday parties on a weekly basis in their department for the last 7 years. A PhD student is even tasked with appearing at the end of each party in a bear costume! Fab!
Here, not only is it possible to observe your child’s social skill, but also their pecking order in the social hierarchy. Yes, just like in the jungle where our primate relations fight it out to be alpha-male and high-ranking female, so all human societies have a social hierarchy, even amongst 4 year olds. At the top end of the social ability spectrum, the highly socially skilled children battle it out for top-dog status. I was first alerted to this by Big Sis’s nursery teacher. One day, she told me that Big Sis had a bad day at school because “there are some girls in the class with strong personalities and they are clashing for dominance”. It didn’t take me long to figure out that Big Sis was one of the said girls and I made a passing comment about monkeys fighting it out to be alpha-male. I was quite used to the concept of social hierarchy in teenagers and adults. The whole genre of teenage movies from “Pretty in Pink” to “Mean girls” and “High School Musical” are based on the well-established angsts of social hierarchy – but really – does it start in nursery and reception?
The sad answer is “Yes”. After frequenting many of these birthday parties and taking the obligatory shot of the birthday girl/ boy blowing out the candles of their cake, I noticed that in every single picture, the same few children, Big Sis included, were at the birthday child’s side. This happened even when the birthday child was not a particular friend of Big Sis. I began to observe a pattern of “top table children” at birthday parties where the same children would be seated around the birthday child, regardless of whose birthday it was. I developed a theory of social hierarchy being played out in the seating of children at birthday parties. I began to watch these top-table children, and they seem to be extremely socially aware of what is going on. For instance, they anticipate exactly when the call to be seated for food will go out, and where the birthday child is likely to sit (usually somewhere in the middle or at the top end depending on table layout). They then seek to position themselves at the prestigious seats which are those with closest proximity to the birthday child.
Big Sis and her friends were experts at this, but one incident stands out. Big Sis broke her leg and was required to use a zimmer frame to hop around. At a friend’s birthday party, at the all-important call to be seated, there was the usual rush amongst children to sit in proximity to the birthday boy. The table was laid in one long line, and the birthday boy moved to seat himself in the middle. I was observing Big Sis. She saw that all the children ran to seat themselves directly next to the birthday boy and there was a tussle amongst “high-ranking” children here to gain the prestigious seats. She was first to see that the seat opposite the birthday boy, of equal prestige was free and hobbled as quickly as she could on her zimmer frame down to get to the other side. Although she was clearly first off the mark, her able bodied “high-ranking” friends who had missed out on the prime seats next to the birthday boy, had now seen the free seats opposite as she had, and they raced passed her to claim the seats. I had to laugh at this as it proved my theory about birthday seating hierarchy correct. Much to my amazement, when Big Sis got to the seats she had wanted, which were now occupied by her popular friends, she started asking them if she could sit there. Clearly no alpha-child was going to give up their seat, but good-on-her for trying! I felt sorry for Big Sis, as she would certainly have got there first had she not had a broken leg, so in this instance I intervened and I pulled up a chair so she could sit there with her friends. They were happy to make space for her, but I am pretty sure that they may not have done this for all children; girls, even age 4 years are quite good at social exclusion.
In complete contrast, Lil Bro appears devoid of this social antenna. He will without fail ask to go to the toilet just before the call to be seated for food at birthday parties, such that we will emerge from the toilets and he will be sat at the last available seat a mile-away from the birthday child, even if the child is a good friend. Even when he is there, he will stand rooted to the spot until all the other children have sat down before finding the last available seat that nobody else wanted. He appears oblivious to social hierarchy and would even risk being isolated to the cold corner seats at his own sister’s party if I did not reserve a seat for him at his sister’s side. The good thing is that it neither concerns him nor bothers him. I have to admit that occasionally it bothers ME, only because I aspire for him to be super sociable and popular, but then I just have to slap myself in the face, recognise that his needs are different from my wants, see with my own eyes that he is happy and confident and let him BE. Imperviousness to social pressure is also a great strength in itself!
Clearly I have never told my children where to sit at birthday parties, and I doubt anyone ever has, so it is interesting for me to observe the presence and absence of these social instincts in such young children. This ability, termed social osmosis (i.e. picking up knowledge from social experience rather than actively being taught) is thought to be lacking in children with autistic spectrum disorder. Those with excellent social osmosis and social ability are able to climb to the top of the social hierarchy. Their success is not based on physical dominance (aggression), but social dominance – the ability to make friends and influence people. The funny thing is that once you are on the look-out for it, you see examples of hierarchy in 4 year olds all the time.
When I volunteered to go into Big Sis’s class to paint faces, the teacher asked me to choose the first child to have their face painted, and then they were allowed to choose the next child. Whilst painting one girl’s face, her male best friend loitered around saying “please choose me next”. Big Sis had told me that these two classmates were best friends, lived close together and did everything together, so I was not surprised when she smiled, and seemed to agree. Then, out of the blue saunters in “alpha-male”. A bigger, and brighter boy with better social skills. “Please choose me next” he said politely. I smiled, the wicked smile of a child psychiatrist about to test human nature, and asked the fateful question: “So, who do you want to go next?”
The answer is as predictable as it is gut-wrenching , but alpha-male wins every time, and “the boy-next-door” had to wait in line. Social hierarchy in children it seems plays out just as social hierarchy plays out in adults. You only have to observe the parents at children’s birthday parties to see this. But that’s a different story…
How to assess your child’s social ability part 2
This is part of the infant 360 degree appraisal series on social ability. This and the next few posts will give you information about how to assess social ability (from minimal to maximal) in children around the age of 3-5 years old (for short, I will refer to 4 year olds). Later on I will post on how you can help young children to develop their social skills.
Problems with social ability are currently rarely diagnosed in the pre-school period unless problems are severe. This is not because they do not exist but because adults, particularly parents are extremely obliging in making up for their child’s weaknesses, and aren’t aware of their difficulties. Even if a child is gibbering in Alien, you can bet, the parents know exactly what is being communicated and get quite grumpy when you infer that you have not a clue what they are trying to say. Play dates at home supervised by adults will involve parental supervision and intervention to assure that children “play fair”, “don’t leave people out”, “wait their turn”, “be nice”, and critically don’t beat each other into a pulp. If another child is “not nice” to your child, they are not invited back. Not so the school playground where your child will have to communicate with other children who are impatient, do not necessarily care to hear what your child has to say, have little incentive to include your child in games and may beat your child into a pulp if they find them annoying. I don’t care what any school says in their prospectus, teachers cannot be there at all times, and it is much wiser to ensure that your child has the social skills to survive! By educating parents to be more aware of their child’s social skills, weaknesses can be identified earlier, leading to interventions, better support and prevention of more difficult problems developing later on.
When people think about social ability, they tend to first think of the confident thespian, the extrovert lead in the school play. Often these people do have good social skills, but social skills are more than confidence, acting and oration. It is about ability to make lasting friendships, seek help, read emotions, understand social situations, adapt to new social environments and avoid trouble. All the skills required to “get on” with other people, the essence of social ability. If your child was assessed for a private school “assessment” at age 4 years, without a doubt one of the key components that they would have been making a selection on was social ability. A sociable child will get on with other children in the class, be easier to teach, cause less trouble and ultimately, make the school’s life a lot easier! These skills continue to be highly valued throughout life, and there is a reason that even into adulthood, we are asked to demonstrate our “people skills”, “ability to be a team player”, and “communication skills” in any career.
Before talking about how you can improve your child’s social skill, it is a good idea to think about assessing you child’s social skill. It may be that your child is extremely socially able and you have no need to do anything. Lucky you. But how do you judge this? Over the next few posts, I will detail here observations that can be made of social skills from the most basic to the fairly sophisticated levels of social skill.
Basic Social Skills
The most basic social skills are required in an interaction with a familiar adult. Most children aged 4 years should be able to interact easily and readily with a familiar adult. Many children with mild autism (de facto impaired social ability) can pass this level of interaction, as the familiar adult will be primed to be patient, can guess from experience what a child wants, is accepting and willing to invest in understanding the child, and letting them have their own way.
Spending time playing with your child and conversing with them can reveal if there are fundamental difficulties in social interaction. Some readily testable tasks are whether your child turns to face you if you call their name from behind them. Can your child ask you to pass something to them that they need? Can your child look you directly in the face when talking to you/ you are talking to them? Can your child smile at you? Can your child smile at you if you smile at them? Can your child spontaneously wave goodbye to you when you leave, shake their head to mean “no” and nod their head to mean “yes”? Can your child use gestures to show you how to do something (e.g. brush their teeth) without using an actual toothbrush? Can your child recognise facial expressions in picture books and tell you what they mean? Can your child point to show you something and check that you are looking at the right thing? Can your child make up a story? Can your child feed their teddy bears or make their dolls talk to each other? Can your child realise/ understand that other children may have different thoughts and preferences to them? Can your child copy what you do?
Most typically developing children can definitely do all of these things by the age of 4 years. Clinicians are looking for the presence or absence of ability in all the above (and many other things) in a typical autism assessment in 4 year olds with typical development. They may sound like an arbitrary list of things to look out for, but they are amongst the basic building blocks necessary in developing sophisticated social ability.
If you do not have a preference for looking at people’s faces, particularly their eyes, which are usually the most expressive, you will fail to pick up all the social nuances in expression that a person is communicating (see part 1). “You idiot” said with angry eyes will mean something different to “You idiot” accompanied by a glint in the eye. If you are not looking at a person’s face/ eyes, you cannot infer intention and you are liable to misunderstanding. If your child does not naturally pick up common social conventions (smiling at people, nodding and shaking the head, waving) they will have more difficulty understanding what is going on as social conventions are so frequently used in communicating with others instead of speech. Think how awkward you feel when travelling to a foreign country where all the social conventions are different (bowing in the Far East, not using your left hand in India). Your actions may be misinterpreted by others and it will affect how you get on socially. If your child has difficulty understanding that others may have different thoughts, they may not act in consideration of other people. If they cannot understand facial expression, they cannot infer how someone else is feeling and act accordingly. If they cannot ask for something to be passed to them, they may have difficulty communicating their other needs in an appropriate way. If they do not naturally copy you and what you are doing, they are missing out on the most frequent method children naturally have to acquire social skill, by emulating their parents and other adults around them.
If your 4 year old child is struggling with all/ most of the above, it would be worth considering the 4 main possible reasons that a child psychiatrist would consider: hearing impairment, speech and language problems, learning difficulty and autistic spectrum disorder.
Intermediate social skill
Interacting with an unfamiliar adult takes more social skill than interacting with a familiar adult as an unfamiliar/ less familiar adult will not know or understand the idiosyncrasies of a child’s communication. For instance, when Big Sis was two, she loved to watch a music DVD called “Fun song factory” (which incidentally starred a pre-fame member of JLS). She was at the time unable to enunciate “Fun song factory”, but called it “Bun song Bactery”, or just “Bactery”. One time, when my mother was looking after her, she repeatedly stated that she wanted “Bactery”. My mother was at a loss at what she was talking about and it led to a lot of frustration on both sides. Indeed, my mother strangely concluded that she was talking about the “lavatory” (rather advanced vocabulary for this age group) and whisked her nappy off and plonked her on the lav. Needless to say, Big Sis was not amused. Eventually, my mother called me and I immediately knew what she wanted. Thus interaction with an unfamiliar/ less familiar adult pushes the need for better communication skills to avoid frustration.
In clinical practice, we often see parents that are so good at compensating for their children’s weaknesses that they cannot see that their children have pretty severe impairment. They get very upset when teachers report difficulties at school and blame the teachers, but the reality is that the level of ability required to interact with an unfamiliar adult is more challenging than interacting with a familiar one. If your child has consistent difficulties interacting with a kind and supportive teacher, the chances are, they will have difficulties interacting with many other people and are likely to have weaknesses in social ability.
Interaction with unfamiliar adults can be observed easily. Leave your children with a trustworthy friend whom they do not know well and see how they behave. How well your child is able to communicate what they want can be observed (child psychiatrists and psychologists would do this crammed behind the one-way mirror in our clinics, but you can do this by poking your head quietly into the room or hiding behind a door left slightly ajar) and you can extrapolate their behaviour in this situation to their likely interaction with their new teacher (an unfamiliar adult). If you want to challenge your child’s social skill a bit more, you can ask the adult to occasionally disagree with the child, or to deliberately thwart them (e.g. accidentally knock down the tower they were building), or try to contribute a different idea to the game they are playing and see how your child responds. If this is all a bit too Cold War, just ask your new babysitter how they got on and garner as much intel from this as you can.
In addition to communicating needs and wants, in this scenario, a socially able child would understand that they will need to behave better than they do with a parent or a familiar adult, this is called “social inhibition”. Even if your children are naturally boisterous and cheeky to you or their grandparents, they should be inhibited by someone they know less well. This natural recognition of social context, the awareness that something is different about this social environment and the appropriate way to respond is part of a child’s natural social ability (whether they are able to sustain behaviour is a different matter). Most children are able to behave well and interact with an unfamiliar adult even at age 4 years for a short time at least, which is why even hyperactive children can behave well when they visit the doctor’s clinic much to the chagrin of their parents who have spent the entire time talking about the child’s inability to sit still. More worrying is the child that is over-familiar with strangers, and goes straight up to cuddle and sit on the lap of a stranger, not only as this has implications for vulnerability to abuse, but as here it is clear that they are unable to pick up the difference in social environment and expectation naturally.
The types of difficulties in social interaction which we professionals would be looking out for fall broadly into the following categories:
1) Aloof – a child with no interest in social interaction. They neither initiate social interaction nor engage in interaction when it is initiated by others.
2) Passive – a child who will engage in some social interaction, but will not initiate it.
3) Active but odd – a child who both initiates and engages in social interaction but does it in an odd or inappropriate way (such as the disinhibited, over-familiar manner described above).
A caveat to this interaction as a means of assessing social skill is the confounding factor of anxiety and security. I will discuss these issues at greater length in another post, but needless to say that if your child has difficulty separating from you or is anxious in new situations and with new people, you will not be able to get a clear picture of their social ability using this type of observation.
Brownie points if your children are well behaved, appropriate, polite and obliging with an unfamiliar adult. Extra, extra brownie points if they are also engaging, interactive and interested. They will have no problems with interacting and communicating with their teachers and in the structured environment of the classroom. However, it is easier for children to interact with adults. Many children with autism are able to interact with adults. This is as adults are generally nice to children and will make allowances for children, will have the ability to guess what a child wants, give in to what a child wants and are generally predictable and sensible. Higher levels of social ability are required in interacting with other children; the basis of next week’s post.
Assess your child’s social ability
I am posting again on my infant 360 degree appraisal series. Moving on from core abilities, I will now focus on social ability.
Social ability is probably as important, if not more so than cognitive ability. There are plenty of people with excellent cognitive ability who somehow don’t succeed as well as they might because they find being with other people difficult (or others find difficulty in being around them), and we all know people who are not the brightest spark, but get very far being affable, cheeky and great fun to be around. The funny thing is that although maths and English are actively taught at school, social ability is not a taught course. Children must somehow divine social understanding from what they observe or experience going on around them. Luckily for most of us, evolution has imparted us with specific hardware within our brains to assimilate and use such information about our social world. Not so lucky for children where this hardware is impaired (e.g. in autism).
Babies will typically smile at around 6 weeks of age. Isn’t it strange that this relatively useless developmental milestone is acquired so early? Not really, when you think about the evolutionary advantages gained by a smiling baby. If you are running from a flood, would you be more or less likely to take your baby with you if it was always smiling adoringly at you? Yes their smiles are evolutionarily engineered to aid their survival, we parents are such suckers.
Another early developmental marker of social ability is a preference to look at faces, and in particular eyes. The centre of human communication is a person’s face. This is the input and output zone for verbal communication and where non-verbal communication is the most expressive. Most adults can tell what another adult is thinking by looking at their face even if they are not saying anything. Even when the person is saying something, the face can convey a different message. There are lots of emails that I have received where I have been unsure about the meaning (joke- or not joke?) because I have been unable to judge the face/ tone of voice with which the email has been written, which exemplifies the importance of non-verbal communication. So common is this problem and so useful is the face, that we now commonly use a face picture in our emails to depict the meaning of emails that we send! Typically developing babies and children are born with in-built ability to hone their attention to people and faces because they know this is where the bulk of social context is going to be gained (Chawarska 2013). No one teaches a baby to do this, you either have it, or you don’t. Early on as a parent, you can check your baby’s social ability hardware by checking whether he/she prefers to look at your face/ eyes and if their eyes follow you Mona-Lisa like around the room.
Babies and young children are primed to attend to their parents’ every action and imitation is present from a very young age. If you make faces at a young baby, chances are, at some stage you will see the baby trying to move his/her face to copy your expression. There are hours of fun to be had doing this. This is early social learning. Later on, they will imitate the vocal sounds that you make, the embryonic stages of speech development, another critical branch of social development.
Babies and young children are also primed to attend to their parents’ emotions, particularly of fear. I acutely remember breast feeding Big Sis while watching a horror movie late one night. At one point, I held my breath in anticipation of something horrible happening on screen. It would have been imperceptible to most people as I did not move or make a sound, and yet, Big Sis stopped suckling, tensed and looked at me. It’s no coincidence that if you start having an argument with your baby in the room, they start crying.
Humans are social beings, they live in communities and societies, they typically like to socially interact. Early social interaction and turn-taking can be assessed by playing with your baby. The typical Peek-a-Boo game (hide your face, then show your face making your baby laugh) popular to all parents and babies is part of the Autism Diagnostic Observation Schedule (ADOS). It is an early indicator of ability to turn-take, an understanding of social reciprocity, of an interaction between two people, a precursor to to-and-fro conversation, to give-and-take in a relationship.
If you are an autism specialist, a first birthday cannot pass without performing a simplified version of the “baby’s birthday party” test from the ADOS. This test is where you set up a dolly’s tea party and play. Many typically developing children are able to give a baby doll a pretend drink from a toy tea cup at the age of 1 year, particularly if they see their parent doing it. If your child is not doing this, don’t worry, many typically developing children acquire this ability to pretend later on, but if they are doing it at age 1 year, as my children were, then it is a sigh of relief that one aspect of their social ability mechanism (pretend play) is functioning.
These building blocks to social ability develop at varying times during infancy in different children, but should be in place by the time of school start. The Autism Diagnostic Observation Schedule has recently been revised to include a Toddler module as it is now recognised that traits are observable at this young age, and in an attempt by professionals to gain early diagnosis to allow children and their families help from as early a stage as possible. It is really helpful to have an early heads-up on potential social problems because school is like the “Hell’s Kitchen” of social ability. Children can get away with pretty poor social skills at home with their parents and adult company, because contrary to popular belief, most adults are nice to children. Children, on the other hand take no prisoners – and going into reception with immature or absent social understanding and ability is truly hard.
When you throw a bunch of children together, that’s when things get really interesting and I will write about this in my next blog on this topic.
Chawarska et al. 2013. Decreased spontaneous attention to social scenes in 6-month-old infants later diagnosed with autism spectrum disorders. Biological Psychiatry, 74, 195-203.
 The Autism Diagnostic Observation Schedule (ADOS) is one of the gold standard diagnostic tools for assessing Autistic Spectrum Disorder. Children and adults with autistic spectrum disorder have deficits in social interaction and communication (as well as repetitive behaviours and restricted interests). The schedule involves games and set conversations to be enacted with the child or adult to press for social interaction and exchange. It is designed so that the assessor initially allows the child to display their natural social ability, but then allows the assessor to give staged prompts to get the best ability out of a child if it is not naturally forthcoming. Scores are given for deficits in social interaction and communication, and autistic spectrum disorder is suspected once a threshold is crossed. Most typically developing children and adults, even the very socially able, will score something on the ADOS, and it would be highly unlikely for someone to score 0, so just because your child has some deficits, it does not mean that they are autistic or on the autistic spectrum. Despite tools such as the ADOS and the Autism Diagnostic Interview (ADI), Autistic Spectrum Disorder diagnosis remains a specialist clinical judgement.
Autism and Empathy
What is autism?
When I give people the formal definition of autism, I see their eyes glaze over as it is rather long winded and meaningless to those who know little about autism. So I’m not going to talk about autism diagnosis, which is somewhat complex, but one aspect of autism: empathy.
Many people equate “lack of empathy” with autism, so much so that whenever someone has been inconsiderate, others may joke that they were “being a bit autistic”. Say this around me and I get really annoyed as autism is more than lack of empathy and most inconsiderate people are not autistic. Autistic empathy problems are fairly specific. Hurting other people without remorse is generally considered as “lacking empathy”, although shrinks prefer to use the term “callous and unemotional” as it does not ascribe a cause to the behaviour. This is important as there can be many different causes to this type of behaviour. I will give you 3 adapted real life examples of callous behaviour involving the death of an animal to see whether you can identify the one most likely to be a case of autism.
(a) A 5 year old boy was playing with his pet hamster. The hamster bit him as he was a bit rough. The boy got his baseball bat out and bludgeoned the hamster to death. In explanation of what had happened, he showed no remorse and said “It bit me on purpose, so it deserved to die”.
(b) A 10 year old boy was playing golf. He was very good at golf. A squirrel appeared in his line of sight, and he had the question as to whether his driving accuracy was good enough to hit the squirrel. He hit the squirrel with the golf ball striking the squirrel hard and killing it. In explanation of what happened, he showed no remorse saying “My aim is very good”.
(c) Two 8 year old boys were pulling at a cat’s tail to hear it hiss which they found funny. They tied string to its tail and used that to pull it around. Then they thought it would be funny to set the string alight, which then set the cat alight. In explanation of what happened, they showed no remorse saying “We don’t know what happened to the cat; it had nothing to do with us”.
In Big Sis’s Oxford School Dictionary (apologies, this is sadly the only dictionary our household possesses), empathy is described as “Noun. The ability to understand and share in someone else’s feelings”. In order to empathise, you require the ability to do the following:
1) Be aware that other beings (animals or humans) have independent thought, action and feeling; this is sometimes called having a ‘theory of mind’.
2) Be able to experience and recognize your own emotions and feelings and the situations in which different emotions arise.
3) Be able to imagine that others may have the same feelings, emotions and thoughts that you experience if they were in similar situations.
Autistic “lack of empathy” relates to inability or difficulty with the fundamental step, step 1, which impacts ability to completely master steps 2 and 3. This “step 1” ability is something that you either have, or don’t have. It relates to abnormal brain wiring which goes awry in pregnancy and early infancy. None of us were ever sat down and taught “this is a table: it does not think, act or feel; this is a human, it is able to think, act and feel”, we just realise it ourselves one day, usually in infancy. To an autistic child, something this fundamental is not obvious. A typical complaint from parents of autistic children, and what I imagine would be the most painful as a parent; is that an autistic child may see parents as no different from anyone else, or indeed, any other object. An autistic child may show interest in a parent as a “biscuit dispenser” or “toy-buyer”, but are unlikely ever to have an intimate and confiding relationship with anyone including their parent, due to their inability to recognise other people as thinking, sentient beings. It is hard to comprehend or to believe, but if you are not naturally aware that other people have independent thought or feeling, then the death of a parent would affect you as much as the loss of a toy (provided someone else stepped in to dispense biscuits and buy toys). Classically, without step 1, steps 2 and 3 are impaired. Autistic children find difficulty in describing emotion in themselves as well as others. Some autistic children with good intellect are able to behave empathically. They are able to actively learn that others are thinking sentient beings, and are able to learn what someone would feel and think in a given situation. They learn it in much the same way that we might learn the highway code. It does not come naturally, but we can learn to behave in the way that is required of us. Just as with the highway code learning, actively learnt behaviour can slip in times of tiredness or stress, and is useless in new situations where the rules are unknown.
“Lack of empathy” frequently occurs in children without autism. The work of the clinicians in an autism assessment is to differentiate these children from autistic children.
Children with ADHD, who have a different brain wiring problem have a tendency to impulsivity. They can behave as if they lack empathy as they typically do things without thinking. If someone falls over, it can look very funny. All of us like to laugh when we see people falling over, which is why slapstick comedy is so successful. In real life, most of us would be able to inhibit our impulse to laugh if the person was actually hurt and crying in pain. The ADHD child, cannot inhibit impulses, and therefore will laugh, appearing to “lack empathy”. However, if you question the child afterwards they are able to interpret the situation empathically and realise that they should not have laughed, although they might say “but I couldn’t help it.” Of course some children with ADHD will also have autism spectrum disorder, as one brain wiring problem increases the risk of another.
Other children without brain wiring (neurodevelopmental) problems can develop difficulties with steps 2 and 3. For step 2, I will give two simple examples, but there are likely many permutations for the development of what shrinks call “callous and unemotional” symptoms in the absence of autism. Firstly, Children who are emotionally neglected and not stimulated to interact with others and experience emotion can have difficulty in experiencing and recognising emotions in themselves and others. The classic example of this is from Romanian orphanages. After the fall of the Communist government in Romania in 1989, aid workers found thousands of abandoned children being housed in orphanages in terrible conditions where abuse and neglect were rife. Babies were literally left alone in cots day in and day out with minimal human contact. When discovered, many of these children appeared to be autistic, as they had difficulties with social interaction, communication and empathy. However, the majority of these children, when adopted out to loving families, gradually acquired the ability to empathise and socially interact normally. Their early childhood experiences of neglect had impaired their ability to experience emotion amongst other things, and therefore they had difficulty in understanding emotion in themselves and others. Love, not rote learning of rules was able to restore their empathy as the majority did not have brain wiring problems.
Secondly, young children who suffer emotional abuse (which can occur alone or with physical and sexual abuse) or are constantly witness to violence and trauma, may have had no biological difficulty in experiencing emotions, but as their emotions are too hurtful due to the extremely stressful environment, they may employ a defence mechanism of “blocking out” or “numbing”/ “desensitisation” of emotions in order to survive. Channelling “I am a block of wood” is sometimes your only defence in a situation where you are entirely powerless. These children find allowing themselves to experience emotion difficult or impossible, which limits their ability to understand emotion in others, even long after the abuse/ trauma has ended.
These two groups of children may have “attachment disorders”; some may grow up to develop “personality disorders”. Emotional availability of parents and care givers and exposure to violence lie on a continuum, and it is likely that even within the general population, there is variation in how in tune people are with their own emotions and the emotions of others even if they have not been through abuse and trauma.
There are children who have no difficulty with step 1 and 2, but have problems with step 3. They understand that people have emotions and they experience their own emotions. However, their own emotions are so over-encompassing, often due to insecurity; that they are unable to think about or care about the emotions and feelings of others. These children may have suffered abuse or neglect as children and pushing heavily for their own needs and wants has been the only way they have been able to survive. If these children are asked about emotions, they are able to describe them well. They are able to demonstrate theory of mind in non-emotive tasks and may even, in a hypothetical scenario that does not involve them, have no difficulty in seeing both points of view. However, when the scenario is switched to involve them, their thinking becomes self-focused and there is no room to think about other people’s feelings. Their own feelings are always prioritised over that of others. These children may be thought of as “narcissistic” and may grow up to have personality difficulties.
Finally, there are children who have no problem with empathy but choose to behave in a hurtful way to other people for their own reasons; they gain pleasure from being in power and deliberately causing pain, to gain membership to a culture or subculture, to extort money, to gain respect or retribution to name a few.
Hopefully, by now, you may have a better chance of determining which of our “animal killers” is the most likely to have an autistic spectrum disorder. Scroll down, to see if you are right.
Case (a) by ascribing intent to the hamster is in possession of basic theory of mind (a more clearly autistic response in this situation would have been to say “The hamster was hurting me so I stopped it from hurting me”); in this case additional examples of behaviour would need to be examined to argue a case one way or another. Case (b) has autism. There is clearly no theory of mind going on here, the squirrel was a mere target for target practice and may as well have been an inanimate object. Case (c) is definitely not autism as cooperating to torture a cat requires social skill between the two boys, unless there is a clear “leader” and “follower”. By attempting to deceive people by denying knowledge of what happened implies quite a sophisticated theory of mind. They would need to realise that you did not know what really happened, and that if they denied knowledge, they may be able to convince you that they were not involved.
Autism has several other criteria (the formal definition of autism being of “a triad of difficulties in social interaction, communication and restricted and repetitive interests”), so you would never make a diagnosis based on something as simplistic as the above. It is however useful to illustrate the importance of detailed information in assessment of every single feature of autism as scenarios which present behaviourally in a very similar way (e.g. killing of an animal) may have very different causes. A typical autism assessment involves information gathered from multiple sources and in depth interview and observation by a multi-disciplinary team.