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.
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.
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.