Refining the Spectrum: We Need Better Diagnostic Distinctions for Children with AS
Lonely, isolated, unwanted, mocked, shunned, rejected, denigrated, despised, ostracized, misunderstood and friendless: stringing together so many negative adjectives may seem a little bit exaggerated – but that’s exactly the point I am trying to make. My recent book, Asperger’s Children: Psychodynamics, Aetiology, Diagnosis, and Treatment shows how Asperger’s children have exactly these kinds of negatively ‘exaggerated’ perceptions and feelings. Adjectives like these have been applied to these children many times over the years. This is the way they most frequently describe and experience themselves. Their inner experience of the social world can with few exceptions be summarized in three words – untrustworthy, unjust and unfair.
It is as if they experience everyone as rejecting them and as a result they have to protect themselves against the overwhelming hurts they expect from everyone else. This is frequently to the extent of feeling either “I need to get them before they get me,” or else “I’d better stay away from them in case they try to get me.”
Perhaps a few examples might help to show that my exaggeration is not exaggerated, so let me tell you some of the things I’ve heard from these children over the years. Let’s start with Matt, 12 years of age. When I first met him, he broke into tears because he felt unable to make any friends. No matter how hard he tried, he always felt laughed at or rejected. During one of our sessions, he told me in a shamefaced way about what he called “a hissy fit” he had in his classroom two days previously. There was a substitute teacher, he told me, because the regular teacher was sick. This teacher let all the students draw on the blackboard. Matt waited until he had finished his work, and then went to get a piece of chalk, but there were none left. He went out and got some chalk. There was no room to draw on the blackboard, so he got a chair and found an empty place. Just as he was finally going to get a turn to draw on the blackboard, the teacher said that drawing time had ended. “So unfair” he commented, in the typical way that many Asperger’s children perceive the world. Just as he was trying to master this hurtful unfairness, another student pointed to a “dumb-looking” picture of a person she had drawn on the blackboard. “It’s you, Matt,” she said to him in what he eloquently described as “a whiplash moment.” He told me he had then “blanked out.” He threw his piece of chalk at the girl, threw his glasses at the blackboard and then stomped on them, pulled a desk on top of himself and curled up in a ball crying miserably. The other students crowded around him in a circle mocking him.
Jack, 13 years of age, told me about his experience of being “betrayed” by a female peer who is in one of his classes. He felt he had established a connection with her during a social event for new high school students. A few days later, Jack spoke to her at the beginning of the class but she completely ignored him. Jack felt that this “betrayal” merited revenge, and when I asked what he imagined, he replied “I would burn her alive.” When I then suggested he wanted to get even, Jack laughed at me. He told me he’d give her back a lot more pain than she had caused him, so she could understand his pain.
Just recently, Jack missed one of our weekly sessions. When I called him at home to see if he had been held up, his father told me he had “forgotten” our meeting. When I spoke to him briefly on the telephone, he apologized and agreed we would meet next week. Naturally, when we next met, I tried to explore what had made him miss the previous session. He referred to an incident in which Turkish forces had recently shot down a Russian warplane. Confused, I asked what had made him stay home because of this incident. Speaking to me as if I ought to understand without explanation, he said he thought there would likely be a nuclear conflict as a result of it. He wanted to stay home in case nuclear war broke out! He then seemed to read my mind by repeating my own private thoughts about the “Cuban missile crisis” (which I had lived through at about the same age he was now). This allowed me to tell Jack that I had gone to school the day of the Cuban crisis, but my history teacher said we should talk about the crisis (instead of Roman history) because we might not be here tomorrow! I was able to say to Jack that it sounded like he felt negative or aggressive interactions might escalate uncontrollably and quickly. I suggested he seemed to lack faith in any capacity people might have to talk, negotiate or de-escalate. He quickly agreed.
What Anthony told me at age 31 about his experiences as an adolescent in high school was definitely frightening. He had become sick and tired of being mocked, denigrated, put down and rejected by his fellow students. He decided to take a large hunting knife to school, concealing it under his pants. His plan was to rescue his self-esteem by stabbing the next kid who mocked him, laughed at him or put him down. Mercifully, nobody mocked or teased him that day. If someone had decided to do so, however, Anthony may well have ended up in jail instead of in therapy.
Another young Asperger’s sufferer, Peter, was in grade 4. He told me with great anguish and tears what had happened to him at school. He had left his seat with the idea of helping some of the other students with a math assignment which he had finished quickly and easily. He told me he wanted to make some friends. However, his teacher became quite irate at him leaving his seat and she showed no interest when he told her he was trying to help the other students. “She put me in the quiet room,” he told me tearfully. “They don’t listen to me,” he said with anguish “they just treat me like I’m a nuisance or a noise. Why won’t they listen to me?”
Vignettes like these about Asperger’s children could be multiplied indefinitely. That’s what drew me to these children in the first place – the amount of suffering they endure on a daily basis, and the hope that listening and trying to understand might enable us to alleviate their suffering to some degree.
I agree with Peter: we need to listen to these children. My book, Asperger’s Children: Psychodynamics, Aetiology, Diagnosis, and Treatment, begins by presenting a number of dialogues I was privileged to have with several Asperger’s children. You get to overhear parts of dialogues I had with a number of children and adolescents and even more importantly, how they tried to keep me on track in my understanding of them and what they were experiencing, and how they tried to put me back on track when my attempts to understand went astray.
After presenting these dialogues, I tried to extract what seemed to be the common underlying themes in what they were trying to communicate to me. I then went on to build on these common underlying themes and tried to construct a way of diagnosing these children and ways of approaching them with the best possible way of treating them in mind. I also outline some preliminary ideas about how Asperger’s children start out in infancy and how they become the Asperger’s children we meet in schools and in our therapy offices.
In my experience with these children, they seem to have two main techniques for emotional self-protection, two important ways in which they try to dampen down the pain of how they experience themselves in the world. The technical names for these two techniques are splitting and projective identification into remote objects. Splitting means to separate and keep apart in the way you feel, think and experience different aspects of the self and also different aspects of others. Asperger’s children, as far as I can see, regularly have a bully aspect and a victim aspect. These two aspects are well aware of each other but also struggle and come into conflict with each other, forcing the child to struggle and disagree with himself. In some children, the victim aspect of the split self is in the foreground and the bully aspect remains in the background. What the teacher or the clinician experiences is a child who complains of being teased, rejected, hurt, bullied and so on, but who also surprises the adult by occasional confessions of rather callous and cruel bullying of other children. This is accompanied in almost all Asperger’s children by a kind of self-righteous vindictiveness in which they sometimes feel entitled to take revenge on others because of their experiences of being hurtfully rejected and despised.
“Asperger’s children regularly have a bully aspect and a victim aspect”
The other aspect, projective identification into remote objects, refers to how these children see parts of themselves and of their own inner functioning in other people, political entities, animals, or in mythological and fantastical people and creatures. I call these others “remote” because the Asperger’s child seems to want to keep these aspects remote and distant from the self, to be able to experience these aspects, but in a way that is far away from the self.
Consider an example of this provided by Jack, whom you may remember stayed at home and missed our session together because he felt Turkey shooting down a Russian warplane would inevitably lead to nuclear war. In his mind, Russia was a swaggering and brutal bully and Turkey a faultless victim of Russian aggression – a victim he praised for standing up for itself and refusing to be pushed around, cowed or bullied. He saw Russia as being nothing but a bully and Turkey has nothing but a victim – a form of splitting bully and victim completely apart in a way which is unlikely to correspond with the many shades of gray in reality. Into Russia, Jack projected hostility, superiority, and a desire for omnipotence. Into Turkey he projected a sense of self-righteous resistance to being hurt or abused. Jack frequently described these aspects as being part of his own functioning, without being aware of this, and was able to see them clearly, provided he kept them at a remote distance far away from his own self-perceptions.
In terms of diagnostics, in my book I’m a bit rough with the old DSM (Diagnostic and Statistical Manual of Mental Disorders) though I certainly don’t denigrate it in general – therapists need some kind of common language. The problem is that many people demonstrated that the criteria for Asperger’s disorder in the DSM-IV simply didn’t work. As a result, the diagnosis is completely tossed out in the DSM-5. I feel this is a mistake. From the therapeutic point of view, we need as fine-grained an understanding as possible of Asperger’s and of all the autism spectrum disorders if we are to bring fine-grained and finally tuned treatments to these children.
I suggest there are three main types or subtypes within the diagnosis of Asperger’s. The three subtypes are first, the inhibited/avoidant type – the type of child who shuns relationships with others and often has the appearance of having a sort of secondary autism; second, the inhibited but relationship-seeking and needy type, children who desperately want friendships; and third, the uninhibited and aggressive type, those children who tend to reject others. This last type includes the children that Hans Asperger himself found overrepresented in the prison system. I link these three types to which aspect of the split between victim and bully is most predominant for the child. For inhibited/avoidant Asperger’s children, it is the victim aspect of the split that is in the forefront and is the first to be seen. For uninhibited and aggressive Asperger’s children, the same can be said of the bully part of the split – it is in the forefront and is the first to be seen. The case with inhibited but relationship-seeking and needy Asperger’s children seems to be a bit different. With these children, there seems to be a rapid oscillation between the victim part and the bully part of their split self, making how they act confusing to themselves and to others as well.
This way of diagnosing Asperger’s children also has implications for how to treat them. As to the three types of Asperger’s children I’ve just described, the treatment implication would be that for the inhibited/avoidant type of Asperger’s child, the therapist needs to hold in mind that there is also a bully part working in the background. This bully part will need to be acknowledged and confronted if treatment is going to be successful. The opposite holds true for the uninhibited and aggressive children – there is a victim part of the split which the therapist may need to hold onto for a long period of time. This part will also need eventually to be acknowledged and confronted. With the inhibited but relationship-seeking Asperger’s children, the therapist may need to keep in mind and be able to quickly react to shifts or oscillations in their split self between the victim and the bully parts.
But another facet to my discussion of treatment for Asperger’s children involves the old distinction between a conflict psychology and a deficit psychology. I suggest that a conflict psychology, and the conflicts of Asperger’s children, can be approached with traditional and unmodified interpretive psychoanalytic psychotherapy. The deficits of Asperger’s children, however, are strongly linked to their neurological differences. These deficits require “hands on,” didactic and supportive approaches. The deficits are especially apparent in the areas of understanding the nuances of relationships and using sophisticated social skills. Traditional psychotherapy is helpful here, especially as the relationship between child and therapist develops and unfolds. But interventions such as supporting the functioning of these children in the school system and providing them with social skills training are also needed. An experiment in providing such a full range of treatment to Asperger’s children is outlined in one of the last chapters of the book.
“An experiment in providing such a full range of treatment to Asperger’s children is outlined in one of the last chapters of the book.”
I hope that my book can be useful and enabling. I hope it can be useful in the understanding of Asperger’s children and as a result in helping to reduce their suffering. And I hope it can be enabling in the sense that future therapists might find it helpful as a stepping stone in their own thinking about these children, as well as helpful in their informed emotional experience of being with them.
Robin Holloway provides psychoanalytic psychotherapy to children and adolescents. He is a graduate of CICAPP (the Canadian Institute for Child and Adolescent Psychoanalytic Psychotherapy) where he is a supervisor and a teacher. He worked in a public hospital and participated in weekly diagnostic intake meetings for children with autism spectrum disorders. He is now in private practice at the Willow Centre in Toronto, where, he has continued to treat high-functioning autistic children and those with Asperger’s Disorder. His latest book, Asperger’s Children: Psychodynamics, Aetiology, Diagnosis, and Treatment, is published this week by Karnac.
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