Autism

Martin L. Kutscher
MDDepartments of Pediatrics and Neurology,
New York Medical College, Valhalla, NY.
Pediatric Neurological Associates, New York and New Jersey
www.PediatricNeurology.Com

Introduction

Great, you figured something out. Congratulations! Now, you may want to share that idea with another human mind. If so, your brain translates the idea into a sequence of words. The words are translated into vibrations that depart from your mouth, sail long distances through the air, and land on my eardrum. These vibrations are turned back into words, and then into meaningful sentences and ideas. My brain also picks up other non-verbal language, such as your facial expression and tone of voice. Meanwhile, I figure out any “hidden agenda” or “subtext” when you said those words. All these elements mix together to come up with an accurate understanding of what your “self” meant to communicate to my “self.”

It’s amazing that this process works at all. It is not really amazing that some people have trouble with some aspect of it. Those people whose primary difficulty is understanding the literal meaning of words are considered to have “traditional” speech and language disabilities. Those people who have difficulty in the non-verbal parts of communication (including their desire and ability to use language in a social context) may be considered to have an Autistic Spectrum Disorder (ASD).

The Skills Involved in Communication

In order for us to effectively communicate, we need skill in multiple areas, including (A) verbal and (B) non-verbal arenas.

(A) Verbal/Spoken Communication Skills (may or may not be affected in ASD)

Semantic language: The ability to use and understand words, phrases and sentences; including abstract concepts and idioms. Aspects of semantic language include:

Receptive verbal language: The ability to understand spoken words and ideas.
Central Auditory Processing (CAP): A mixed group of abilities needed to process and derive meaning from sounds and words; including the abilities to distinguish between similar sounds, and to pick out the main voice from background. In short,“what we do with what we hear.”

Expressive verbal language: The ability to express our ideas with spoken words.

Articulation: The ability to speak each word clearly.
(B) Non-Verbal/Non-Spoken Communication Skills (Problematic in ASD)

Urge to initiate shared social interaction and two-way communication: Theory of Mind.
The ability to socialize/relate/empathize requires a working “Theory of Mind.”

Theory of mind refers to the relatively unique ability of humans to understand:
(1)that I have a mind, (2) that you have a mind; and most importantly, (3) that our minds may not know or be feeling the same things. Without a theory of mind, there is little point in communicating. After all, who would you be communicating to? There is limited ability to truly recognize that there is another human being in the room. It will be difficult to feel the need to communicate with anyone else. It may seem as if there is a plane of glass between the child and others. Eye contact will be poor.

With limited ability to “get inside your mind,” it will be frequently difficult for the child to demonstrate empathy for what you are feeling. For example, a child with theory of mind problems may assume that since he is happy, then you must be happy; or the child may not understand that someone else is deceptive when his own mind always attempts honesty.

Thus, the ability to recognize that you have a mind, the ability to relate to that mind, and the ability to empathize with that mind are all parts of the same skill. It is felt that theory of mind problems underlie many of the difficulties seen in the Autistic Spectrum Disorders.

Closely related to the “interest” in social communication (that arises from a working theory of mind) are the following skills. They are required to actually achieve the meaningful interaction. Certainly, if you don’t have these skills, your ability to appear interested in social interaction may become blunted.

Pragmatic language: The practical ability to use language in a social setting, such as knowing what is appropriate to say, where and when to say it; and the give and take nature of conversation. Effective pragmatics requires a working theory of mind: the ability to figure out what the other person does or does not already know—or might or might not be interested in hearing about.
Examples of pragmatic language/theory of mind problems would be: A new student moves into the school district and enters the classroom for the first time. The teacher asks him where he comes from. The Autistic Spectrum child responds: “From the hallway.”

As an Asperger’s child walks into the office, the doctor notices that her pink shirt matches the color of her jacket. He jokes, “If you change into a green shirt, does the color of the jacket change, too?”

The child responds: “My wardrobe includes a turquoise shirt, not a green one.” This child’s spoken language is precise, but she misses (1) the actual meaning of the question; and more importantly, (2) misses that the whole purpose of this conversation was just a little fun chit-chat to initiate an interaction.

The skill to know what is—and what is not—important
Ability to see the big picture rather than fixate on details.
Ability to maintain a full range of interests.

Symbolic play skills
Give a child a yellow box on wheels, with thin long black strips on it. The ability to understand that this object actually represents a school bus is a type of communication—just like the ability to recognize that the letters “C-A-T” stand for a furry animal. Both involve the use of symbols rather than the actual object to communicate.

By 18 months, most toddlers start to use objects as symbols for something else. For example, a cup is for drinking, but it also makes quite a handy telephone. By 3 years of age, most children are quite good at “let’s pretend” activities, such as “You be the cowboy!” The toy school bus is not fascinating because the cold metal box can move, but because little toy figures chat while getting on it as they go to school. Stuffed animals are not just warm rags of cloth to drag around, but living creatures that have feelings and needs.

So, by 18-36 months of age, typical children make continuous progress in the skill of appreciating the representational meaning of a toy, rather than focusing on its straight forward visual attributes.

Failure to develop representational/symbolic/pretend play is a strong marker of the Autistic Spectrum Disorders. After all, if you cannot understand that a physical toy bus represents a real truck, how could you understand that the even more purely representational sound “bus” represents a real truck.

Non-verbal (non-spoken) transmission of language. The simple sounds are not the only thing my body sends through space when it attempts to communicate with you. It also transmits:
Facial expressions
Body language
Tone and prosidy of voice
Associated skills sometimes also involved with language problems:

o Motor (muscle) coordination, including both gross and fine motor.
o Spatial orientation.
o Overall cognition.