syndrome, because I can pass a simple theory-of-mind test and I have greater cognitive flexibility than a classic Kanner autistic. All of my thinking is still in visual images, though it appears that thinking may become less visual as one moves along the continuum away from classic Kanner's syndrome. My sensory oversensitivities are worse than the mild difficulties some Kanner autistics have, but I do not have sensory mixing and jumbling problems. Like most autistics, I don't experience the feelings attached to personal relationships. My visual world is a literal one, though I have made progress by finding visual symbols to carry me beyond the fixed and rigid worlds of other people with classic Kanner autism.
In an article written by Oliver Sacks in The New Yorker, I was quoted as saying, «If I could snap my fingers and be nonautistic, I would not. Autism is part of what I am.» In contrast, Donna Williams says, «Autism is not me. Autism is just an information processing problem that controls who I am.» Who is right? I think we both are, because we are on different parts of the autism spectrum. I would not want to lose my ability to think visually. I have found my place along the great continuum.
Update: Diagnosis and Education
Both parents and teachers make the mistake of thinking a diagnosis of autism, PDD (Pervasive Developmental Disorder), ADHD (Attention Deficit Hyperactivity Disorder), or Asperger's is precise. It is not precise the way a diagnosis for measles or meningitis is precise. It is a behavioral profile and different doctors and psychologists often come up with a different diagnosis because they interpret the child's behavior differently. At the time of writing this update, there is no definitive brain imaging or laboratory test for the diagnosis of autism.
Since Thinking in Pictures was written, the mild Asperger diagnosis is being used more and more. At the many autism conferences that I attend, I am observing more and more very smart children with a diagnosis of Asperger's. Some of these children should be in a gifted and talented class instead of being sent to special education. There are other Asperger's individuals who may need special education in their area of weakness and be in an advanced class in their area of strength. I am worried that students who would be capable of a challenging career in science, engineering, or computers may be shunted into a special education rut. In fairness to special education teachers, it is difficult to work with a spectrum that can range from nonverbal to genius.
Diane Kennedy, author of ADHD Autism Connection, was one of the first people to write about the confusion of Asperger's with attention deficit problems. I talk to more and more parents of children with a diagnosis that switches back and forth between Asperger's and ADHD. Many parents have told me that stimulant ADHD medications such as Ritalin (metehylphenidate) and Adderall (a combination of four different types of amphetamines) have greatly helped their children. It is likely that some individuals on the high-functioning end of the autism spectrum share traits with ADHD. Children or adults who have more classical types of autism or are nonverbal often become agitated and worse on stimulants. A trial of only one or two pills is all that is needed to determine if stimulants will be helpful or terrible.
Brain Research and Early Diagnosis
During the last ten years, there has been an increased understanding of autistic brain abnormalities. A normal child's brain grows at a steady rate. Detailed brain scans of autistic children in Dr. Eric Courchesne's lab indicated that in the first year of life there is premature overgrowth of the brain followed by an arrest of growth. Children with greater amounts of abnormal overgrowth usually have more severe autism. Research has also shown that the serotonin systems in the autistic child's brain are highly abnormal. This may explain why doses for SSRI antidepressants often need o be kept very low to prevent agitation. The degree and pattern of abnormal overgrowth will be highly variable from child to child. David Amarel at the University of California found that the variability of overgrowth was greatest in low-functioning autism. He also discovered that the immune system is often abnormal and may affect the brain.
The excess of brain overgrowth causes the infant's head to become abnormally large between the ages of one and two. Later in childhood, the head size returns to normal due to later undergrowth of the brain. Measuring a young infant's head circumference (hat size) with a tape measure could be used as a simple screening tool for detecting babies who might be at risk for autism.
Other early screening tools that are being developed test for joint attention. Joint attention occurs when normal babies orient and follow an adult's gaze. When the adult is playing a little game, asking the baby to look at the pretty birdie, the baby will look where the adult is looking. The infant at risk for developmental problems will not follow an adult's gaze. Patricia Kohl at the University of Washington is working on another screening tool. This tool will detect children at risk for developmental problems who do not orient toward normal speech sounds. This is due to being unable to hear consonant sounds. Normal babies prefer to listen to «motherese»—expressive slowed down speech where the mother enunciates the words. Autistic babies prefer computerized warbling nonspeech sounds. The test would be conducted by observing the infant to determine which sounds he orients toward.
Early Education
Both scientific studies and practical experience have fully confirmed that young children with autism need at least twenty hours a week of intensive one to one teaching by an adult. All experts agree that the worst thing to do with an autistic two- to five-year-old is to let him watch TV all day. There is much debate about the best early education programs. I have observed that the best teachers tend to use the same methods regardless of the theoretical basis of the program. A review of teaching methods by Sally Rogers at the University of California at Davis indicated that discrete trial or ABA (Applied Behavioral Analysis) teaching methods were the most effective to get language started. This structured highly repetitive method helps jump-start language in young two- to five- year-olds. The discrete trial programs used today are usually more natural and less rigid than the older Lovaas method. To teach socialization and play skills methods such as Greenspan's floor-time and Dr. Lynn Kern Koegel's program are more effective. Dr. Koegel's book Overcoming Autism is full of practical teaching methods. In the floor-time method, the teacher engages the child in many interactive games and encourages social play.
Autism and PDD are highly variable and the methods that work for each child should be used. Dr. Koegel found that some little children respond well to a highly structured Lovaas-style program and other types of autistic children, who are more socially engaged, may make more progress with a less structured program. Do not get too single-minded on one method. Use things that work and eliminate things that do not work. Sometimes a combination of methods is best. For older high-functioning children, highly repetitious programs are boring and they need lessons that will stimulate their minds. In elementary school children a child's fixation can be used to motivate learning. If a child loves trains, then read a book about a train or do a math problem involving trains.
If shooting-type video games had been available when I was little, I would have become a total addict and I may not have developed more career-related interests such as building things or flying kites and airplanes. The video games with lots of rapid movement are the most addictive. For me, rapid movement video games would have just been another way to «stim» and «zone out.» I would rather encourage the older child to become really interested in doing science on a computer or learning programming. Free software is available that will turn a kid's computer into part of a super computer that crunches numbers on a real scientific project. The May 6, 2005, issue of Science is devoted to these fascinating projects. Looking at the NASA Web site and following a space probe during its journey is a wonderful way to use computers. The problem with video games is that both parents and teachers tell me that some students get so addicted that they have no other interests. I get hypnotized by screen savers with changing patterns that move rapidly. I cannot stop looking at them and for me to get any work done I have to shut them off. Video games or screen savers that move slowly do not have this effect.
Totally banning shooting-type games is probably a bad idea, but the time playing them should be severely limited. This is especially important for a child like me. They provide an activity that the autistic child can discuss
