Diagnosticians prefer the general label of Autistic Spectrum Disorder (ASD) as opposed to Asperger’s Syndrome (AS) or High Functioning Autism (HFA), and some prefer to describe Autism as a condition rather than a disorder. The problem with labelling someone as having High Functioning Autism (HFA) is that it suggests such a person can manage by themselves without external networks of support such as mental health services or personal independence funding from the government. For many with ASD, this is evidently not the case. Some people with ASD can show a high degree of academic intelligence and yet struggle with executive function and social interaction in everyday life and may need quite a lot of support from family, friends, and professionals. Autism is a neurodevelopmental condition that affects a person’s ability to interact and communicate socially. It is often characterised by restrictive and repetitive patterns of behaviour, obsessional and highly particular interests, social anxiety and difficulties with social interaction, and sensitivity to sensory stimulation via the five senses (sight, hearing, smell, taste, touch). The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) defines Autism as a neurodevelopmental disorder that affects social communication and behaviour. It defines ASD by two main symptom areas: deficits in social communication and interaction, and restricted, repetitive behaviours, interests, or activities. Autism is believed to be a hereditary condition, though the exact causes remain unknown. It is a lifelong condition and is often described as a form of neurodivergence. There is no such thing as being ‘a little bit autistic’. You are either autistic or you are not. It is a spectrum condition for those who are already on the spectrum – not for all humanity in general. Prevalence of ASD has been estimated by the World Health Organisation (WHO) as approximately 1 in every 100 children worldwide. Boys are more likely to be diagnosed than girls, with a gender ratio of about four or five boys to every one girl.
Children with Autism may show delayed social maturity and social reasoning, though this is by no means always the case. Some children with Autism can be highly intelligent and articulate and are able to ‘mask’ symptoms well into adulthood before being diagnosed. This is particularly true of females with Autism who are much less likely to be diagnosed than males – perhaps owing to their tendency to be less disruptive in the classroom. Women with Autism present differently and are often better at ‘masking’ than men. A person with Autism may struggle with the expression of empathy, possibly owing to being over empathetic or having ‘too much’ empathy and not being sure how exactly to express or explain such feelings and emotions to others. Note that this does not mean than a person with Autism is unempathetic, only that they may have difficulties showing their empathy to others. A person with Autism may struggle with making or maintaining friendships and often find themselves as the targets of bullying in the classroom or workplace. They often show unusual language capabilities as children, including advanced vocabulary and syntax, as well as unusual prosody and a tendency to be pedantic. Autistic children are sometimes described as ‘little professors’ and may sound and appear quite adult for their age. They may prefer the company of adults to children. A person with Autism may also show undue fascination with particular topics or special interests which are characterised by an obsessional intensity or focus. They may face difficulties maintaining attention or interest with matters that fall outside of their special interests. They may have an unusual profile of learning abilities and other conditions and comorbidities such as ADHD, dyslexia, treatment resistant anxiety and chronic depression. They may need help with executive function and organisation, and will often show sensitivity to specific sounds, textures, smells, tastes, or lighting. They may also struggle with hand-eye coordination and show clumsiness in terms of gait and posture, particularly in sports exercises. Some autistic people also struggle with maintaining appropriate levels of eye contact, though this is by no means always the case. When social or sensory factors overload a person with Autism, they may experience a meltdown which is similar to a panic attack in adults and may include shouting, screaming, crying, or lashing out physically. On the other hand, a person with Autism may simply shutdown or ‘switch themselves off’ by retreating within themselves. This can appear similar to disassociation or avoidance in other mental health conditions. It is important to stress that Autism cannot be cured by medical treatment. It is a lifelong condition. However, various therapeutic approaches have been shown to benefit people with Autism – particularly mindfulness-based approaches such as Radically Open Dialectical Behaviour Therapy (RO DBT) which is specifically designed for disorders of overcontrol (OC).
However, many autistic people would argue that Autism is not a condition needing cure or therapy, it is rather a form of neurodivergence – a fundamental difference in the way that the brain works. The reason autistic people struggle with society is owing to the neurotypical way in which the world works – not being designed for autistic people. If there was greater awareness regarding Autism, perhaps society could be arranged in such a way as to help and accommodate people with a diagnosis of ASD, rather than antagonise them. There are many positive characteristics of Autism that are sometimes neglected in the diagnostic criteria. These might include attention to detail, an ability to focus deeply on a particular subject, keen observational skills, superior recall and memory, expertise in a specialised subject, a methodological and analytical approach to data and information, innovative solutions to problems, creativity, determination, kindness, acceptance, integrity, honesty, and loyalty – to name only a few. The idea that people with Autism cannot empathise is a myth. Autistic people may struggle with reading others and showing empathy, but this does not mean that do not feel empathy and understand the emotions and feelings of others. Autism is not a mental health condition. It is a different way of seeing and understanding the world. However, autistic people are more likely than neurotypicals to experience social and generalised anxiety as well as depression and low mood – largely owing to the difficulties they face in navigating a neurotypical world. They are also more likely to have developmental and neurodivergent conditions such as ADHD, dyspraxia, and dyslexia as already mentioned.
This paper will explore the history of Autism, its meaning or definition, and proper treatment of its comorbidities. The author of this paper identifies as a person with Autism and was diagnosed as an adult in 2022. This article reflects his own experiences and understanding of Autism, as well as his personal experience of therapeutic approaches that have been found beneficial in treating comorbidities associated with Autism.
I. History
In terms of pre-1900 examples of Autism, some references to a twelve-year-old boy with similar symptoms to what is now known as ASD occur in the writings of the Protestant Reformer Martin Luther (1483–1546) – notably in his Table Talk discussions compiled at the time by his friend and colleague Mathesius. The earliest well documented case, however, is that of Hugh Blair of Borgue (1708–65) as detailed in a 1747 court case involving his brother who successfully petitioned to have Blair’s marriage annulled to gain his inheritance on the grounds of his brother’s mental instability. Henry Cavendish (1731–1810), a natural philosopher, also showed traits similar to Autism and was considered to be an eccentric during his lifetime. He was arguably one of the most important scientists of the early modern period. An unusual feral child found in 1798 known as Victor of Aveyron was also documented with symptoms that would now be classified as Autism. He would attempt to run away from civilisation and seek seclusion multiple times and was eventually captured and his case was taken up by the physician Jean Marc Gaspard Itard (1774–1838). Other premodern cases were documented by John Down (1828–96) who would become known for his description of the genetic condition Down’s Syndrome (this is not to be confused with Autism) and Adolf Kussmaul (1822–1902) in 1877, while German psychiatrist Hermann Emminghaus (1845–1904) documented similar psychic disturbances among children in his 1887 study of general psychopathology. The French psychiatrist Pierre Janet noted for his work in the field of dissociation and traumatic memory also observed introverted personality types similar to Autism in 1903, and his study was believed by Grunya Sukhareva to be describing components of schizoid psychopathy in childhood – or what would now most likely be diagnosed as ASD.
In 1908, Eugen Bleuler, a Swiss Psychiatrist who was the director of a mental health unit associated with the University of Zurich, coined the Latin terms ‘Autismus’ when defining certain symptoms of schizophrenia. He coined several psychiatric terms including ‘Autism’, ‘schizoid’, and ‘schizophrenia’. The term Autism is derived from the Greek word autos meaning ‘self’ in reference to the way in which autistic children would become withdrawn within themselves. In 1938, the Austrian scientist Hans Asperger first used the word Autism in its modern clinical sense during a lecture on childhood psychology. The term ‘Asperger’s Syndrome’ (AS) is derived from his name, though it is no longer considered as an appropriate description of High Functioning Autism (HFA) since Hans Asperger collaborated with the Nazis during the Holocaust and sent children to Am Spiegelgrund Clinic, where some of them were murdered. The soviet child psychiatrist Grunya Sukhareva (1891–1981) was arguably the first to comprehensively define what is now considered to be ASD under the umbrella of schizoid personality disorder and based on her research between 1917 and 1921 in a psychiatric hospital in Kyiv and also during her work with children with psychiatric disorders in Moscow.
The American Scientist Dr Leo Kanner (1894–1981) described a group of children whom he was studying as having high intelligence and a ‘powerful desire for aloneness’ and an ‘obsessive insistence on the preservation of sameness’.[1] Kanner also coined the term ‘early infantile Autism’. In 1944, Hans Asperger published a study of four boys who showed high cognitive function and an advanced degree of intelligence but who had difficulties with social interaction and obsessional interests – showing signs of social anxiety and eccentricity. Much of Hans Asperger’s research would not become known to non-German researchers until the 1970s when his work was translated into English. In 1964, research psychologist Bernard Rimland published a book on early infantile Autism owing to the presence of the disorder in his own son. He considered Autism to be a biological disorder with neurological causes – though much of his work has since been discredited. He also supported the controversial use of negative reinforcement in treating children with Autism – an ethically dubious practice that has since been rejected in most countries. In 1967, Bruno Bettelheim published a now discredited study called The Empty Fortress that popularised the false idea that Autism is caused by childhood neglect. Much of his work would be discredited by accusations of plagiarism, not to mention the abuse and mistreatment of patients. A much healthier approach to Autism was developed in the work of A. Jean Ayres, an American occupational therapist, who identified that children with Autism may also have sensory difficulties associated with the five senses of sight, hearing, smell, taste, and touch. She became known for her work on sensory integration theory and has done much to identify problems of sensory overload in children with Autism. Dr Lorna Wing (1928–2014) identified a triad of impairments in children with a diagnosis of Autism in 1979: social interaction, social imagination, and social communication. She argued that Autism is a spectrum disorder with symptoms that vary across a continuum. She would become involved in the establishment and promotion of the National Autistic Society (NAS) in Great Britain and in raising awareness about Autism in general. In 1981, she first used the term Asperger’s Syndrome (AS) to identify a subcategory of Autistic Spectrum Disorder (ASD).
The film Rain Man in 1988, starring Dustin Hoffman as Raymond Babbitt, portrayed the protagonist as an autistic adult with savant abilities. Despite being a sympathetic portrayal of Autism and raising awareness of the condition, it led to unrealistic expectations of people with Autism as having special savant abilities. Not everyone diagnosed with Autism will have savant or special abilities despite frequently showing above average intelligence. By 1994, Asperger’s Syndrome (AS) was accepted as the official diagnosis of High Functioning Autism (HFA) in The Diagnostic and Statistical Manual of Mental Disorders (DSM). However, in 1998, a deeply misleading study was published by Andrew Wakefield which suggested there was a link between the measles, mumps, and rubella (MMR) vaccine and Autistic Spectrum Disorder (ASD). These findings have been thoroughly discredited and elements of his research were shown to have been deliberately falsified. In 2003, Mark Haddon published an influential bestselling book entitled The Curious Incident of the Dog in the Night-Time. It offers considerable insight into the mind of someone with High Functioning Autism (HFA) as narrated from the first-person perspective of Christopher John Francis Boone, a 15-year-old boy with Autism. By 2013, the diagnosis of Asperger’s Syndrome (AS) would be removed from the DSM and diagnosticians would now use the more generic term Autistic Spectrum Disorder (ASD) to diagnose Autism. In terms of Autism awareness, Mary Temple Grandin (b. 1947) is one of the most accomplished adults with Autism in the world as an American academic, animal behaviourist, and Autism spokesperson. She is famous for her work in raising awareness about Autistic Spectrum Disorder (ASD), especially via her book The Autistic Brain: Exploring the Strength of a Different Kind of Mind (2013). The character of Sheldon Cooper in the American sitcom The Big Bang Theory, though not explicitly defined as autistic by the producers, displays many of the core traits associated with Autistic Spectrum Disorder (ASD) in a humorous light. While Sheldon shows many of the key traits of Autism, he claims sanity on the basis that ‘his mother had him tested’.
In summarising the history of Autism, we make the following points: firstly, in the 1930s and 1940s, Hans Asperger and Leo Kanner were lead scientists on two related syndromes known as Infantile Autism (IA) and Asperger’s Syndrome (AS) respectively. Kanner believed that that the condition he observed in children was different to schizophrenia and schizoid personality disorder despite sharing some similarities with both disorders. From this period, research into what is now known as ASD accelerated around the world. By the early 1970s, it had become more widely acknowledged among academics that Autism and schizophrenia were actually distinct psychiatric conditions and should not be confused in the diagnostic criteria with Autism. This distinction was formalised for the first time in the DSM-III. Asperger’s Syndrome (AS) had been introduced to the DSM as a formal diagnosis in 1994. However, it would be removed from the DSM in 2013 owing to Hans Asperger’s involvement with National Socialism and to emphasise the fact that Autism is a spectrum condition with a range of symptoms and severity levels, rather than differing categories of the condition. Asperger’s Syndrome (AS) would be unified into a single diagnostic category in DSM-V with other Autistic spectrum conditions. Autistic Spectrum Disorder (ASD) is currently the standard category used by medical professionals in Britian and America.
II. Meaning
This article has already briefly considered the DSM definition of Autism in the introduction, it remains to explore the cognitive theories about Autism, and the mental, physical, and relational aspects of ASD. According to the DSM, Autism is made of two key elements: 1) persistent deficits in social communication and social interaction across multiple contexts and 2) Restrictive or repetitive patterns of behaviour, interests, or activities. Difficulties with social communication can include trouble with making and keeping friends, understanding social rules, reading the thoughts and feelings of others, making small talk or chit chat, understanding facial gestures, body language, and eye movements, holding conversations outside of one’s particular interests, and grasping non-literal language, sarcasm, and certain forms of humour. In terms of restricted or repetitive patterns of behaviour, people with Autism prefer structure and routine to randomness. They often function better in environments that favour routine such as when following a weekly university or workplace timetable, they can rely heavily on routine and repetitive behaviours in times of anxiety of stress, and they can find change difficult to accept or cope with. These behaviours can lead to a person with autism being either socially isolated and anxious or too dominant in conversations and difficult to interrupt.
Cognitive Theories
There are three major cognitive theories with respect to ASD that seek to explain how the autistic mind works. These are Theory of Mind (ToM), Weak Central Coherence (WCC), and Executive Function. Theory of Mind (ToM) is the idea of knowing what is on someone else’s mind. It concerns understanding how a person is thinking or feeling and what their intentions may be. This should not be confused with the philosophical approach to the existence of other minds. ToM takes for granted that other minds exist and that it is possible to understand someone’s thoughts and intentions to some degree by reading their body language, facial expressions, eye movements, and listening to how they express themselves. A person with Autism may struggle to read what someone else is thinking or feeling, leading to difficulties in social communication. They may especially struggle with eye contact and reading someone’s facial gestures and expressions. This can impact a person’s ability to interact socially and communicate with others. It could be difficult for a person with Autism to ‘read’ others, understand the ‘unwritten rules’ of society, grasp someone else’s thoughts or intentions, and determine whether someone is interested in what they are saying or not.
According to a 1989 study by Uta Frith, a person with Autism may also be said to have ‘weak central coherence’ (WCC) in that they prefer to consider the details rather than the big picture. In other words, they are so focused on details that they cannot see the situation in its entirety – they can often miss the wider point being made. A child with ASD may have superior attention to detail than neurotypical children, but as the idiom goes ‘they cannot see the wood for the trees’ and often miss the bigger picture or point being made. For example, they may focus on small details in a painting rather than the whole picture itself. Uta Frith did not consider this to be a deficiency or weakness in people with Autism, but rather a different way of thinking about the world – a detailed-focused cognitive style. WCC is also known as local bias, global impairment, or detail orientation. Executive functioning refers to a wide range of mental processes such as thinking, planning, organising, prioritising, and transitioning between tasks. People with ASD have difficulties in all these areas. They may have strict routines and struggle with changes to routine or new situations. They may struggle to consider alternatives or accept when things change. Creating routines, writing lists, making things visual with diagrams, using a diary, setting reminders on a mobile phone – all these things can help an autistic person maintain cognitive control of a situation. General calming activities can be helpful when struggling to accept change or to manage transitions between activities such as taking a break, practicing mindfulness or meditation, exercising, stimming, or allowing oneself to space out or rest in a quiet and dark room.
Relational Aspects of Autism
Autistic people may have trouble understanding friendship and identifying who belongs in their friendship group or tribe. Friendship may be defined as a mutual affection between two or more people as part of a tribe. In the early developments of friendship during childhood, an adult (such as a teaching assistant) may act the part of a friend toward an autistic child to teach them the social protocols of friendship. They may teach the child what it means to take turns and ask for help, play pretend games with the child, give positive appraisal when the child is being friendly, teach the child basic social signals, and encourage the child to be part of a tribe of two or more people. A teacher may use role-play to teach a child cooperative play, help the child develop a sense of humour, teach the child what not to say in certain social situations, encourage the child to act the part of an anthropologist in learning social customs, and enrol the child on social skills programmes. As the child matures into adolescence, teachers may encourage the pupil to pursue same-gender and opposite gender friendships, they may assign a peer mentor or buddy to the student, they may help the student find the right group of friends, encourage them to attend drama classes to learn aspects of social interaction and social signalling, and they may encourage them to use books and internet resources to learn friendship skills. A person with Autism may also be encouraged to view animals or pets as potential friends (especially cats and dogs). They may also be encouraged to use the internet as a potential source of finding friendship – particularly social media accounts and forums – though appropriate caution should be taken when talking to strangers over the internet. And a therapist or peer-mentor should give advice to adults and children with autism about the disclosure of autism to others – when it is appropriate to tell someone you are autistic or not. In terms of long-term relationships, there is no reason why a person with Autism should not have a long, happy, and satisfying relationship with a prospective partner. ‘While men with Asperger’s syndrome tend to seek a partner who can compensate for their difficulties in daily life – that is, someone from the other end of the continuum of social and emotional abilities – women with Asperger’s syndrome often seek a partner with a personality similar to themselves’.[2] People with Autism can find it tricky to know when another person is romantically interested in them as they struggle to read social signalling and relevant cues regarding romantic interest. It may be the easiest approach to simply declare a romantic interest in someone with a diagnosis of Autism, rather than waiting for them to figure out all of the tricky social cues you might be sending.
Teasing and bullying at school or in the workplace is often a problem for autistic people especially as they may be perceived as different, unusual, or weird by others. Hans Asperger observed that ‘Autistic children are often tormented and rejected by their classmates simply because they are different and stand out from the crowd. Thus, in the playground or on the way to school one can often see an autistic child at the centre of a jeering horde of little urchins. The child himself may be hitting out in blind fury or crying helplessly. In either case, he is defenceless’.[3] Schools and workplaces should adopt a zero tolerance approach to bullying and make sure students and staff know exactly what constitutes bullying and what the consequences may be for bullying someone in the school or workplace environment. The effects of bullying on children or adults and their self-esteem can be extremely detrimental and can cause serious mental health problems such as anxiety and depression – even many years after the events. If school children were to bring the bullying into the adult world, they would surely face serious consequences for their actions such as dismissal from the job or even a custodial sentence. Children should be made aware that bullying could have serious consequences such as detentions, suspension, or even expulsion from school – not to mention reporting of the actions to their parents or guardians.
Students with Autism may have a better time of things at university or college than they did at school. This is because peers become more accepting as they grow older, and universities and colleges have wider support networks for students with disabilities. Students with Autism will be entitled to a personal mentor who supports the student in terms of time management, study skills, and general wellbeing. They may also have access to programmes like Brain in Hand that allow students to monitor their emotions and plan their time accordingly and PresentPal which helps students prepare for giving presentations and speaking in seminars. If students are worried about handwriting in examinations, laptops and keyboards can easily be provided in today’s technological environment and extra time given to students with ASD who require it. After completing their studies, students with Autism should consider applying for jobs that suit their special interests and specific needs. They may also need to disclose to prospective employers their diagnosis of Autism and ask what help and support would be available to them should they choose to accept the particular job or line of work being offer to them.
Mental Aspects of Autism
Autistic people sometimes have difficulty understanding or labelling emotions – both their own and the emotions or feelings of others. The DSM criteria for ASD refer to ‘a lack of social or emotional reciprocity’ in clients.[4] People with Autism are disproportionately more likely to suffer with a mood disorder such as anxiety or depression. Research indicates that individuals with ASD are more likely to develop bipolar disorder as well as delusional disorders and paranoia. Such comorbidities naturally impair emotional reciprocity. A person with Autism may also have limited emotional responses to situations. Where others would be sad, embarrassed, jealous, anxious, or confused, the person with ASD may have only one response – anger. Parents with autistic children have observed that ‘the degree of expression of negative emotions such as anger, anxiety, and sadness can be extreme, and described by parents as an on/off switch set at maximum volume’.[5] Anger management is often needed for both children and adults with Autism. The primary psychological treatment for manging outbursts of anger is Cognitive Behaviour Therapy (CBT) which has been shown to significantly reduce mood disorders in children and adults with ASD. An emotional toolbox may be used to identify different kinds of strategies or tools for coping or fixing the problems associated with negative emotions such as sadness, anger, and anxiety. It can be helpful to create an emotion wheel which expands on vocabulary to describe emotions in more detail and with greater accuracy. For example, the inner part of the wheel might say ‘angry’, while the outer part suggests more specific emotions such as ‘frustrated’, ‘critical’, ‘mad’, ‘bitter’, ‘humiliated’, ‘let down’, and so on. This can help a person with Autism accurately label and identify his or her own emotions. The practice of mindfulness can also be helpful to soothe difficult emotions. It may be helpful to note as thoughts and feelings arise whether you are ‘thinking’ or ‘feeling’ them and perhaps give a clear label to the emotion: ‘I am feeling the emotion of x, y, z’.
People with ASD often have highly specialised interests. Hans Asperger observed an autistic child who ‘had specialized technological interests and knew and incredible amount about complex machinery. He acquired this knowledge through constant questioning, which it was impossible to fend off, and to a great degree through his own observations’.[6] Autistic children may be interested to such an extent in their specialized subjects that they exclude all other activities and show a repetitive adherence to the subject. They may also show stereotyped and repetitive mannerisms such as hand or finger flapping, twisting, rocking, or whole-body movements – this is commonly known as ‘stimming’ (from the phrase ‘self-stimulation’). Some stims may also be verbal and present as if the child or adult has Tourette’s syndrome (TS) in repeating certain words or phrases, tics, and mannerisms. Autistic children may also show fascination with the parts of objects rather than the whole such as the wheels on a car or the mechanism in a watch. Autistic children and adults may collect items relating to their special interests such as books, artwork, precious stones, mechanisms, Lego, or electrics. Special interests during adolescence may evolve to include electronics, computers, fantasy and science fiction, or a fixation on a certain person or idol. Ideally adults would find a line of work that aligns with their special interests. It is not surprising to find students with Autism studying for advanced degrees in their specialised interests – including for PhDs. The special interest has several important functions. It helps the person with Autism to overcome feelings of anxiety, it provides pleasure and relaxation, it ensures greater feelings of certainty in life, and it creates a sense of identity and occupation.
Children with Autism will invariably show unusual language abilities. Some may have the ability to speak but choose to remain quiet in certain circumstances or social settings – this is known as selective mutism. Some autistic children are completely non-verbal despite showing considerable signs of comprehension. Other autistic children will show initial signs of language acquisition, followed by a delay in language acquisition, followed by a sudden advancement in language development. They may sound very adult when they begin to show sudden advancement and sound like ‘little professors’ and ‘philosophers’ – coming out with whole and advanced sentences in one sweep. They will often have an unusual prosody and tend towards being pedantic – though this is by no means always the case. It is important to teach children and adults with Autism listening skills and train them in giving and receiving compliments and criticism. Knowing when to interrupt a conversation can be tricky for people with Autism and they may need help in knowing when it is or isn’t appropriate to interrupt a conversation. Autistic adults and children also need to be encouraged to ask questions when they are confused about what to say or do in a social situation. Adults and children with ASD may struggle to understand idioms, irony, figures of speech, innuendo, and sarcasm and may need help and guidance in learning about these aspects of language. ‘It is also important to allow the person with Asperger’s syndrome some time to consider his or her thoughts before anticipating a response to a question, and not to feel uncomfortable with momentary silences and a lack of eye contact’.[7] People with autism often need time to process new ideas, thoughts, words, or phrases.
Physical Aspects of Autism
Hans Aspeger observed that children with Autism struggled with movement and coordination: ‘The clumsiness was particularly well demonstrated during PE lessons. He was never able to swing with the rhythm of the group. His movement never unfolded naturally and spontaneously and therefore pleasingly – from the proper coordination of the motor system’.[8] Children and adults with autism may show an idiosyncratic gait that lacks coordination, fluency, and efficiency. They may struggle to catch, throw, and kick a ball or have difficulties in learning to ride a bike. Clumsiness may also affect handwriting which can be difficult to read in children with Autism. They may also struggle with painting, using a scissors, and cutting in a straight line. Modern technology has generally come to the rescue with respect to handwriting in that most school and university work is now typed on computers with word processing documents. Physical education can be tricky in school environments socially for children with Autism who are often picked last due to their clumsiness and lack of hand-eye coordination. Teachers should ensure that children with Autism nonetheless feel included and enjoy participation in sport and exercise.
It is well documented that people with a diagnosis of Autism struggle with sensory sensitivity and sensory overload – particularly as it relates to the five senses of sight (visual), sound (auditory), smell (olfactory), taste (gustatory), and touch (tactile), but also to broader sensory categories such as balance or vestibular senses, proprioception or awareness of body position, and interoception or internal senses and self-awareness. People with Autism often notice pain differently to neurotypicals. They may only perceive pain when they actually see the cut or bruise on their arm for the first time. They may feel temperature differently and wear inappropriate clothing for the weather such as multiple layers in the summer or shorts and t-shirts in the winter. They may not notice that they need to eat regularly, or they may eat all the time but never feel full. It is helpful to think of the sensory profile of a person with Autism like a series of sliders on a soundboard. There is the normal position in the middle of the soundboard representing the ideal sensory state, then there are higher sensory states known as being hypersensitive and lower sensory states known as hyposensitive. A person with autism may be hypersensitive to bright lights, but hyposensitive to dark rooms. Bright lights may cause anxiety, while dark rooms may cause depression and low mood. If a person with Autism is unable to self-regulate sensory information, there can be severe complications such as meltdowns or shutdowns. Both may occur as the result of sensory overload which people with ASD can find particularly overwhelming. A meltdown can be similar to a panic attack and can result in extreme behaviours such as shouting, screaming, throwing things, lashing out, and aggression. This can be particularly distressing for family and friends witnessing the meltdown. A shutdown is like the opposite of a meltdown. During a shutdown, an autistic person totally withdraws from the world into his or her own self. It can be similar in appearance to disassociation and avoidance within other mental health conditions. The distress tolerance skills in the traditional Dialectical Behaviour Therapy (DBT) are particularly helpful for managing meltdowns in children and adults with Autism – particularly the TIPP skill and the STOP skill. With a respect to shutdowns, it may be helpful to encourage the person with autism to lie down in a dark and quiet room into reset – similar to the way in which you would reboot a computer by pressing the restart button. A self soothe box with items the autistic person finds comforting or soothing to the senses may be an appropriate aspect of the meltdown/shutdown toolkit.
III. Treatment
In using the word ‘treatment’, the author of this article does not mean to imply that Autism is an illness or a mental health problem that needs to be cured or treated as such. Some therapies such as Applied Behaviour Analysis (ABA) have proven to be harmful to children and adults with Autism. What is meant by the term ‘treatment’ is ways and methods of managing some of the problematic symptoms associated with ASD such as meltdowns, panic attacks, as well as comorbidities such as social anxiety, depression, self-harm, and low mood. These are methods and therapies that the author has personally found helpful for managing his own times of crisis and experiences of meltdown, anxiety, or despair as a person with ASD. Mindfulness and guided meditation can be especially useful for autistic people to manage times of anxiety and distress. Mindfulness is the art of paying attention in the present moment often by focusing upon the breath as it enters and leaves the body. It is not the goal of mindfulness to bring a sense of peace and calm (though this may be a happy by-product of mindfulness meditation). Mindfulness takes us away from worry about the future and regret about the past by grounding us in the present moment – the eternal ‘Now’. Sometimes mindfulness may involve noticing distressing thoughts and feelings and letting them pass like clouds in the sky or leaves floating upon a stream. There are several useful books on the practice of mindfulness including Jon Kabat-Zinn, Wherever You Go, There You Are: Mindfulness Meditation for Everyday Life (1994), Eckhart Tolle, The Power of Now: A Guide to Spiritual Enlightenment (1999), and Mark Williams and Danny Penman, Mindfulness: A Practical Guide to Finding Peace in a Frantic World (2011). You can find many guided mindfulness meditations on the internet (especially on YouTube), there are however several useful apps (such as Headspace and Calm) that teach you how to practice mindfulness and guide you through various meditations. Mindfulness is also a core component of several therapeutic approaches that have been shown to benefit people with Autism. These mindfulness-based therapies include Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), and Radically Open Dialectical Behaviour Therapy (RO DBT). We will also consider some positive affirmations by way of conclusion that can help a person with ASD accept themselves and embrace their inner neurodiversity.
Acceptance and Commitment Therapy (ACT) is a practical mindfulness-based therapy developed by Stephen C. Hayes that differs from traditional Cognitive Behavioural Therapy (CBT) in that rather than trying to teach people how to control or challenge their thoughts, feelings, or sensations, ACT simply teaches the person to ‘notice’ them and let them pass like clouds in the sky as with traditional practices of mindfulness. ACT attempts to get the individual into contact with a transcendent sense of self so that you become the observer of your thoughts and feelings rather than getting psychologically entangled in them. The goal of the therapy is to increase psychological flexibility allowing the person to cope with changes of circumstance and respond with openness, flexibility, and creativity. ACT may be summarised by the following acronym:
A = Accept your thoughts, feelings, and emotions.
C = Choose a valued direction or goal.
T = Take action to achieve your valued goal.
There are six core principles within ACT therapy to help clients develop psychological flexibility: cognitive diffusion, acceptance, contact with the present moment, the observing self, living by values, and committed action. Those wishing to pursue this therapy in further detail should consult the core text by Steven C. Hayes, Kirk D. Strosahl, and Kelly G. Wilson (eds), Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (2012) as well as the various popular books by Russ Harris including The Happiness Trap (2007), The Reality Slap (2011), and The Confidence Gap (2011).
Dialectical Behaviour Therapy (DBT) was first developed in the United States by psychologist Marsha M. Linehan. Originally designed to treat borderline personality disorder (BPD), DBT has been extended in application to treating a variety of mental illness, particularly suicidal behaviours, and self-harm. With respect to Autism, the distress tolerance skills are particularly helpful in terms of providing coping strategies during a crisis or meltdown experience – especially the TIPP skill and the STOP skill. In DBT the client and therapist work together on acceptance and change-orientated strategies, ultimately aiming to balance and synthesise them. This process is ultimately comparable to the Hegelian dialectical process of thesis, antithesis, and synthesis. DBT is an evidence-based therapy that has proven benefits in treating borderline personality disorder, severe depression and anxiety, drug and alcohol abuse, post-traumatic stress disorder, eating disorders, and various mood disorders. Mindfulness is a core component of DBT. It helps connect us with the present moment, freeing us from worry about the future or regrets about the past. Mindfulness anchors us in the here and now, giving us a place of safety and relative calm even in distressing situations. In addition to mindfulness, there are three major components of DBT: emotion regulation, distress tolerance, and interpersonal effectiveness. These modules are usually supplemented by one-to-one psychotherapy and telephone coaching. This therapy, though not designed for disorder of overcontrol (OC) such as Autistic Spectrum Disorder (ASD), can nonetheless be helpful towards managing crisis, self-harm, and suicidal behaviours which sometimes present alongside of a diagnosis of Autism.
However, the gold standard treatment for disorders of overcontrol (OC) such as ASD is Radically Open Dialectical Behaviour Therapy (RO DBT). This therapy was originally designed by Professor Thomas R. Lynch to treat disorders of overcontrol such as chronic depression, anorexia nervosa, obsessive compulsive personality disorder, treatment resistant anxiety, autistic spectrum disorders, and maladaptive perfectionism. Though named after Marsha Linehan’s ground-breaking treatment for borderline personality disorder (BPD), Professor Lynch’s therapeutic course radically revises and adapts dialectical behaviour therapy for disorders of overcontrol (OC). There are three core aims at the heart of RO DBT for achieving psychological health or well-being: 1) cultivating openness to new experiences, novel behaviour, and/or disconfirming feedback to facilitate learning; 2) fostering flexibility in adapting to ever changing environments and conditions; 3) promoting intimacy and social connectedness with at least one other person and belonging as part of a tribe. RO DBT reminds clients of their basic tribal nature as homo sapiens and the importance of tribal belonging for species survival. Social signalling is important for belonging in a tribe and RO DBT encourages clients to practice aspects of social signalling such as the Big Three Plus One, awareness of facial gestures and body language, and positioning of eyebrows when interacting with others. Radical openness reminds the client that we see things from our own perspective rather than objectively or from a neutral vantage point. Our vision is tainted by our own subjectivism: we don’t see things as they are, but as we are. Radical openness involves a willingness to learn, question ourselves, and respond flexibly to unplanned events and novel circumstances. It aims to show overcontrolled clients (often referred to as OC clients) that they often ‘take life too seriously and that, rather than needing to learn how to be better or work harder, they need to learn how to relax, play, and laugh at their mistakes, with kindness’.[9]
There are three philosophical ideas behind RO DBT including Hegelian dialectics, radical openness, and self-enquiry. The word dialectic means that for everything there exists an opposite. Light is the opposite of dark. Up is the opposite of down. Dialectics tells us that opposing points of view can sometimes both be true or merged to form a truth in order that we might learn something new. This is the case with a thesis and antithesis forming a synthesis as in the Hegelian concept. There is always more than one side of an argument, and it is important to look for both sides in a discussion. We must learn to move away from extremes because seeing the world in black and white or in an all or nothing way can be destructive. It is helpful to have a more balanced view of things and achieve synthesis. The goal of dialectics is to be able to see both sides of something and respond flexibly to events and situations. Radical openness is also a key component of RO DBT. It encourages clients to practice learning from disconfirming feedback. According to Professor Lynch, radical openness involves three key steps: 1) Acknowledging disconfirming events or feedback; 2) Practicing self-enquiry by asking the question: what can I learn from this experience? 3) And responding flexibly and with humility to the situation or event in order to learn something new. Radical openness does not mean blind approval, naïve acceptance, or mindless acquiescence. We must use our minds and think carefully about the events or situation, but where appropriate we should respond with openness, flexibility, and humility. Self-enquiry is the third key aspect of RO DBT. This involves a willingness to question oneself, rather than always assuming that our own perspective is the only right way of thinking or behaving in a situation. We could be wrong. The goal of self-enquiry is to ask a good question, not find a good answer: what is it that I might need to learn from this? Clients are encouraged to keep a daily RO self-enquiry journal to practice asking questions about events and situations in their daily lives. As a person with Autism, I have found RO DBT immensely helpful in stabilising my condition and giving me the skills not only to live, but to thrive.
Conclusion
By way of conclusion, the self-affirmation pledge written by Liane Holliday Willey for children and adults with ASD may become something a mantra or liturgy when practicing mindfulness:
v I am not defective. I am different.
v I will not sacrifice my self-worth for peer acceptance.
v I am a good and interesting person.
v I will take pride in myself.
v I am capable of getting along with society.
v I will ask for help when I need it.
v I am a person who is worthy of others’ respect and acceptance.
v I will find a career interest that is well suited to my abilities and interests.
v I will be patient with those who need time to understand me.
v I am never going to give up on myself.
v I will accept myself for who I am.
It can be helpful to write these affirmations down on flash cards and say them when you wake up in the morning or before you go to bed at night. The last affirmation is particularly important for people with a diagnosis of ASD – self-acceptance and embracing one’s neurodiversity should be the goal of all therapeutic approaches to Autism.
References & Recommended Reading
Attwood, Tony, The Complete Guide to Asperger’s Syndrome (London and Philadelphia, 2007).
Beardon, Luke, Autism in Adults (London, 2017).
Beardon, Luke, Avoiding Anxiety in Autistic Adults: A Guide for Autistic Wellbeing (London, 2021).
Dijk, Sheri Van, DBT Made Simple: A Step-by-step Guide to Dialectical Behaviour Therapy (2012).
Drew, Gillian, An Adult with an Autism Diagnosis (London and Philadelphia, 2017).
Feinstein, Adam, A History of Autism: Conversations with the Pioneers (Chichester, 2010).
Fletcher-Watson, Sue, and Francesca Happe, Autism: A New Introduction to Psychological Theory and Current Debate (London and New York, 2019).
Frith, Uta, Autism: A Very Short Introduction (Oxford, 2008).
Grandin, Temple, The Autistic Brain: Exploring the Strength of a Different Kind of Mind (London, 2014).
Harris Russ, The Confidence Gap: From Fear to Freedom (London, 2011).
Harris, Russ, The Happiness Trap: Stop Struggling, Start Living (Boston, MA, 2007).
Harris, Russ, The Reality Slap: How to Survive and Thrive when Life Hits Hard (London, 2011).
Hayes, Steven C., Kirk D. Strosahl, and Kelly G. Wilson (eds), Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (New York and London, 2012).
Kabat-Zinn, Jon, Wherever You Go, There You Are: Mindfulness Meditation for Everyday Life (London, 1994).
Linehan, Marsha M., DBT Skills Training Manual (New York and London, 2015).
Linehan, Marsha M., DBT Training: Handouts and Worksheets (London and New York, 2015).
Lynch, Thomas R., Radically Open Dialectical Behaviour Therapy: Theory and Practice for Treating Disorders of Overcontrol (Oakland, CA, 2018).
Lynch, Thomas, R., The Skills Training Manual for Radically Open Dialectical Behaviour Therapy (Oakland, CA, 2018).
Price, Devon, Unmasking Autism: The Power of Embracing our Hidden Neurodiversity (London, 2022).
Silberman, Steve, Neurotribes: The Legacy of Autism and How to Think Smarter about People who Think Differently (London, 2015).
Tolle, Eckhart, The Power of Now: A Guide to Spiritual Enlightenment (London, 2020).
Williams, Mark and Danny Penman, Mindfulness: A Practical Guide to Finding Peace in a Frantic World (London, 2011).
N.B. I have also found the Post-Diagnostic Handbook from the Integrated Autism Service in South Wales helpful in writing this article, in addition to their booklet Autism: A Guide for Adults and Marc Segar’s booklet Coping: A Survival Guide for People with Asperger Syndrome.
[1] Leo Kanner, ‘Autistic Disturbances of Affective Contact’, Nervous Child, 35, 4 (1943), 217–250.
[2] Tony Attwood, The Complete Guide to Asperger’s Syndrome (London and Philadelphia, 2007), p. 314.
[3] Cited in Attwood, Asperger’s Syndrome, p. 95.
[4] Cited in Attwood, Asperger’s Syndrome, p. 128.
[5] Attwood, Asperger’s Syndrome, p. 131.
[6] Cited in Attwood, Asperger’s Syndrome, p. 172.
[7] Attwood, Asperger’s Syndrome, p. 227.
[8] Cited in Attwood, Asperger’s Syndrome, p. 259.
[9] Thomas R. Lynch, The Skills Training Manual for Radically Open Dialectical Behaviour Therapy (Oakland, CA, 2018), p. 5.
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