Can someone outgrow autism
Like Snow White in a glass coffin - the motif sometimes comes to mind when talking about autism. The beautiful but unapproachable child is so far away and yet within reach. Can the evil magic, like in fairy tales, be broken someday? Parents have always clung to this idea and hoped that one day suitable ways and means would be found. Healing methods are touted and tested, but none can be empirically supported. Perhaps it is time to replace the fairy tale picture with a more realistic one based on scientific methods. But is it even possible to get an idea of the true inner being of an autistic person?
Psychological and physiological research has now shown that those affected have by no means withdrawn into themselves (in Greek autos), as their behavior suggests (Fig. 1); Rather, they are victims of a biological defect that makes their psyche and intellect, their experience and actions completely different from the healthy. Despite the profound differences, they are emotionally responsive.
It is not absurd to compare autism with blindness. Just as the blind person is incapable of seeing the world in person, the autistic person seems to be incapable of perceiving the inner life of persons according to more recent findings. In a certain sense one could speak of a blindness for psychic processes - analogous to that for physical ones.
Of course, autism is not a blockade of sensory inputs. That makes it a more difficult problem - scientifically as well as for the general understanding: Who can imagine without further ado what blindness actually means for psychological processes in a person.
Like true blindness, autism persists for life; But here too, special educational and caring strategies help those affected and their families to cope with it in practical life. While some autistic people can cope with their disability amazingly well, others can plunge them into anxiety, panic, or depression. Much can be done to prevent such problems. Whatever the effort, the first step must always be to understand the nature of this handicap.
Research started fifty years ago
According to historical sources, autism is not a new disease; It was first described as such, however, only in 1943 by Leo Kanner from the Children's Psychiatric Clinic at Johns Hopkins University in Baltimore (Maryland). In his seminal essay entitled “Autistic Affective Contact Disorders”, he presented observations on eleven children who formed a recognizable group of patients. They all had the following peculiarities in common: they separated themselves from the outside world, persistently doing the same thing, repeating, for example, almost stereotypically simple sounds, sentences and movements, they resisted changes to everything familiar, had strangely narrow interests, and showed a preference for so-called complex ritualized behaviors and were characterized by certain skills, which appeared remarkable in view of the deficits (Kanner spoke of island talents).
At the same time, albeit independently of Kanner, Hans Asperger wrote his habilitation thesis on the same type of children at the University Children's Hospital in Vienna. He also used the term autistic in the heading to refer to the main characteristics of the disorder. Both scientists had borrowed it from adult psychiatry, where it is used to characterize the progressive loss of contact with the outside world that occurs in schizophrenics. However, autistic children seemed to suffer from such a lack of contact from a very early age, which is why Kanner described the disease as early childhood autism in his second publication.
His first case, a boy named Donald, has long served as the diagnostic prototype of the autistic child. Even at a very young age, he was noticeably different from his peers. By the age of two he was able to hum and sing melodies from memory flawlessly. He soon learned to count to a hundred and to recite the alphabet and the twenty-five questions and answers of the Presbyterian Catechism. Donald was, however, manically fixated on turning toys and other items like tops. Instead of playing like other toddlers, namely with stuffed animals or cars, he almost exclusively arranged pearls and other things neatly by color or threw them on the floor again and again, apparently delighted at the noise they made. He always took what he was told literally without understanding the underlying intent of the speaker (for example, an autistic child would answer yes to the question of whether he could have enough salt instead of taking the sentence as a prompt).
Kanner was first introduced to Donald at the age of five. It was noticeable that the boy paid no attention to people around him. When someone interfered in his lonely pursuits, he never got angry with the person, but impatiently pushed aside the hand that was in his way. He only had some social contact with his mother; but that too seemed mainly to be due to the fact that she was taking special pains to do something with him.
When Donald was about eight years old, most of his conversation consisted of repetitive questions. His relationships with other people were limited to his immediate wants and needs, and he stopped contact as soon as his questions were answered or he was given what he wanted.
Some of the children Kanner described were silent. But the others who spoke did not actually communicate either, they used language in a strange way. Five-year-old Paul, for example, parroted everything like a parrot. For example, he said - analogously to the mother's question - "Do you want a piece of candy" when he meant "I want a piece of candy". Almost every day he repeated the phrase "Don't throw the dog off the balcony," a statement his mother attributed to an incident with a toy dog.
Twenty years after the first examination, Kanner took another look at the now adult members of the group. Some seemed to have adjusted socially much better than others - although they were still unable to have real conversation and personal relationships, and although their pedantry and narrow interests persisted. Language acquisition before the age of five and relatively high intellectual abilities were evidently required, but not a guarantee, of learning certain social behaviors. Typically, the most intelligent autistic people began to feel uncomfortable as adolescents; it seemed as if they vaguely suspected that they were different. Often they made a targeted effort to adapt. Often this brought new problems. But even those who conformed well socially were seldom able to develop self-confidence or develop friendly relationships. Generally helpful - regardless of language acquisition and intellect - only one thing seemed to be: an extremely regulated environment.
Soon after the groundbreaking work on autism as an independent disease in children became known, every major clinic found examples among its patients. It turned out that in addition to the social ones, other intellectual abilities are usually also significantly impaired - without, of course, excluding island talents (see box on page 50). For example, many of these children can easily reproduce a given mosaic pattern with playing pieces. However, when it comes to questions that can only be solved with the help of common sense, even the most capable fail.
Search for biological causes
Autism is rare. According to the strict criteria applied by Kanner, around four in 10,000 children are affected. According to the currently usual, somewhat broader definition of symptoms, this proportion is much higher: one or two cases per 1000 births. This makes autism about as common as Down syndrome - a congenital defect, also known as mongolism, that is associated with intellectual disability. Boys are two to four times more likely to have autism than girls.
For many years, autism was thought to be a purely psychogenic disorder with no organic cause. This was because, with the then limited means of brain research, often no neurological problems could be detected in those affected. Theories about alleged psychological causes and their remedies were repeatedly proposed and taken seriously. The central idea was that a small child could be driven to withdraw from social relationships because of an experience threatening his or her existence - namely rejection by the mother - in such a way that others would ultimately no longer have access to its isolated inner world.
This is not based on any scientific findings - and they are also difficult to find because there are numerous cases of extreme rejection and withdrawal of love in childhood, none of which have led to autism. In addition, the parents of autistic children are no less loving than others. Unfortunately, there are still therapies that rely more or less on such ideas and expose the parents concerned to the feeling of guilt that they are responsible for the supposedly avoidable and allegedly correctable breakdown in interpersonal interaction. In contrast, well-structured behavior modification programs have often helped families deal with an autistic child, especially when their behavior is severely disturbed. Such programs, however, do not claim to help him develop normally.
Because the explanatory approach that the root of the evil was psychological damage could not be supported empirically, various scientists began to look for biological causes of the disease - with increasing success. As explained later, the assumption is that a defect in the brain makes it impossible for autistic people to become aware of their own ideas or to understand the inner world of other people.
Autism also appears to be closely related to several other medical conditions. These include maternal rubella during pregnancy, chromosomal abnormalities, early brain damage, and seizures. Probably the most impressive are research results that show that in most cases autism has a genetic basis. In the case of identical twins, for example, in comparison to dizygotic twins, both are affected much more often than just one person alone; and the likelihood of autism occurring twice in the same family is 50 to 100 times what would be expected by chance.
In the meantime, structural anomalies have actually been discovered in the brain of autistic people using anatomical examinations and modern imaging methods. Furthermore, as epidemiological and neuropsychological studies have shown, autism is very often associated with mental retardation, which in turn is clearly related to neural disorders (Fig. 2). This fact fits well with the idea that autism results from the impairment of a particular brain function, which is often part of a more extensive damage: a more extensive anomaly will make the intellectual disability more severe and at the same time more likely to affect the decisive system in autism is. Conversely, it is also possible that only the critical system is damaged; these would be the cases in which autism appears in its pure form, so to speak, not accompanied by clear mental retardation.
Neuropsychological tests have also provided evidence that there is a fairly circumscribed brain abnormality in autism. Otherwise capable autistic people fail especially in test tasks that require planning, initiative and the spontaneous development of new trains of thought. The same deficits also have patients in whom the frontal lobe is damaged. Thus it seems plausible that whatever structure may be defective in autism, this region of the cerebral cortex is also affected.
A triad of impairments
Lorna Wing and her colleagues at the Social Psychiatric Research Unit of the British Medical Research Council in London have found in population studies that the various symptoms of autism do not just happen together. Above all, the impairments of communication, imagination and the ability to socialize are key features - they form a characteristic triad.
Inadequate communication skills can be seen in phenomena as diverse as dumbness or at least delayed language acquisition and the difficulty of understanding body language or of using it yourself. Another peculiarity already mentioned is that some autistic persons speak fluently, but only understand what is spoken literally.
The limitation of the imagination in autistic toddlers manifests itself in the monotonously repeated play with the same objects. In some adults, obsessive-compulsive interest in certain facts is typical; for example, wherever a patient goes, he photographs all the numbers on lampposts in order to collect them.
One recognizes the disorder of the social ability to relate, among other things, that autistic in many interpersonal relationships - for example, when it comes to making and maintaining friendships - behave inappropriately. Still, many of them enjoy being around and trying to please others.
Answering the question why this triad of impairments - and it in particular - occurs is a theoretical challenge. The theory we propose revolves around a specific cognitive mechanism that is innate and undetectable. It can only be defined very abstractly. It can best be described by one of its main functions: to grasp psychological conditions on which action and communication are based.
According to our theory, this mechanism is damaged in autistic people, namely - as we also assume - from birth and as a result of a defect in a single cerebral substrate, be it an anatomical structure, a physiological system or a chemical transmission path. If the affected brain substrate could be identified, the biological cause of the autism could be identified.
The importance of this critical cognitive component for normal development can be seen at a very early age. For example, near the end of the first year of life, children usually begin to exhibit behavior known as mutual interest. For example, they can only point to something because they want to share their interest in it with someone else. When autistic children point to an object, it is only because they want it. If children don't look for a common interest in this way, it can be one of the earliest signs of autistic disorder.
In the second year of life one observes a developmental step in normal children in which the critical cognitive component expresses itself almost dramatically: They begin to pretend something, so develop the ability to play imaginative and pretend games. Autistic children cannot understand such activities and do not dictate anything in their own games. Their otherness can be seen, for example, in the typical mother-and-child game, when a teddy bear or a doll is fed with an empty spoon. The normal child makes all the necessary movements and accompanies them with the appropriate slurping noises. The autistic child, on the other hand, finds such behavior inexplicable. Instead, it tends to play a different kind of game, such as turning the spoon over and over or knocking it on the table over and over again.
It is precisely the lack of previously simple communicative behaviors such as mutual interest and pretend games that often arouses the first nagging doubts in parents about whether their child is developing properly. They feel, quite aptly, that they cannot incorporate it into the usual emotional and social interplay.
Inability to meta-represent
My colleague Alan M. Leslie has developed a theoretical model of the component of cognition that underlies the elementary skills of mutual interest and pretend play. He postulates an innate mechanism for developing and deploying what could be termed secondary or meta-representation.Our environment consists not only of visible physical things and real events that can be understood through primary representations, but also of invisible conditions such as a person's psyche and of mental events that require secondary representations. Both types of representations need to be remembered and kept apart.
This ability to mentally represent real objects, situations and events and - decoupled from them - thoughts, plans and objectives about real conditions makes it possible to resolve apparent contradictions that occur continuously in information processing. Suppose a normal child sees his mother handling a banana as if it were a telephone receiver. In his head there are facts about both objects, that is, primary representations; however, the child is not in the least confused and will not begin to eat the telephone receiver or speak into bananas (except as a game). This is avoided because the child derives from the concept of pretense (a secondary representation) that his mother is doing something real and something imaginary at the same time.
The way Leslie describes this mental process, it should be understood as the creation of a three-sided information context - between an actual situation, an imaginary and a somewhat pretending agent. The imaginary situation is then not treated like the real one.
In the same way as pretense, a person can normally also understand belief, knowledge and feeling - he represents the respective spiritual-psychological, i.e. mental states. If it is true that autistic children lack the ability to meta-represent, then they should not be able to understand that someone is believing something wrong because they do not know what they themselves know. It was therefore possible here to experimentally check a theoretically well-founded prediction. We were able to fall back on the innovative research of Heinz Wimmer and Josef Perner from the psychological institute of the University of Salzburg, who had examined the understanding of such false beliefs in children. Together with our colleague Simon Baron-Cohen, we used a slightly modified test by the two Austrian developmental psychologists, which has become known as the Sally Anne experiment: Sally and Anne play together. Sally has a ball that she puts in a basket before leaving the room. During her absence, Anne takes the ball out of the basket and places it in a box. When Sally returns and wants her ball back, of course she looks in the basket.
As Wimmer and Perner have shown, normally developed four-year-olds or older children, to whom the scene is presented as a puppet show, for example, is perfectly clear that Sally will look in the basket when they return, even if they themselves know that the ball is no longer there is located. So you can cognitively represent both Sally's false expectation and the true relationships. In our test, on the other hand, 16 of the 20 autistic children examined, with a mean intelligence age of at least nine years, did not succeed in specifying where Sally would look - even though they correctly answered many other questions about the individual circumstances of the episode (Fig. 3) . They couldn't imagine that Sally could believe anything that wasn't true.
Amazingly simple, but no less informative, is another experiment that was also developed in the Salzburg Psychological Institute. A tubular cardboard container for candy, which is well known to all children, was used for this test. They all expected Smarties to be in that box, of course, and they were all disappointed when only a small pencil fell out. When the autistic children were asked what another child who came to the test for the first time would say, almost all of them answered incorrectly with "a pencil". Here, too, it was shown that autistic children do not have a bad memory: If you ask for their first answer, they remember well that they had said “smarties” themselves, but cannot understand that someone else made the same mistake would. They just don't know why they answered “Smarties”.
Many comparable experiments in other laboratories have largely confirmed our theory: Autistic children lack the naive mentalism with which we ascribe to ourselves and others a rich inner life - thinking, feeling, wanting, doubting - and with which we behave ourselves and others Explain to people. All of these inner states operate with - secondary - representations that are decoupled from reality.
The normal functioning of this innate mechanism, which underlies naive mentalism, has far-reaching consequences for higher-order conscious processes: It supports the specific ability of the human mind to reflect on itself. Thus, the trinity of autistic disorders - impairment of communication, imagination and social relational ability - can be explained by the failure of a single cognitive mechanism.
The difficulty of reading minds
Because healthy people are able to intuitively evaluate the mental states of others, they know how to read minds in a certain sense. With appropriate experience, they can develop and apply a kind of intuitive psychology that makes it possible to speculate about motives for behavior and to influence the opinions, beliefs and attitudes of other people.
Autistic people lack the mechanism to represent what others might believe; they have no "theory" of the psychic world. Therefore they cannot understand how behavior results from certain mental states and cannot understand how beliefs and attitudes can be manipulated; therefore it is also difficult for them to understand what deception and fraud are.
Beate Sodian, developmental psychologist at Maximilians University in Munich, has shown in an experiment that autistic children do not understand deception with difficulty because the facts are complicated, but because deception presupposes the representation of the mental state of another person ( Picture 4). She initiated a game in which the child, in order to gain points, is not allowed to let an "enemy" access the treasure in a chest. If the key and lock are ready, i.e. if the looting can be prevented with a physical means (sabotage), autistic children solve the problem very well. But if a psychological remedy (deception) is necessary - for example the lie that the chest is locked - then most of them fail. In contrast, even mentally handicapped children cope with this task with ease.
Neither in a direct nor in a figurative sense, autistic people understand how to read between the lines when communicating. The only finely indicated undercurrents, whether in real life or in fictions, remain completely inaccessible to them - i.e. everything that gives interpersonal relationships a special charm.
“People speak to one another with their eyes,” once stated an attentive autistic adolescent. "What are you saying to yourself?"
In the absence of such a meta-representation, autistic children develop very differently from healthy ones. Normally, in the course of cognitive development, increasingly complex social and communicative skills develop: for example, children become increasingly aware that there are false and genuine expressions of emotions and they learn to take this into account. Accordingly, when reading between the lines, they will be experienced as a fundamental aspect of human communication and will soon be able to say something themselves through the flower; Humor and irony open up to them. In short, dealing with imaginary ideas, interpreting emotions and merely recognizing intended intentions - all these are achievements that are ultimately based on an innate cognitive mechanism and are therefore generally taken for granted. For autistic children, however, they are difficult or even impossible. And, in our opinion, this is due to a defect in this very mechanism.
This cognitive psychological explanation of autism is so specific that it is possible to identify very specific types of situations in which autistic persons will or will not have difficulties. A good example is that they understand sabotage, not deception. Our explanation does not exclude that autistic people have special characteristics and abilities that are independent of the critical mechanism. You can certainly learn those social behaviors that do not require mutual reflective understanding; they are able to acquire many helpful social routines and sometimes even perfect them to the point where they can cover up their problems. Moreover, the cognitive disorder postulated by us is so specific that it does not exclude extraordinary skills in such diverse activities as drawing or painting, making music, mathematically combining and memorizing facts.
However, the juxtaposition of outstanding and extremely poor achievements on the one hand has not yet been well researched. Whether other - emotional - disorders are the reason why some autistic children are not interested in social stimuli is also open. Nor can we explain why there are so often stereotyped narrow interests. It is as if autistic people lack a great integrative power - the inner urge to seek meaning and coherence in all appearances.
Help and understanding
The fairy tale image of autism was misleading in more ways than one. It is wrong to believe that inside the glass coffin there is a normal person waiting to be set free; Neither is autism a disorder that is confined to childhood.
The film "Rain Man" came in handy to give an interested audience a new idea. Dustin Hoffman plays Raymond, a middle-aged man who is extremely remote and self-centered and therefore too easily manipulated by others. He is unable to see through his brother's ambiguous intentions, which are obvious to viewers. But in shared experiences - mind you - the brother succeeds in learning from Raymond and building an emotional relationship with him. This story is by no means far-fetched; we can actually learn a lot about ourselves through the phenomenon of autism.
Of course, one shouldn't romanticize the illness. Autism is a serious and - like blindness - lifelong disability. The autistic child is hardly able to develop self-confidence with its own psyche, which is totally alien to us.
However, with better insight, we can now begin to identify the specific types of social behaviors and emotional responsiveness that autistic people are capable of. Affected people can learn to express their needs and to foresee the behavior of other people if it is controlled by external, observable factors and not by certain mental states. You can develop emotional bonds with others. Often they seriously strive to please other people and to acquire the rules of interpersonal contact (Fig. 5). There is no doubt that a satisfactory level of sociability can be achieved within the rigid constraints.
Autistic isolation doesn't have to mean loneliness. The cool reluctance that so alienates many parents about their child is not a permanent feature; often it is replaced by increasing sociability. And just as one can take into account the needs of a blind person or another handicapped person, the life circle of an autistic person can also be adapted to his own.
On the other hand, one must realistically recognize the degree of adaptation that individual personal limitations permit. One can hope that an autistic person will to some extent compensate for his handicap and, to a modest extent, also cope with difficult situations. On the other hand, it would be unrealistic to expect that he would grow out of his innate non-reflective personality, for which he has not made a decision himself. For their part, those affected can claim that we have a more sensitive understanding of their misery if we understand better how their psyche differs from ours.
From: Spektrum der Wissenschaft 8/1993, page 48
© Spektrum der Wissenschaft Verlagsgesellschaft mbH
This article is contained in Spectrum of Science 8/1993
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