AUTISM

AUTISM

June 20, 2012

Difficult teens with autism, and guest psychologist's observations



Michelle Garcia Winner

The following are some thoughtful words from a psychologist to a Social Thinking clinician regarding two teen clients who are struggling to benefit from treatment. The psychologist would like to stay under the radar, so he has chosen to go by the moniker, Dr. Panglos.

Albert and Steven live in different cities in an urban metropolis somewhere west of Asia; they are high school age and they don’t know each other.

From Dr. Panglos to a clinician he is working with:
Okay, here is what I think. Symptoms are multiply determined and although Albert and Steven both have profound social deficits that, on the surface, make them appear to meet the criteria for being "on the spectrum" I no longer feel that A.S. describes the true nature of their deficits. That said, they are very much alike in how they do present so if it is not Asperger's than what is it, and what do you do about it? First, what is it?


It would be great if we could list the behaviors/symptoms and pull out the DSM-IV and look these guys up but their pathology is not so simple. The way I see the ingredients that make up both boys is this. They came into the world with particular temperaments that made them difficult from day one. The parents were disappointed and felt burdened by these difficult kids. Early on the parents lost hope and deciding that there was nothing that they could do to mold them, they became conditioned to avoid conflict by meeting their boys’ every want and need. No frustration went un-rewarded. So on top of having difficult temperaments the tail ended up wagging the dog and THIS, makes therapy a real challenge. These boys, and kids like them, have never learned to delay of gratification (never needed to), they have poor frustration tolerance, (never had to wait), and this leads to difficulties with sustained attention, motivation, and yes, even profound social deficits.

By age 5, around the time that school started, the die was all ready cast. In their respective families they knew not the meaning of the word "compromise", and "sharing" was something other people did, not them. Lacking any basis of comparison they were ill prepared to co-mingle with age mates on the playground or in the classroom and given their skewed self-perception, they expected to be accepted not as equals to their peers, but as their superiors.

As it would be with princes set among commoners so it was for Albert and Steven. Their angst was genuine and it was intense. From the boy's perspectives the world was not recognizing what to them was obvious - their superior intellect and the recognition of it by others, after all, if it were true in the home why would it be no less true in the classroom? The slings and arrows they encountered at school pierced them deeply. Lacking the psychological equivalent of armor, shields, or helmet they were forced to retreat deeper into the bosom of their families where their reigns went unchallenged, and their hegemony was secure.

During the period when age mates were making forays into the larger world via activities of every type, our warriors were pacing in their castles, stewing in their juices and giving vent to their rage by constantly reminding their parents who was ruler and who was ruled.

And just when they may have come to terms with their own limitations, they found “World of War Craft” and online “games” like it. Here was the world they had yearned for, and so captivated by this "pseudo" world of war, rage and the illusion of mastery that no one in the family seemed to notice the onset of puberty. While age-mates were making forays into the larger world, our boys, sealed in their bunkers, fought on, racking up points and “feeling” as if they were doing something useful.

Enter the therapist.
Disheveled, intense and articulate about their one true love, MMORPG (Massively Multiplayer Online Role Playing Games) they sit across from me and plead their cases. They are not very good perspective takers.

Unlike many other kids with social/communication problems who can be taught the skills they lack in a straightforward manner in a group setting with a white board and examples, these boys and kids like them present as something of a challenge. Why? Because Princes don't mingle with commoners and they don't take well to authority figures pointing out that they have faults. To acknowledge that they need help at all is perceived as a challenge to their over-valued sense of self-worth, (like the great and mighty Wizard of Oz).

In boys such as these, stunted social development magnifies this skewed but powerful belief that their social isolation is self-imposed due to their superior minds and the belief that they are leaders – and leaders are never led. This is why no good deed with them goes unpunished, and this is, perhaps, at the heart of the rut that has become their lives - those who could help and want to help, are held in contempt and dismissed.

What can be done?
One thing I've come to appreciate is that any work with boys like these is going to be glacial. Involving the parents is worth attempting but I have found that it is rarely fruitful. Change is always difficult and the status-quo is often stronger than promises made in session. Apparently, the conditioned reflex to "appease the prince" with trinkets and tributes is expedient in the moment to quell unrest, but it does make the therapist's job that much more difficult.

Truth be told there are days when I feel like a hanger-on in the court, part of the retinue of hired help. A participant in the parade the parents surround themselves with to show the world their level of commitment. Together we "professionals" form a palisade behind which the family hopes to hold off intrusions from the greater community. But, the moment we buy into the argument that "the world needs to change" (and not the family) we become unwitting diplomats in defense of dysfunction.
On other days I am more sanguine. Between the epiphanies we hope for, trust is being formed and strengthened. Push some- then pull back. Socratic questions create conversation and sow the seeds for self-reflection. Let them talk about what interests them but all the while looking for openings to tug the conversation towards core topics, like cooperation, participation, and how to behave in ways that girls might like to get to know them.

Although stretches of time go by without much overt reason for me to feel hopeful it is crucial to fight the impulse to view kids like these as being sick, damaged or disturbed beyond repair. Deep down this is what they fear most about themselves and this, I suspect, is what they are defending against being conscious of. The energy it takes to keep this thought at bay makes them prickly, arrogant and at times, even paranoid.

Michelle's Comment:
I felt this is important to post, although it may be uncomfortable to read. Our clients are members of families that most often help with tremendous positive support and outcomes are brighter; which means the family held the student accountable to how he or she behaves as well as how they impact others. However, we also have to wrestle with the client who fails to participate in society in part because there are too many allowances given to his or her challenges in the home, so they fail to learn to tolerate an choices other than their own. Their own poor choices often back them into corners without them realizing that by ruling their worlds they end up living in an incredibly confined space.

Unfortunately, there is no public law about how to parent children with difficult temperaments. There is only public law about how to handle them during the school hours by the teachers and administrators who are powerless as Dr. Panglos states above. Helping our parents learn to say “no”, limit hours of computer time and watching their children cry or fuss in the name of learning to cope without resolving the negative feelings in the moment are all things we also have to advocate for to help our students become adults who can function as part of society.

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