As with all of my blog postings, materiel information about people is changed to protect their identity.
I received a call from a distraught mother yesterday. Her son's psychiatrist, having known this kid for many years, offered (seemingly in frustration) that "maybe he should be tested for high functioning autism." Mom was aghast. Her son certainly had cause for depression - there are lots of stressors in the family that don't need to be enumerated here. He may well have ADHD. The psychiatrist is treating for both, and that's fine. He's a bright boy, and bright can be a blessing as well as a challenge. He can be hard headed (not shocking for a smart young man who does well in regular education classes who is in early adolescence with some significant but not crippling family issues) but I'm not sure it makes for a diagnosis of high functioning autism (HFA). It makes for a kid who's "behaving badly" in the words of Ross Greene, author of The Explosive Child. If the boy even did have the diagnosis, which I'm quite sure he does not, as being hard headed and angry is way different from the rigidity that comes with classic autism, even HFA. And even if he was very rigid, would we not look at anxiety first, since there are no stereotypic (repetitive) behaviors or significant social impairments in evidence? It seems to me this off the cuff remark was someone who, at best, was thinking out loud and didn't have the "should I say that out loud" filter quite on tight enough. I've certainly been there, so I can't be too critical on that front. At worst, it is a reflection of the pathologizing of people who struggle.
And interestingly, the new DSM seems to, essentially, fudge together autistic diagnoses with one broad "Autistic Spectrum Disorder" brand with modifiers as to the need for more or less support, more or less impairment etc. which might be valuable for kids who are lower functioning, but I'm not so sure that it always matters for the very high functioning kids.
I saw a self referred law student a while back, certain he had Asperger's. I didn't bother the schpiel informing him that the DSM had done away with that diagnosis, not wanting to pop any bubbles. He was smart, doing well in school, was living with his girlfriend in a relationship that he described as working well. He admitted to worrying a lot. I suggested he might have anxiety issues. He was uninterested and went for another opinion and, no surprise, received a diagnosis of Asperger's. NIMH states that almost 30% of adults will meet diagnostic criteria for anxiety in the course of their life. This is in comparison with 2.3% of adults who will meet diagnostic criteria for autism, and that's according to the highest rate recorded, which could well be an over estimate of the incidence. Didn't we all learn that "when you hear hooves think horses not zebras" because horses are much more commonly found than are zebras? I thought that was standard diagnostic practice. Look at what's more likely, not what's trendy or intriguing.
With the young man whose psychiatrist suggested autism testing, maybe it was the lack of effectiveness of the anxiety/anti-depression medications that were being prescribed. Not every kid responds so well, or so easily to medications. Why suggest autism testing and send mom into what seems an unnecessary tizzy when there are many other more obvious ways to understand his presentation? Why not look at the issues facing this guy, his strengths, his weaknesses, his family dynamics? It seems to me the answers are not to be found in finding (or is it creating?) an autism diagnosis for this kid.
I'm not opposed to testing, nor am I opposed to diagnoses. I refer for autism testing all the time and value my colleagues' input into how to best understand some kids. Yet I'm also in some agreement with the new DSM trend towards describing individual issues and challenges. But I'm becoming more interested in solving problems. I'm not at all sure chasing after a diagnosis is always the smartest move.
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