I learned many years ago to assess gun safety in the homes after working with one very kind, nice boy who intentionally shot his stepmother in the head with a shotgun stored in her bedroom for safety. Another child found a gun in the home and killed his brother, having no intent to do so. And still a third was paralyzed from the chest down when his cousin discharged an unsecured weapon, also by accident.
Young adults with Asperger's and High Functioning Autims (HFA) often have a difficult time expressing their emotions. They also are often very pre-occupied with video games. And among the most popular are tens of millions of violently themed games with very realistic shooting of enemies, real and imagined, their realism increasing with the technology. The movies' ability to depict violence is even more striking and have broad audiences both on large and small screens. Kids, including kids with Asperger's and HFA are saturated with these increasingly realistic fictionalizations.
It is the nature of people with Asperger's and HFA to struggle with their emotions and emotional expression. It is often that they will express their emotions in action and not word. They often struggle with the skills involved to talk out their emotions which is why a significant number of them may end up tantrumming and even being violent instead of articulating their feelings as a way of discharging the emotional energy stored up. It is to this end that talk therapy, social skills groups and the like are so often recommended to individuals with Asperger's and HFA. It is also common for these folks to benefit from medications to lower their anxiety or to help organize their thoughts that can be distorted and illogical.
But not everyone in need of these services receives them. Many parents, for various reasons, do not pursue such services for their children and teens. Many people in need resist them. How, then, do they express their powerful emotions? It is not uncommon for this group of people to become depressed, and while signs of depression can include dispair that can lead to suicidal feelings, it can also lead to irritability and anger. The lack of ability to manage emotions, then, can be overpowering and the violent images (that might be normal for anyone to experience in a time of stress) can become all the more seductive, fueled by the images so rampant on our screens. Mix that with poor judgement, implusivity, social isolation and the possibility of distorted thoughts and logic and, well, you get the idea.
Parents of people with Asperger's and HFA, particularly those who are gun owners should, then, follow the basics of gun safety. The NRA advises that "dozens of gun storage devices, as well as locking devices that attach directly to the gun, are available." There is no better security than insuring that access to weapons is strictly controlled.
It seems intuitive that violent games and movies should be monitored, limited or even (gasp) not allowed to individuals who are unable to discuss and understand in detail the differences between the reality and fantasy of violent games and movies, and be able to well articulate their own emotions. This should apply to people on the Autistic spectrum as well as those who are not.
The issue of this entry is not gun ownership, but rather one of responsible gun ownership. And not just for families of children and young adults on the autistic spectrum, but families who have children or young adults who are typically developing, or families that have visitors, or anyone who might be burgled - which is everyone with a firearm.
Monday, December 17, 2012
Wednesday, December 5, 2012
DSM V and Asperger's
I'm not really worried about the upcoming changes in the DSM's categorization of Asperger's. In fact, I think it'll help clarify the many errors in how Asperger's, "high functioning autism" and pervasive developmental disability, not otherwise specified (PDD NOS) are currently diagnosed. Over time, it's seemed more and more rare to see kids who clearly fit the DSM IV's Asperger's criteria. I don't think that's due to the criteria being particularly vague. Rather, I think it's due to a combination of pressure from families and "mission creep" among professionals.
Diagnosing Asperger's requires a certain understanding of the population that increases by working with them - and the more one works with them, the more one understands what distinguishes someone with Asperger's from someone with PDD NOS or other diagnoses altogether. Yet, clinicians are often under a gun of sorts when parents bring their children, desperate for an answer to "what's wrong." Such pressure takes some strength to fight. Many parents are absolutely sure their child has Asperger's, and I believe clinicians have sometimes succumbed to that pressure.
I fear some succumb to the pressure by short cutting and forgetting to look at the "whole" child, the whole picture and context of who the person is within the family and the family's functioning. I also believe that it's hard for many to say "I don't know" or "let's meet for a while to see how comfortable Johnny is with a consistent relationship and then review the issue of diagnosis." And one of my favorite short cuts (oft quoted by a former colleague:) "He's kind of quirky, it's Asperger's." Quirky - in and of itself - is not a code word for Asperger's.
It seems that the day of the classic Aspie are gone. Very often kids with the diagnosis come in with lots of strengths and skills socially and interpersonally - unheard of for an Aspie in years past. It was almost refreshing recently to have a 12 y/o Aspie walk in my office, breeze past me as if I was not even there when I extended my hand and said hello, look around the office and sit down, totally avoiding eye contact, and initiate a discussion about a favorite science fiction book in a hyperactive way that was as much a discourse as it was discussion. Now THAT's Asperger's. This child had all the classic criteria: he was very "adult" in his presentation. He has significant social challenges - just not knowing how to mix socially with his peer group. He's very rigid, exploding when small things don't go right. He had a lot of anxiety when it came to discussing his own behavior, and a very ADHD profile. He could discuss his preferred topics in detail and at length, but was quickly disinterested and easily distracted when structured to discuss a to a different one.
Over the years, folks diagnosed with Asperger's coming for therapy have a much broader presentation. They may have appropriate social skills; good eye contact; an understanding of the subtlety of communication; a wry response to a bad joke (I specialize in bad hokes - it's a bit of a test to see how socially astute they are); facility in the flow of conversation; a broad range of affect in the prosody of their speech (the musicality and stress of words in their speech); spontaneous, genuine and quick compassion in social settings. Some had received the diagnosis when relatively young, in early grade school, and no re-assessment of that diagnosis has ever occurred, even as they approach adulthood. These kids seem to have a diagnosis that sticks as The Scarlet Letter did - never to be removed. Some parents, it seems, even seem to be hesitant for such a review, as the diagnosis explains all of the issues they and/or their kid may have. It sometimes seems a badge of some honor - even when it is quite evident that the diagnosis given to this child so many years ago is in dire need of review as he or she ages into the mid and late teens.
So why are people who've been diagnosed with Asperger's no longer seem to fit the diagnostic criteria? The most frequent thing I've seen is kids (or adults) who have the very challenging combination of ADHD and anxiety that may include obsessive compulsive behaviors and can result in the stilted and over controlled presentation that many folks on the spectrum display. ADHD with anxiety is a tough combination - and as so many kids on the higher end of the autistic spectrum have both, it's an understandable conclusion. A learning disability, particularly one that is based in language processing (NVLD - Non Verbal Learning Disability is a common one) is another challenge that can be misdiagnosed as Asperger's. Folks with language based learning disabilities may take longer than usual to consider and respond in the course of conversation. Their responses may be over deliberate, or be a bit tangential, as they have difficulty with language comprehension of or formulation of language. That can be a very challenging issue, but not necessarily Asperger's. Mix in the distractability, hyperactivity and/or impulsivity of ADHD and a conclusion of Asperger's can easily be understood, though inaccurate. Not to mention the "quirky" kids.
Professionals trained to work with kids know that developing a relationship over time provides an important cushion against these errors. However pressures of time, money, parental anxiety and, if I may say, over confidence can result in a premature and inaccurate "answer."
So I think the DSM V may ease some - but not all of the challenges clinicians have when diagnosing what is soon to pass in the official nomenclature as Asperger's, but I just don't think it'll amount to much. Folks with the diagnosis will still have an "autism spectrum disorder" and be eligible for special ed services and disability. And there will continue to be those included in the autism spectrum who really don't belong there - that's certain not to change.
So whether it's pre DSM V or post DSM V, my recommendation to clinicians remain: Don't forget to take time with the child. Some typically developing kids are genuinely shy and need more than your allotted amount of time to warm up. Get to know the dynamics of child's family to see how much that may be contributing to the child's presentation. Very challenging dynamics such as bitter divorce, substance abuse can create havoc in a child's sense of stability. Living in an emotionally "dysfunctional" (sorry for the use of the word, but it does capture a lot) family creates tons of stress on kids, whether they are on the spectrum or not. If they weren't anxious children before such stresses, they certainly can become that way after those stresses. Look at all the data, then look again, particularly if the diagnosis is not crystal clear. Look for the child's emotional reserve and availability. And most important, don't be afraid to say "I don't know." I think that's the boldest comment a clinician can make.
For parents: What is the experience the clinician has with diagnosing and working with kids on the autistic spectrum? Do you "click" with the clinician and develop a trust with them to communicate freely and openly? Remember that you are the expert on your child. Also remember that you are the consumer - you have the right to move to another clinician if you are uncomfortable. Also despite everything you've read on the Internet, don't go in with a presumption of what the final diagnosis is, part of the process of becoming a professional is being able to distinguish subtleties.
Most important to parents: remember that what most needs attention with your child is the their symptoms, not their diagnosis. Nobody treats Asperger's. What is treated is the symptoms of Asperger's. Whether it's a presentation of anxiety, ADHD, poor social skills, sensory issues etc., it is the symptoms that are treated, not the diagnosis.
So, DSM V, bring it on!
Diagnosing Asperger's requires a certain understanding of the population that increases by working with them - and the more one works with them, the more one understands what distinguishes someone with Asperger's from someone with PDD NOS or other diagnoses altogether. Yet, clinicians are often under a gun of sorts when parents bring their children, desperate for an answer to "what's wrong." Such pressure takes some strength to fight. Many parents are absolutely sure their child has Asperger's, and I believe clinicians have sometimes succumbed to that pressure.
I fear some succumb to the pressure by short cutting and forgetting to look at the "whole" child, the whole picture and context of who the person is within the family and the family's functioning. I also believe that it's hard for many to say "I don't know" or "let's meet for a while to see how comfortable Johnny is with a consistent relationship and then review the issue of diagnosis." And one of my favorite short cuts (oft quoted by a former colleague:) "He's kind of quirky, it's Asperger's." Quirky - in and of itself - is not a code word for Asperger's.
It seems that the day of the classic Aspie are gone. Very often kids with the diagnosis come in with lots of strengths and skills socially and interpersonally - unheard of for an Aspie in years past. It was almost refreshing recently to have a 12 y/o Aspie walk in my office, breeze past me as if I was not even there when I extended my hand and said hello, look around the office and sit down, totally avoiding eye contact, and initiate a discussion about a favorite science fiction book in a hyperactive way that was as much a discourse as it was discussion. Now THAT's Asperger's. This child had all the classic criteria: he was very "adult" in his presentation. He has significant social challenges - just not knowing how to mix socially with his peer group. He's very rigid, exploding when small things don't go right. He had a lot of anxiety when it came to discussing his own behavior, and a very ADHD profile. He could discuss his preferred topics in detail and at length, but was quickly disinterested and easily distracted when structured to discuss a to a different one.
Over the years, folks diagnosed with Asperger's coming for therapy have a much broader presentation. They may have appropriate social skills; good eye contact; an understanding of the subtlety of communication; a wry response to a bad joke (I specialize in bad hokes - it's a bit of a test to see how socially astute they are); facility in the flow of conversation; a broad range of affect in the prosody of their speech (the musicality and stress of words in their speech); spontaneous, genuine and quick compassion in social settings. Some had received the diagnosis when relatively young, in early grade school, and no re-assessment of that diagnosis has ever occurred, even as they approach adulthood. These kids seem to have a diagnosis that sticks as The Scarlet Letter did - never to be removed. Some parents, it seems, even seem to be hesitant for such a review, as the diagnosis explains all of the issues they and/or their kid may have. It sometimes seems a badge of some honor - even when it is quite evident that the diagnosis given to this child so many years ago is in dire need of review as he or she ages into the mid and late teens.
So why are people who've been diagnosed with Asperger's no longer seem to fit the diagnostic criteria? The most frequent thing I've seen is kids (or adults) who have the very challenging combination of ADHD and anxiety that may include obsessive compulsive behaviors and can result in the stilted and over controlled presentation that many folks on the spectrum display. ADHD with anxiety is a tough combination - and as so many kids on the higher end of the autistic spectrum have both, it's an understandable conclusion. A learning disability, particularly one that is based in language processing (NVLD - Non Verbal Learning Disability is a common one) is another challenge that can be misdiagnosed as Asperger's. Folks with language based learning disabilities may take longer than usual to consider and respond in the course of conversation. Their responses may be over deliberate, or be a bit tangential, as they have difficulty with language comprehension of or formulation of language. That can be a very challenging issue, but not necessarily Asperger's. Mix in the distractability, hyperactivity and/or impulsivity of ADHD and a conclusion of Asperger's can easily be understood, though inaccurate. Not to mention the "quirky" kids.
Professionals trained to work with kids know that developing a relationship over time provides an important cushion against these errors. However pressures of time, money, parental anxiety and, if I may say, over confidence can result in a premature and inaccurate "answer."
So I think the DSM V may ease some - but not all of the challenges clinicians have when diagnosing what is soon to pass in the official nomenclature as Asperger's, but I just don't think it'll amount to much. Folks with the diagnosis will still have an "autism spectrum disorder" and be eligible for special ed services and disability. And there will continue to be those included in the autism spectrum who really don't belong there - that's certain not to change.
So whether it's pre DSM V or post DSM V, my recommendation to clinicians remain: Don't forget to take time with the child. Some typically developing kids are genuinely shy and need more than your allotted amount of time to warm up. Get to know the dynamics of child's family to see how much that may be contributing to the child's presentation. Very challenging dynamics such as bitter divorce, substance abuse can create havoc in a child's sense of stability. Living in an emotionally "dysfunctional" (sorry for the use of the word, but it does capture a lot) family creates tons of stress on kids, whether they are on the spectrum or not. If they weren't anxious children before such stresses, they certainly can become that way after those stresses. Look at all the data, then look again, particularly if the diagnosis is not crystal clear. Look for the child's emotional reserve and availability. And most important, don't be afraid to say "I don't know." I think that's the boldest comment a clinician can make.
For parents: What is the experience the clinician has with diagnosing and working with kids on the autistic spectrum? Do you "click" with the clinician and develop a trust with them to communicate freely and openly? Remember that you are the expert on your child. Also remember that you are the consumer - you have the right to move to another clinician if you are uncomfortable. Also despite everything you've read on the Internet, don't go in with a presumption of what the final diagnosis is, part of the process of becoming a professional is being able to distinguish subtleties.
Most important to parents: remember that what most needs attention with your child is the their symptoms, not their diagnosis. Nobody treats Asperger's. What is treated is the symptoms of Asperger's. Whether it's a presentation of anxiety, ADHD, poor social skills, sensory issues etc., it is the symptoms that are treated, not the diagnosis.
So, DSM V, bring it on!
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