I'll call him Mike. He's 18, finishing HS and came to see me with a diagnosis of Asperger's disorder (or, per our new DSM, High Functioning Autistic Spectrum Disorder, HFA for short) and never quite fit the bill. Or did he? He was the ever logical thinker. Feelings were always framed in thoughts. He would sometimes get angry and would always justify and rationalize it. He had a utilitarian view of school - if a class appealed to him, he'd participate and do well. If it didn't, he would all but ignore it. Relationships with peers, family were always distant, strained and his participation was based on his logical deduction of its need. Lots of HFA characteristics.
He comes from a normal suburban Atlanta family. Mom was in her second marriage, but the couple had been married for 20 years and seemed to have nothing more than their own brand of normal ups and downs of 20 years of raising kids - Mike, with HFA (and ADHD, of course, so frequently found in kids with any developmental difference) but did OK together. His sibs, older and younger, were all pursuing their individual lives. Finances were OK. No drug or alcohol problems. No "systemic" family issues which us family therapists love to ferret out.
So Mike and I began to meet and talk, the "chief complaint" being his anger, compliance with school etc. When we began to meet 1 1/2 years ago he had been suspended for his arguing, stridently, with a teacher. Over time we met weekly at first, and then as things calmed, less frequently. We discussed his academic prowess - science was really his thing. Science covered everything. Science could account for virtually every aspect of life's challenges and choices. And when science failed, math could be substituted. Yeah, Aspie - ish. It was the "ish" that continued to nag at me.
Also consistent with the diagnoses were the behavioral problems in school as well as his lack of emotional regulation. At one point had thoughts of suicide that landed him in a local psychiatric hospital. Very Aspie. Happens all the time.
We spent time reviewing his relationships with his family. Standard family therapy practice, sometimes including his parents. Lots of time was spent reviewing his relationships with his siblings, parents, communication styles. Suggestions and strategies. And of course, the (dreaded) obsession with video games.
Most of our time was spent strategizing how he could best approach the academics he did not enjoy. He's so smart that I (and his parents) felt this to be a very critical concern. While his logic was great, it seemed to fail re: the importance of passing Spanish, a requirement for his graduation. Aspie. He was very critical of certain teachers, scoffed at the uselessness of certain assignments. All the classic things these guys can get hung up on. His high level of intelligence, sometimes well engaged, sometimes not made it all the more frustrating to his parents (yes, and to me.)
We slogged through some of the computer based classes he had to take to make up incomplete work - and then, surprisingly,wonderfully, things began to turn around. His work was getting done, his attitude better (relatively, of course.) What happened?
I'll call her Jane, a lovely young lady - Mike even brought her for some of the sessions. She had her own story, parents divorced, one of them chronically ill, but most importantly similar interest in Mike's interests, scientific and video. She's also a bit of a STEM (science technology engineering and math) kind of a kid as well, but with a smile and lots more emotional availability than Mike.
As Mike's progress in school continued as did his relationship with Jane, I broached the subject of birth control, as I do with most any late adolescent who's dating, spectrum or not. Mike reverted to a typical HFA stance: He didn't think sex was necessary or appropriate at this time. He thought they could cuddle, make out maybe, but he was not at all interested in sexual contact, even though Jane was. Well that did it for me. What NT (neuro-typical) boy in his late teens (who was quite clear that he was straight) would ever pass on sex with an available, attractive, of age girlfriend. One who WANTED to have sex, but was respecting his desire to not. Only an Aspie. Only an Aspie. It fit perfectly - some, but not too much intimacy - more than many Aspies I work with. Avoidance, perhaps of the massive tactile stimulation that sexual relations entails. I was surrendering to the HFA diagnosis despite this ongoing clinical itch that something...something....but what....was different about him.
And on we went. Just a few more make up classes in the arts (not sciences!) for him to finish before HS graduation. College acceptance in the bag, he and Jane would be attending the same local school and discussed rooming together (asexually?) Maybe this began to make more sense after his parents found them in a compromised position in their den. Maybe he decided to have sex after all. Maybe there was more....
And then he casually mentioned how his older step brother sexually molested him for a couple of years when he was younger. Matter of fact. Just like that. After 18 months of therapy, there it was. The molestation had gone on for 2 years and he said he had told his folks - thought he had told me. Just another piece of data to share - true to style. No biggie. Just letting you know.
How did it start? The brother was older and demanded Mike have sexual contact with him. Not an uncommon occurrence, sad as it is. We discussed how an unequal balance of power is a way of understanding sexual abuse. That once his brother's authority over Mike was established the sexual demands increased. How did it stop? Mike simply said "no" a couple of years later. He's a strong willed kid, so I can see that. Why did he wait till now to discuss this? The brother - with whom he's understandably had a very hostile relationship since the abuse stopped, had already left home to work. All Mike wanted at this point was to live and let live - we'll see if that sticks. Not talking about abuse is common. We'll also see what other questions come up - I know I have a zillion of them.
And what of Jane? He shared with me that a week earlier he had "taken her virginity." "Taken?" I reviewed with him that she is the one who'd been waiting for him to have sex, not the other way around. He didn't "take" anything. It was offered freely and willingly.
And I realized, finally, that we weren't dealing with Autism, we were dealing with a kid who'd been sexually abused, who tried to cope with the pain, shame and isolation that children who've been sexually abused carry, and that it looked like a kid with high functioning autism. His reaction to being abused was to became rigid, controlling, angry - at one point I thought he was psychotic (viewing the chair in the room as a combination of mathematical and scientific formula.) Same kid, different history, different dynamic and different diagnostic formulation.
We discussed virginity. In his organized, intelligent and thoughtful fashion, he shared his confusion. Mike's virginity had been taken from him by a bully, a member of the family, just a few years older than he forced sexual contact. Mike had been raped. He didn't use the word, maybe didn't even see himself as a victim of rape, but that's what it was. The emotional effect for him is the same as for any victim of sexual abuse. This is why he didn't want to sleep with Jane - he feared hurting her as he had been hurt. Fearing that sex was an act of taking and not one of mutual giving. This is what fueled Mike's best coping tool - his intelligence, making him look much more Aspie. He's a smart kid - it makes perfect sense now. As we discussed these issues he teared up, beautifully, believably. He had responded to his emotional hurt by restricting his relationships with others - the better to stay safe from other emotional hurts. That's not HFA. As I thought about it, I realized that what happened to Mike caused him to react in a way that led to a classic misdiagnosis,
Mike may well have ADHD, I think it'll take a bit of time for this to be seen, given his decision to discuss his trauma. He would think, think, think to try to cope with reality. In a variety of ways that's served him well - I think he'll do great in college. But that can also look like a rigid hyper intellectual presence that is typical of HFA's.
The most important lesson we can learn from Mike would be the importance of enduring therapeutic relationships. It's been many years since managed care began its clamp down on out patient visits. I've always been very mixed about their role. A part of me hates them and their nosiness into our business (and finances!) Another part of me believes that clinicians support people's financial reality by accepting their insurance, and thus it becomes a necessary evil. I'm not prepared to take on national public health policy. As a therapist who believes strongly in the "use of self" and the value of the therapeutic relationship, what Mike has done after a year and a half of therapy makes perfect sense. He needed time. Simply. He needed time to trust. He needed time to grow, time to find some distance away from the abuse, away from the perpetrator he was forced to live with for years. He needed time to understand his own strength, his sexuality, time that Jane beautifully provided for him. He needed time to deal with the seething anger that sexual abuse survivors so often have - another symptom that is often evident in HFA kids and in his case mis-interpreted.
Towards the end of the session Mike brought up a new video game he was mastering. He played some clips from the website and pointed out that this particular game defined his experience well. It was a game in which the hero figure would suffer, repeatedly, against the evil foe. But unlike lots of the video games these setbacks didn't really end the game, they just allowed the hero to learn how to better cope, how to better address the enemy so they could survive and find whatever holy grail that game provided. It allowed Mike to symbolically play out his own journey where he could learn, master and grow. And so he will continue.
