The Many Faces of Asperger's Syndrome

Trudy Klauber, Maria Rhode, Trudy Klauber, Maria Rhode

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367328214
• eBook ISBN: 9780429921384
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This is the first book on the psychoanalytic treatment of children, young people and adults with Asperger's syndrome. It includes multidisciplinary contributions on psychiatric perspectives and psychological theories of the condition. There is an overview of relevant psychoanalytic theory, and chapters on Asperger's original paper, on firstperson accounts, on assessment and on care in the community. Clinical case histories of children, young people and the first published account of work with adults provide the possibility of using psychoanalytic work as a means of diagnostically differentiating between sub-groups, as well as providing a detailed insight into the emotional experience of people with Asperger's syndrome.

Part I

This is Asperger’s Syndrome

The chapters in this first part offer a number of different view points on the condition that is Asperger’s syndrome. Hans Asperger himself wrote that the children whose condition was named after him formed an “immediately recognizable” group, but investigators since then have increasingly debated the differing ways of conceptualizing the relationship between the various features of the syndrome. Writing in 1991, Lorna Wing pointed to the confusion created by the absence of a comprehensive list of the features of Asperger’s syndrome. This is no longer the case since the publication of ICD–10 (WHO, 1993) and of DSM–IV (APA, 1994). However, debate continues about the relationship of Asperger’s syndrome to autism, to schizophrenia, and to various other syndromes such as Wolff’s “schizoid personality in childhood” and Gillberg’s DAMP (Deficits in Attention, Motor Control and Perception) (Gillberg, 1991b). Uta Frith’s groundbreaking book Autism and Asperger’s Syndrome, published in 1991, contains contributions by a number of authors who disagree on these and other fundamental issues. As Sally Hodges points out in chapter 2, it can be difficult to get a clear picture from research on basic issues such as the difference between Asperger’s syndrome and high-functioning autism because of the lack of uniformity of methods and definitions employed in various studies, with the resulting consequences for comparability.

David Simpson, in chapter 1, provides a review of psychiatric perspectives on Asperger’s syndrome and a discussion of its relation to autism, as well as to schizophrenia and to antisocial behaviour, including violence. Simpson is less convinced than some other authors of the continuity on an “autistic spectrum” of autism and Asperger’s syndrome: instead, he sees the former as a psychotic condition of childhood and the latter as a lifelong personality disorder, as did Asperger himself. He reviews the conflicting evidence on the incidence of violent behaviour in people with Asperger’s syndrome, an issue that has generated much heated disagreement. Finally, he outlines the contribution that psychoanalytic theories of cognitive functioning, which distinguish rote learning from a creative relationship to a field of knowledge, can make in bringing together a number of otherwise apparently unrelated features of Asperger’s syndrome.

In chapter 2 Sally Hodges similarly discusses the relationship between autism and Asperger’s syndrome, before going on to review a number of the most widely held and enduring psychological theories that have been put forward to account for observed behaviour. All of these theories were originally developed in relation to people with autism, but they have been widely invoked as explanations for Asperger’s syndrome functioning as well. Hodges provides a comprehensive account of those features that are explained by each theory, as well as of those that are left unaccounted for. She stresses the essentially cognitive nature of all of these theories, which do not address the emotional experience of people with autism or Asperger’s syndrome; as she illustrates by means of a clinical vignette, the relational stance that characterizes these two conditions is very different, even when the level of intellectual functioning is comparable. She concludes with a discussion of Peter Hobson’s theory of autism, in which the developing child’s interpersonal relatedness is accorded a position of primacy and which explains features that are not accounted for by purely cognitive theories.

Trudy Klauber, in chapter 3, provides a discussion of Asperger’s original paper from the point of view of a present-day child psychotherapist. She shows how some of the seemingly disparate features of Asperger children may be subsumed under a unifying psychodynamic theoretical framework. Asperger emphasized the spitefulness of these children—a characteristic that has tended to be overlooked in subsequent writing. The exception to this is the different interpretation offered by such authors as Frith (1991a), according to whom spiteful acts are not expressions of a wish to inflict suffering, but derive from a failure to understand the experience of another person, together with the wish to elicit a reaction. In fact, these explanations are not mutually exclusive: a concern with pain, whether suffered or inflicted, is compatible with a failure to understand how to deal with it and with a failure to imagine how another person could do so. Some of the children described in the case histories in this volume needed help in managing their aggressive impulses—as, indeed, do many children without a diagnosis of Asperger’s syndrome. Klauber argues that one of the motives underlying some of their aggressive behaviour was the need for it to be communicated and dealt with.

Maria Rhode, in chapter 4, discusses the first-person accounts by two very different women with diagnoses of Asperger’s syndrome. Both of them received their diagnosis in adulthood, after they had battled to achieve a way of managing their condition. While each of them made use of various kinds of support, it is clear that their own courage and tenacity were decisive. These first-person accounts raise interesting questions in terms of “theory of mind” (see chapter 2), since both women report substantial problems with reading other people’s motives, while at the same time their books are beautifully written and take full account of the likely state of mind of the reader. While some of the case histories in this volume illustrate the evolution of “theory of mind” in the course of therapy, the natural history of Asperger’s syndrome remains an essential area for future research. Maria Rhode discusses these accounts in terms of developments in psychoanalytic theory. The importance of fears of falling, of sensory and perceptual impingement, and of failures of bodily integration emerges as paramount.

Finally, in chapter 5 Caroline Polmear describes two adults with Asperger’s syndrome in psychoanalysis and psychotherapy. Here, too, sensory, perceptual, and bodily issues are of central importance, along with the gradual process of learning to manage emotions, particularly aggressive impulses. The image of dead or deformed babies occurs repeatedly in connection with the vulnerability of these women’s infant self; this is an important feature of other clinical histories in this volume, and one to which we return in Part III and in the Endpiece. Another central issue in this chapter concerns the analyst’s use of the countertransference as a means of understanding the patients’ emotional communications when they are still incompletely verbalized; again, this is a salient feature of the other case histories. This use of the countertransference means that something that looks like an attack can be understood as a communication (Joseph, 1987) and used as a means whereby the therapeutic relationship can develop. In this way, the patients’ fear of their aggressive impulses could be modified, and emotional contact, which had previously been terrifying, could be experienced as helpful. Polmear discusses the extent to which her patients felt impinged on by their own emotions as well as by the external world—what she calls a state of mind–body overfulness. This links with the issue of emotional regulation, which is a feature of many of the later case histories, and also with the degree to which these patients were frightened of contact.

Before the diagnosis of Asperger’s syndrome became current, patients such as these would probably have been described as borderline with autistic features. This is an issue that it is useful to keep in mind while reading chapters 6 and 7, by Anne Alvarez and Graham Shulman, in part II, as well as the clinical histories by Tanja Nesic-Vuckovic, Michèle Stern, and Brian Truckle, in chapters 9, 11, and 13, respectively, of part III. We return to this question in the Endpiece.

It will be obvious that the authors of these five chapters hold differing opinions on various points of fact or emphasis. It is our hope that this will assist the reader in refining his or her own viewpoint.

Chapter One

Asperger’s syndrome and Autism: distinct syndromes with important similarities

David Simpson

In 1944, Hans Asperger published his thesis Die “Autistischen Psychopathen” im Kindesalter [Autistic Psychopathy in Childhood] in which he described “a particularly interesting and highly recognizable type of child”:

The children I will present all have a common and fundamental disturbance which manifests itself in their physical appearance, expressive functions and, indeed, their whole behaviour. The disturbance results in severe and characteristic difficulties in social integration. In many cases the social problems are so profound that they overshadow everything else. In some cases, however, the problems are compensated for by a high level of original thought and experience. [Asperger, 1944, in Frith, 1991, p. 37]

In 1943, unknown to Asperger, Leo Kanner had published his seminal paper on “Autistic Disturbances of Affective Contact” (Kanner, 1943), in which he introduced the clinical entity of “early infantile Autism”.

Asperger’s syndrome and Kanner’s autism^* are, in my opinion, distinct clinical syndromes, although they show important common features. In this chapter, I consider Asperger’s syndrome in the context of Kanner’s description of children with autism and highlight some important areas of difference as well as correspondence. I then discuss the relationship of Asperger’s syndrome, first, to schizophrenia and, second, to violent behaviour and criminality. Finally I consider the difficulties that those with Autism or with Asperger’s syndrome have with being curious. This is a feature that is important clinically but has received little attention and could be fruitful in furthering our understanding of both conditions.

Asperger’s syndrome and Kanner’s Autism

Early infantile Autism

Leo Kanner, like Hans Asperger, was born in Austria and trained in Vienna. After emigrating to the United States in 1924, he eventually became head of the Department of Child Psychiatry at the Johns Hopkins University Hospital in Baltimore. In his 1943 paper he gave a lucid description of 11 child patients. This description showed remarkable clinical acumen and laid the foundation for the definitions of the Autistic syndrome that are in use today.

With regard to the following three main features of Kanner’s description there is virtually no disagreement with present-day views:

1. The children showed a profound lack of social engagement from or shortly after birth.
2. They showed a range of characteristic communication and speech difficulties. Three of his group were mute, but the language of those with speech was remarkable for features including, echolalia, literalness, and pronomial reversal.
3. They showed an anxious obsessive desire for sameness, exhibiting monotonously repetitive behaviours and utterances. This included an unusual relationship to the inanimate environment. They might, for example, not be particularly responsive to parents but be exquisitely sensitive to some sounds, or they might have major difficulties with transitions or changes in routines. They showed a limitation in the variety of their spontaneous activities but could be particularly fond of inanimate objects and might enjoy for example, continuingly spinning objects.

Kanner described these children as physically normal and attractive in appearance, with no associated medical conditions and with good cognitive potentialities, including excellent rote memories. He also mentioned that, in many incidences, their parents, and particularly their fathers, were remarkably intelligent and successful, but that their interactions with their child seemed strange: he noted obsessiveness and coldness in the parents’ attitudes and in their marriages (Kanner, 1973, p. 42). However, since the children’s Autism began virtually from birth, he stressed that the type of early parental relationship could make at most a limited contribution to the clinical picture.

With regard to these latter features, current views diverge from Kanner’s formulations. Although isolated good cognitive abilities are recognized in Autism, it is now believed that about 75% of children with Autism also suffer from mental retardation (Rutter, 1979). A substantial proportion (25–40%) develop epilepsy, particularly in adolescence (Deykin & MacMahon, 1979; Olsson, Steffenburg, & Gillberg, 1988; Rutter, 1970; Volkmar & Nelson, 1990). With regard to the influence of parenting, Kanner is out of tune with those who consider Autism to be wholly the result of neurological and inherited factors; however, his opinion is surprisingly balanced. Kanner believed the fundamental problem to be an “inborn autistic disturbance of affective contact”, but he explicitly acknowledged possible environmental influences on this.

Kanner considered the syndrome to have two cardinal features (Kanner, 1973, p. 33): The first is “extreme autistic aloneness”, leading to an “inability to relate themselves in an ordinary way to people and situations”. He did not believe this to be a “withdrawal” from existing established relationships but thought that it was there from the beginning. From the start, he wrote, these children show “self-sufficiency”; they act “as if people are not there”, “as if hypnotized”. Any attempts to disrupt their aloneness is treated “as if it weren’t there” or resisted powerfully as a distressing interference. Kanner quoted Gesell, who showed that in normal development infants as young as four months make anticipatory motor adjustments by face and body posture to their mothers lifting them. All the mothers of Kanner’s cases expressed astonishment that their child did not do this.

The second cardinal feature is an “anxiously obsessive desire for the maintenance of sameness”. The autistic child’s world seems to be made up of elements that, once they have been experienced in a certain setting or sequence, cannot be tolerated in other settings or sequences or in any other spatial or chronological order. Kanner believed that the obsessive repetitiveness characteristic of children with Autism, their phenomenal memory and even their tendency to reverse pronouns might follow from this.

Kanner named the syndrome “early infantile Autism” (Kanner, 1973, p. 45), borrowing the term “autism” from Bleuler (1911), who originally used it to describe the self-centred thinking seen in schizophrenia. Kanner believed that early infantile Autism was related to schizophrenia, on the basis of the features of extreme autism: obsessiveness, stereotypy, and echolalia (Kanner, 1973, p. 40). He carefully noted how early infantile Autism differed from the usual description of schizophrenia in a number of important features—namely, the absence of any period of normal development; the child’s undisturbed relationship to physical objects; and the general tendency of the children he observed to move out of their aloneness in the direction of increased contact with others, which contrasts with the usual tendency in schizophrenia towards greater withdrawal. However, he originally placed Autism within the group of the schizophrenias and described it as “the earliest possible manifestation of childhood schizophrenia” (Kanner, 1973, p. 55). This again contrasts with the current view, as discussed below in the section on “Asperger’s syndrome, schizophrenia, and violent behaviour”.

Asperger’s syndrome

Hans Asperger was a paediatrician and an advocate of “remedial pedagogy”—a therapeutic educational approach for children with disabilities. He became Director of the children’s hospital at the University of Vienna. In his 1944 post-graduate thesis, he gave a detailed clinical description of four boys aged between 6 years and 11 years who showed marked problems of social expression and interaction but who appeared to possess good linguistic and cognitive skills. (See also chapter 3, this volume.) Asperger’s deep interest in these children is obvious from his paper. He favoured a holistic, observational, and intuitive approach to them, and he strove to gain insight into their way of being by describing their means of expressing themselves, consciously refusing to impose a system of explanation. He, like Kanner, believed that the disorder was determined by genetic factors (Maria Asperger Felder, in Klin, Volkmar, & Sparrow, 2000).

Asperger used the term “autism” to define the basic disorder that generated an abnormal personality structure in the child. Like Kanner, he adopted the word “autism” from Bleuler’s original use of the concept in the context of schizophrenia. Autism in this sense refers to a “fundamental disturbance of contact that is manifest in an extreme form in schizophrenic patients”.

In Asperger’s view, it was the children’s autism that disturbed and limited their interaction with their environment, shutting off a relation between themselves and the outside world. He considered autism to be the paramount feature that disturbed affect, intellect, will, and action in the children he described, as it does in schizophrenia. Unlike Kanner, however, he did not consider these children to be schizophrenic. In contrast to the picture in schizophrenia, the loss of contact in Asperger children was not progressive, but was present from the start, and they did not show a disintegration of the personality. In his opinion, they showed no more than a hint of thought disorder; in fact, he knew of only one child with this syndrome who went on to develop schizophrenia. He did not consider these children to be psychotic but considered their problem to be a fundamental disorder of personality. This disorder explained their difficulties and deficits as well as their special achievements.

Asperger noted many other common features in the children he described, although he stressed their individuality. Each child was distinguished not only by their degree of disturbance but by the originality of their personality and mode of interaction with the world. In all the children, their characteristic difficulties persisted over time. Asperger stressed the importance of the disharmony between their affect and their intellect and the way in which this caused a disturbance to both.

Affective disturbance was shown by the children’s poor empathy and tendency to intellectualize, with problems in understanding social cues. Despite this, Asperger interestingly notes their extreme homesickness when admitted to hospital, describing “an exceptional degree of bonding to objects and habits of the home, bordering on the obsessional and causing these children to suffer much at separation”. He believed that they were capable of very strong feelings.

Their linguistic and communicative capacities were, in his view, affected by a disturbance of the “contact-creating expressive function”. He noted the impoverishment in their use of facial expression, gaze, and gesture and abnormalities in their use of volume, tone, and flow in speech. These features, which have more recently been described as the pragmatic aspects of communication (Volkmar & Klin, 2000, p. 31), underlie Asperger’s observation that these children do not show appropriate modulation and reciprocity with their sp...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Dedication
• CONTENTS
• ACKNOWLEDGEMENTS
• SERIES EDITOR’S PREFACE
• ABOUT THE EDITORS AND CONTRIBUTORS
• PREFACE
• Introduction
• PART I This is Asperger’s syndrome
• PART II Is this Asperger’s syndrome? Issues of assessment
• PART III Clinical case histories
• Endpiece
• REFERENCES
• INDEX