CRITICISM OF THE "TRIAD OF IMPAIRMENTS"
- Appendix to Essay 1
Since my understanding of autism ties in closely with alternative views of the phenomena described by the 'Triad of Impairments', I shall address each part of the triad, and then describe the conclusions drawn from these as a whole.
Of the hypotheses contained in the 'Triad', particularly the assumption of 'lack of role play' and 'adherence to rituals and routines' somehow reflecting rigidity in thinking has struck me as highly suspect. I do not find it likely that the two are closely connected, and as I will describe below, I believe that all autistic 'rituals and routines' might not be pathological in themselves, but rather a broad and varied category containing some very healthy adaptive responses.
Let us consider a very central issue in autism, one that directly affects social interaction; the problem in attention sharing. I feel that even this could be interpreted in a crucially different way than current theory states. A key early indicator of autism is failure in calling attention to something by pointing and gaze shifting (Baron-Cohen, 1995). The basic description of the observed phenomenon is 'lacking or abnormal eye contact'. The failure to maintain eye contact is interpreted as a fundamental lack some basic ability or other that enables most people to do it. Yet autistic people can enjoy rough-and-tumble play, essentially a non-competitive social activity, and use eye contact in that context. We can check whether someone is attending to things we are doing by establishing brief eye contact, if the other person is acting in a discreet, non-invasive manner - Murray has written an excellent descriptions of this (2001). Autistic children can be spurred to making eye contact, and offering help, by seeing another person clearly in distress about a physical danger (Evans, residential school lecture, Sep 2002). The autistic adults I've encountered report having no difficulty in eye contact with very young children, and the level of difficulty with adults being highly dependent on situation and emotional state. These observations seem to contradict the assumption of a lack of ability. I believe that a crucial factor has been ignored in interpreting the autistic person's sharing of attention. If eye contact feels invasive or painful, as numerous autistic adults have repeatedly testified, why would a child try to establish joint attention by inviting it? A child would quickly learn to avoid pointing, if it always results in discomfort, with adults immediately and instinctively trying to make eye contact. There is a different way of observing whether joint attention is happening; through observing posture and movement. I believe that many able autistic people do not actually have a fundamental inability to share attention, but a different method for establishing and observing it. From this would follow that we might not find a true lack of a 'Theory of Mind' in autism, either primary or secondary, but rather something different, a 'Theory of Autistic Mind' which, among other things, might be more visually based than normal ToM, causing autistic people to perform poorly in language-based ToM tests (Rutherford et al, 2002). This would cause problems with the normal population, reminiscent in some ways of the lack of empathy and understanding between people from extremely different cultures. An autistic child might assume that eye contact is uncomfortable for everybody else too, or that people deliberately ignore displays of attention or desire, when the child only uses posture and movement to communicate these - essentially, an autistic child might be treating other people as if they were autistic, not as if they were objects. Phenomena of a similar nature have been described in hearing children of deaf parents (Rainó, 2000), who seem to acquire something like a 'Theory of Deaf Mind'.
In the events described in the introduction to Essay 1, I feel that it could have been my gut reaction to subtle movements, such as I might make myself when needing to gain people's attention but wanting to avoid facing them, that were visible to me and invisible to care workers. These would be things like maintaining a communication distance for some time while looking away, looking past people but not quite at them, and approaching and staring pointedly at things that are desirable or disturbing.
Further, autistic people seem to be able to observe the presence of hierarchies and positions of power. Wing (1996) mentions how able autistic people tend to address the 'person in charge', and finds this mysterious as we are supposed to be too deficient in our social understanding to do this. In a study of aggression in autistic people, it was found that autistic people in institutions tend to aim aggression at those who are in positions of power relative to them, instead of their peers. In a report on a pilot project to develop services for able autistic people living independently, it is mentioned that the participants would not accept help that could be seen as patronising or demeaning (MacLeod, 1999). These examples are consistent with my observations of autistic communities, which seem well aware of power issues connected to support situations.
Autistic people have also since Asperger's time been observed to have a way to sense who is genuinely on their side and who is not. In autistic communities, many agree that they may be easy to trick in the short run, but practically impossible to lie to for longer periods, since they sense attitudes quite accurately.
On the basis of the above, it seems to me that autistic people have several areas of social cognition that work very well indeed, or work differently from the normal in a way that could be seen, depending on context, as adaptive rather than pathological. We can connect to children and some of our closest people by using eye contact, although we don't choose to engage in it extensively. We can use eye contact in emergency situations, and in non-threatening joint physical activity. It seems like the eye contact is 'lacking or abnormal' in a very specific and selective way, mainly in the case of sustained eye contact with adults in the absence of signals that would cancel the 'threat' signal inherent in such situations. We can also recognise who is at the top of a hierarchy, and respond to support measures perceived as demeaning or controlling by aggression, refusal or avoidance, depending on the situation - thus, we have mechanisms to avoid being completely subdued. We detect the difference between friendliness and hostility, and we detect similarity between other autistic people and ourselves, often having a more immediate empathy towards the autistic person than towards the normal.
2. Rigidity in thinking
Autistic 'rituals and routines' are taken as signs of rigidity in thinking characteristic of autistic people. I find this doubtful, at the very least an over generalisation. Moreover, I believe that lack of pretend play may have causes quite separate from those that lead to 'ritual and routine'.
Although the claim of a lack of imagination in autism has been largely abandoned, it is hard to see how 'ritual and routine' could not imply it. They are obviously terms to describe non-imaginative activities, showing a lack of function and understanding, implying a psychological problem to be remedied from the outside. Wing (1996) invites people to observe autistic children longer than most normally do, to see that their elaborate 'rituals' do not change, and are therefore not signs of creative thinking. I would like to invite everyone to observe the children - and adults - even longer, to see how the 'rituals' do change; the autistic person invents the 'ritual', modifies it over time, and eventually abandons it in favour of a new creation. I do not see how one could overlook the fact that complex activities do not suddenly come into existence out of nowhere, unless one is, consciously or unconsciously, wanting to belittle the abilities of the autistic person.
I believe that the 'ritual and routine' behaviours are highly heterogeneous in form and function, and should not be lumped together as signs of any kind of single deficiency. Many autistic people report that a number of such activities are necessary and useful for them, involving no negative effects except dislike by other people. This is also my own experience, so I take the view of Baron-Cohen (1999) that the term 'obsessive' should not be used in this context. Autistic people may exhibit also obsessive behaviour, but it is not really known whether this is more common than in the population generally. Where I've seen and experienced clearly obsessive behaviour, it has been connected to extreme long-term stress situations.
I tend to see inventiveness in creating novel and unique 'routines and rituals' as an actual sign of flexible, independent imagination. One function of these activities is obviously play. In a social psychological view, play is seen as 're-creating' culture; children select elements of their surrounding culture, and by incorporating them into play, give them personal meanings, adopting and modifying cultural beliefs (Corsaro, 1997). Much of this normally happens in social play. If social play is inaccessible or uninteresting to the autistic child, it would be only natural to increase the amount of play with physical aspects of one's cultural and natural surroundings. It might be easy to label such play 'ritual', simply because it is hard to see the personal meanings and emotions the autistic person attaches to it. Much of social play looks also ritualistic, when seen from an autistic point of view.
Tendency to line up and systematically arrange objects has been observed to be a common activity in deaf children with no language (Sacks, 1989). It hasn't been taken as a sign of mental rigidity in them, and I don't think it should be taken as such in autistic people either. One might assume that it has to do with re-routing the language faculties of the brain, by creating visual categories and concepts to aid thinking, since the two groups share problems with pragmatics of language. I find this likely in the light of many able autistic people reporting a preference for visual/kinaesthetic thinking (e.g. Grandin, 1999), even when language does not seem appreciably impaired. In practise, 'reducing autistic behaviour' might then mean reducing engagement in useful self-teaching methods.
A very common use of 'ritual and routine', as reported by able autistic people, is reduction of anxiety. If many autistic people do have generally high or poorly modulated arousal levels (McDonnell and Hardman, 1996), activities that create a sense of comfort through familiarity, block out stimuli that could cause further arousal, or activate the parasympathetic nervous system, answer a clear need - once again, I do not see what with a simple need to alleviate discomfort has to do with mental rigidity.
There is some evidence of autistic people lacking ability to relate past events in narrative form (Jordan, 1999). 'Ritual and routine' could in this case serve to utilise long-term implicit memory instead of personal episodic memory to navigate everyday situations, as the latter may be poor (Powell and Jordan, 1993). Structuring the environment and providing visual cues may reduce frustration caused by such memory problems, but if such support is too extensive, it might also take away the need to create personal adaptations, and lead to unnecessary dependence in the more able autistic people.
Powell et al (1994) have suggested that a lack of 'experiencing self' may be fundamental to autism, and lead to the emergence of repetitive behaviours. Jordan (1999) has extended this by hypothesizing that autistic people's 'inability to mark their own effects on the world', could lead to seeking forms of sensory stimulation that require no activity, and thus no sense of self. Why one would seek something that reduces a sense of self, if one already has a lack of this, is unclear to me, and I would tend to think that memory problems cause difficulty in maintaining sense of self, rather than the other way around.
Some of the 'ritualistic' activity seen could also result from a simple lack of exercise and physical stimulation. Ordinary sports activities are not always accessible or desirable for autistic people, and some might do physical 'routines' because they produce pleasant sensations and relaxation. Social interaction is also a source of physiological stimulation, so autistic people who have no access to this might need to compensate for this.
Last but not least, I believe that unusual forms of cognitive ability may be far more common in autism than people assume. Unusual abilities exhibited by autistic people tend to be written off as 'mysterious' or 'splinter' skills (presumably with gaping voids in between the splinters), without considering how they derive from the overall cognitive picture, or how they might be potential adaptations to evolutionary pressures. For example, good performance in the block design part of WAIS was taken as a sign of weak central coherence in autism (Frith, 1989), yet later studies have shown a preference for 'wholistic' processing, at least in the precategorical phase (Jordan, 1999). Somehow no one seems to consider the possibility of visual processing specifically adapted to being unusually flexible, allowing the person to see the whole first, and then proceed to details without the 'coherence' that blinds most people to them - and possibly back to the whole again, at will, thus lacking nothing but an 'automatic focus' that facilitates social sharing of impressions in most people. If we were to assume then that a person has highly developed visual abilities and conceptual thinking, but not enough language to effectively communicate the thought processes to others, the things he or she does might appear 'ritual' to the rest of the world, not because they lack content and meaning, but because other people lack the cognitive ability necessary to see the content and meaning - they might be coded in ways that are, effectively, invisible to the normal person.
To summarise, I feel it is not justified to assume that autistic 'rituals and routines' are signs of exceptional rigidity in thinking. Rigid attitudes may be present in autistic people, but these might just be natural responses to the situations we face. I do not believe that reduction in 'ritual and routine' can automatically be taken as a measure of success when providing for autistic people. A reduction may signal a positive outcome, if for example the person's enjoyment of social interaction increases, and there is less need to alleviate boredom, but it could also mean that the autistic person is abandoning emotionally meaningful or adaptive activities because of expressed or implied disapproval from the environment. This could, in part, result in what Jordan (Residential School lecture, Birmingham, Sep 2002) described as 'benign prisoners', autistic people who are docile and easy to handle, but seem to lack the energy and initiative to advocate for themselves and break out of the narrow niche allowed them by the support system.
3. Disorder of communication
Wing (1996) has stated that it is likely that a “more fundamental impairment of psychological function underlies the triad”, suggesting a lack of central coherence as described by Frith (1989) as a likely candidate, and further that at an even deeper level one might find a difficulty in assigning different degrees of emotional significance to experiences. The latter possibility does not seem to be often considered when exploring the communicative ability of autistic people. A lack of performance is automatically assumed to show a lack of ability rather than lack of desire. As mentioned before, I believe that the sheer discomfort involved may stop many autistic people from seeking direct social interaction; thus, it would also cause a disinclination to use communicative skills in social situations, or a lowering of ability due to having to fight the discomfort.
Many autistic people communicate brilliantly on the Internet, when freed from the baffling face-to-face situation, particularly the time pressure involved. Many also respond to people who act in discreet, non-invasive manner, as described by for example Murray (1999; 2001). Reports on the narrative ability of autistic children show highly contradicting results, and I feel this might be due to subtle differences in the way the narratives are elicited, leading to differences in the children's motivation and anxiety levels (Bruner and Feldman, 1993; Capps et al, 2000). An approach that does not cause anxiety, allowing the child to focus on an object rather than just the researcher and the verbal process, seems to elicit a wide repertoire of communicative language, while the structure of the narrative remains different from the normal in a recognisably autistic manner (Capps et al, 2000). The remaining difference seems to be in the overall temporal organization of the narrative, and a different focus of attributions so that emotions are not seen as causes of action; the children do not seem unaware of the purpose of the narrative, or the listener as a separate conscious being. This agrees with my experiences of autistic Internet communities and discussions. Narrative and comment are the very essence of peer support on the Internet, and both are used fluently. Spoken exchanges do have a characteristic style though, suggesting the participants often have some difficulty keeping track of what they have already said, and how much tangential information can be fitted in. In a group, the effect may be that of long, carefully constructed little presentations being given in turn, while interruptions and distracting comments are not appreciated. Formal structuring is frequently necessary, as otherwise the group will disintegrate into pairs of people talking to each other, while some withdraw completely. On the Internet, with the possibility of rereading and editing, and with no danger of interruptions, the form may in some ways approach more 'normal' conversation.
I do not see why a 'lack of experiencing self' would be necessary to explain the autistic person's problems with narrative language. If we go back to very basic neuropsychology (Atkinson et al,), we find that better recall using context-specific cue is by no means specific to autism. One could perfectly well assume that there is a primary deficit of short-term explicit memory, or processing of information from this to store it, leading to defective construction of events as and when they happen. The faster things happen, the more load there would be on these systems, leading to a characteristic feeling of 'overload', or inability to 'take things in'. This is a stressful situation, easily leading to a feeling of detachment and lack of control, such as anyone can experience when pushed to the limits of their capacity. Obviously, testing explicit memory in autistic people could give some clues as to whether this is true. In an experiment measuring language functions of autistic subjects, Bailey (2001) found an autism-specific lack of ability to connect an ambiguous word to a preceding sentence, if the delay between the sentence and word was longer than 0,5 seconds; if the word was given immediately, the context dictated the interpretation of the word. This was seen as a sign of short-term memory problem, leading to a lack of 'central coherence' in language interpretation, which could in turn cause exactly the kind of problems in recall and description that we see in autism. The autistic person might have difficulty maintaining any mental context long enough to use it effectively, as most people do, to select aspects of sensory information that are relevant to that context and form a recognisable event. Or, as I find more likely, the memory 'deficit' could be specific to social situations and narrative as a highly social form of language. If we assume a different focus of attention, such that the autistic person's attention is naturally drawn to non-social aspects of any situation, it could be that the autistic person remembers just as much of any given situation as a normal person. Instead of automatically selecting things that can be incorporated in narrative, the autistic person would select things that potentially support the development of skills related to the physical aspects of that situation. The person's self-image could then be based on 'the skills I have' rather than 'how I have acted and how people responded', i.e. it would not be based on narrative, but it would not be non-existent either.
A major factor that is easily ignored in studies on communication is the other side of the communication. Studies like the ones on children's narrative abilities mentioned above say very little about how exactly the researchers are communicating with the autistic children. I believe that unconscious attitudes play an important role, which has been totally neglected in research. It is known that mothers with facially deformed children show less nurturing behaviour than those with normal children, although they report that they love them equally and treat them equally with their other children (Durkin, 1995). Mothers of autistic children sometimes admit to feelings of extreme irritation, although mostly they are ashamed of such feelings and there is little open discussion. I believe that autistic children may, just like the deformed babies, from an early age receive significantly different feedback for their attempts to communicate from what normal children receive, and that this actually continues in adult life. Even when the behaviour and the content of the communication has been very close to what is expected, there may be a subtle 'wrongness' about a facial expression or a tone of voice that causes responses to be tense, hesitant or even stop people from reacting altogether. Many able autistic adults immediately recognise what I mean if I mention 'invisibility', a phenomenon where people seem to look right through the autistic person despite desperate efforts to attract attention, or for example go looking for the person when he or she is clearly visible in the same room. Perhaps there is some kind of signal of 'presence' that people tend to broadcast through their posture and movement, and that does not happen in autistic people.
I would not wish to bring back a mentality of blaming the parents; no neglect or lack of caring should be implied. Studying such phenomena might help parents to observe and handle their own responses more consciously and reduce their anxieties, but I do not feel a subtle change in parental attitude would make a huge difference in an autistic person's life. It is school and working life that seems to handicap us, not home environment. While these phenomena have not been researched, I find that programs designed to teach communication tend to work on the naïve assumption that the social environment the autistic person faces is the same environment as the normal person's; words like 'polite', 'correct' and 'appropriate' tend to figure more than, for example, 'effective'. I believe the environment is a different one, best described by autobiographical texts, e.g. the examples collected by Sainsbury (2000). It requires different skills, for example much more extensive methods of self-defence, and unusual means of convincing other people of one's actual intelligence level - things that people with various disabilities might recognise and be able to teach more effectively than someone with no corresponding experience. These goals cannot always be achieved by means normally considered polite or appropriate. Thus, 'inappropriate' communication might sometimes be better interpreted not as lack of skill, but possibly the only existing effective communication in a situation that no normal person ever has to face.
Summary - an Evolutionary View
Writers like Baron-Cohen (2001) and Murray (1999) have suggested some evolutionary advantages connected to autism. Lay theories suggesting similar things turn up now and then in the Internet communities. I find, however, that these address autism in a fragmentary manner, seeing it as mainly a disability, with some coincidental positive outcomes that maintain a balance in gene frequencies. Lay theories also often selectively pay attention only to positive features, and incorporate teleological ideas. Jordan (1998) has addressed the issue in a more holistic manner, yet little has been done to explore the implications of the evolutionary element to theory or provision in detail.
I suggest that what is currently described as autism could be largely seen as a particular kind of evolutionary strategy, adopted by an organism in specific circumstances. These circumstances could represent one of two main categories: genetic and brain trauma-related, with possible overlap between the two. In the first case, development could proceed down the autism pathway due to powerful genetic factors, as the characteristics involved may have been advantageous particularly when resources have been scarce and the human population spread thinly over large areas, and investment in social hierarchy generally low in the whole population. In situations like primitive societies living in harsh conditions, cultural acceptance and utilisation of autistic features could mask fairly high incidences. In the second case, autism could be a 'last resort' to salvage some of the individual's fitness, since he or she would be unlikely to ever successfully negotiate social hierarchies, although these are a major factor determining fitness in most of the population. The key common denominator would be an evolutionary advantage connected to a relative reduction of investment in social activities, and a corresponding increase of investment in dealing with the physical environment. This could have led to an increased likelihood of developing 'unusual' skills that could either be used as currency to negotiate a position relative to a group, or improve chances of survival in relative isolation.
Unusual abilities exhibited by autistic people tend to be written off as 'mysterious' or 'splinter skills', without considering how they derive from the overall cognitive picture, or how they might be potential adaptations to particular evolutionary pressures. I would suggest that a co-ordinated shift in several cognitive abilities could serve the purpose of turning the person's focus of activity away from the social sphere, and into the physical world. A relative reduction in the reliance on explicit memory use and narrative language ability, and a corresponding increase in reliance on implicit memory and visual memory, could provide the individual with a potential to develop unusual skills that would be useful in a natural environment and a primitive society. This potential could be close to what Baron-Cohen calls 'systemising'. An emotional attitude towards physical objects and aspects of the world, leading to a tendency to 'obsessively' pursue activities related to them, would further serve to keep the individual focused on developing skills that are truly exceptional, and thus potential currency for negotiating a place in society. In the modern world, much of the adaptive value would be lost, since there is an abundance of man-made objects and constructions that easily distract the autistic mind from essentials - only the fortunate few who are naturally drawn to useful pursuits, and have scientific, technical or artistic ability, seem to do quite well. Throughout most of human evolution, availability of materials and the simple force of hunger would have been powerful structuring factors, steering the individual towards adaptive activities. Thus, some of the seeming increase in autism would be likely to be an increase in the problem modern societies have with autism.
On the basis of the above, I would suggest that autism might be seen not only as some positive features connected to a basic disability, stemming from a single shared psychological feature, but instead a co-ordinated developmental pathway that has in the past been adaptive as a whole. Furthermore, autism might still be the 'best bet' for survival in some environments and circumstances, by ensuring a minimum of engagement in social interaction for safety and reproductive purposes, possibly also co-operative participation in physical activities, while minimising participation in rivalry and hierarchy building when these are likely to be too costly. This would mean that autism could well have evolved several times, slightly differently, in different populations, and that there could be several genes involved, expressed in a co-ordinated manner. An obvious prediction would then be that autism should actually appear at different frequencies in different populations, and that these differences could be detected if truly objective, culture-independent measures of autistic features could be found.