Describe the three main areas of psycho-social difficulties experienced by people with ‘autism spectrum disorders’. Discuss how psychologists/healthcare professionals and carers can best support individuals in these areas in their daily life.
Unlike Kanner assumed in 1943 autism is not a distinct and definite disorder (Wing & Gould, 1979). Wing and Gould (1979) state that autism shall be classified together with further disorders containing developmental issues. They wished for autism being seen as a spectrum and the end of defining sub-groups (Wing & Gould, 1979). This desire was met by the edit of the “Diagnostic and statistical manual of mental disorders (DSM-5®)” in which the condition is referred to as the “Autism Spectrum Disorder” (ASD) (American Psychiatric Association, 2013). At a later date Wing, Gould, & Gillberg (2011) declare that there are several “autism spectra”. The authors also explain while referring to experience in making a diagnosis, that dissociating between the multiple syndromes belonging to ASD is challenging task. It is common that patients have symptoms from various subgroups or that the occurring symptoms change through the years (Wing et al. 2011).
In 1979 Wing and Gould coined the term “Triad of Impairments”. The authors described three areas in which individuals with ASD show fundamental difficulties: “Social interaction”; “social communication”; and “social imagination” (Wing, 1981). Researchers often modify the last-named element. It is described as “flexibility” (Forrester-Jones & Broadhurst, 2007) or “repetitive activities in place of imaginative symbolic interests” (Wing & Gould, 1979). The issues in these three fields steadily appeared jointly in autistic individuals, which led to the assumption of dealing with a triad of abnormalities (Wing & Gould, 1979).
Wing et al. criticize the fifth version of the DSM for neglecting the difficulties in social imagination, replacing this third element by “restricted behaviour” and merging the issues in social interaction and communication into one criterion (2011). For an exact and complete description of the established criteria please refer to the “Diagnostic and statistical manual of mental disorders (DSM-5®)” (American Psychiatric Association, 2013).
While studying the meta-analysis conducted by Hayes and Watson it becomes clear, that parental stress is a major issue for parents of children with ASD especially compared to parents of ordinary developed children but also compared to parents with otherwise disabled children (2013). By way of example, Holroyd & McArthur discovered parents of children diagnosed with ASD to experience more parental stress than those of children with Down Syndrome (1976).
Researches tried to investigate which characteristics of individuals in the spectrum may cause the increased amount of parental stress: Bebko, Konstantareas, and Springer discovered, that parents experienced issues in verbally articulating language as well as abnormalities in social interaction as extremely demanding and stressful (1987). Furthermore parents stated that they struggle with highly divergent levels of functioning in different areas (Bebko et al. 1987). Kasari & Sigman revealed that higher rates in “responsiveness” were associated with less parental stress (1997). In addition, according to Gabriels, Cuccaro, Hill, Ivers, & Goldson parents are especially afflicted with the rigid, monotonous way of behaving which can be seen in individuals with ASD (2005). On top of this, Van Berckelaer-Onnes, Van Loon, and Peelen demonstrated, while describing the case of J, that it is devastating to ignore the special needs for treatment that arise with an autism spectrum disorder. In the case of J caregivers only paid attention to his learning disability, while forgetting the ASD diagnosis which was associated with language impairments. The emerging issues in interpersonal communication produced challenging behaviour in J (Van Berckelaer-Onnes, Van Loon, & Peelen, 2002).
The fact that a lack of knowledge for the triad of impairments accompanied by insecurity in how to face and deal with those impairments causes negative, unpleasant feelings and the prevalence rate for ASD (according to Newschaffer et al. not less than 60 per 10,000 (2007)) is more than enough reason to discuss the “triad of impairments” and opportunities, how to achieve an improvement in these areas for individuals on the spectrum.
Wing et al. (2011) describes the impairments as following: Difficulties in social communication roughly include deficits in communicating non-verbally as well as verbally and issues in understanding and interpreting. Not proactively showing curiosity in emotional and physical closeness or reacting to other people around him attempting to get in touch characterize the “impairment of social interaction”. The “impairment of social imagination” involves the missing ability of being able to comprehend the repercussions of the own behavior and understanding the concept, that everyone has an unique mind with a diverse way to think and perceive (Wing et al. 2011).
After reviewing the existing research and consulting individuals from the autism spectrum Forrester-Jones and Broadhurst compiled examples for the impairments as mentioned above (2007): The social interaction impairment can be observed in problems to “greet others; start conversations; keep eye contact; smile; talk about feelings/emotions; have empathy for others; be aware of various social rules or adjust behaviours in response to social rules” (Forrester-Jones & Broadhurst, 2007). “Literal interpretations of language; difficulties while asking for help/expressing problems or difficulties with appreciation of social uses and pleasures of communication as well as talking (too loudly or too quietly)” (Forrester-Jones & Broadhurst, 2007) refer to the communication impairment. And finally “tendencies of attention to detail; difficulty seeing the bigger picture; adoption of rigid routines …; ritualistic behaviour; difficulty accepting and coping with change; obsessive interests …; difficulties with imagination … and/or internalizing own thoughts; exhibiting sensitivity to and shock at criticism or negative remarks” (Forrester-Jones & Broadhurst, 2007), which specify the imagination impairment.
While exploring the “triad of impairments” it became clear, that they cannot be clearly separated from each other. It is undeniable, that they not only overlap but also depend on and cause each other. Furthermore, especially regarding the communication impairment and the development of language in “high-functioning” individuals with autism (the term “high-functioning” is outdated though), it is not unlikely to find great differences.
Upwards of 40 percent of surveyed parents having offspring with ASD reported the belated or absent linguistic development as one of the first symptoms they noticed (Howlin and Moore, 1997). Individuals on the autism spectrum do not have the ability to use figurative speech and show difficulties with humor or irony (Happé, 1995). On top of that high-functioning autistics use excessively precise, explicit and formal language (Szatmari, Bartolucci, Bremner, Bond, & Rich, 1989). The difficulties in communication are based on social deficits such as lacking interest in or reaction to (attempts of) social exchange already well before the manifestation of speech starts (Paul, 2007).
There are two important aspects in the development of communication: “Intentionality”, which refers to the knowledge that by using communication one can wield influence on other people (Yoder & Warren, 1998), and “symbol formation”, the insight into the meaning of the figurative characteristics while communicating (Noens & van Berckelaer-Onnes, 2004). Those two aspects are at most poorly developed and therefore display the main point on which interventions should focus in order to enhance the satisfaction in the daily life (Noens & van Berckelaer-Onnes, 2004).
Individuals with ASD face trouble with recognizing emotional and social signs and appropriately reacting to them (Rutter, 1983). As mentioned above, this problem paves the way for impairments of communicative skills, but also difficulties in social interaction.
In early childhood those with ASD were described to be distant and uninvolved. They appear to be satisfied while being self-isolated (Prior & Ozonoff, 2007). Individuals on the spectrum do not acquire comfort or support on a regular basis and avoid social contact in general (Wing & Wing, 1976). They face great problems with engaging and maintaining friendships, because they struggle with “reciprocal social interaction at every age and every level of functioning” (Prior & Ozonoff, 2007). Besides these deficits it is also characteristic for people with ASD to behave societally inappropriate and intolerable (Prior & Ozonoff, 2007).
At this point it is important to introduce the concept of “joint attention” which implies the attempt of a person to bring the attention of his interaction partner to an item or occurrence. This involves reciprocal communication such as eye contact. Joint attention is therefore a crucial ability when it comes to social interaction but also for the development of language (Prior & Ozonoff, 2007). However, joint interest can hardly be seen in children with ASD (Prior & Ozonoff, 2007).
In addition, children with autism struggle with comprehending that other people do not feel in the same way as they do and do not know everything they know but, furthermore,
have their own feelings ask thoughts. This phenomena is caused by a lack of “theory of mind” (Gillberg, 1992). Gillberg states that due to his clinical work he has reasons to believe that children with ASD are able to feel strong emotions but cannot grasp the fact that other people around them do also have emotional experiences. Therefore it is a logical consequence that they are not able to naturally show empathy (Gillberg, 1992).
Discussing the “theory of mind” directly leads to the third impairment: Social imagination. The above explanations already touched the abnormalities in social imagination.
People with autism might show difficulties when it comes to understanding the mental state of interaction partners as already mentioned above. As well as foretell further events such as consequences to their own behavior. They do struggle with changes in the daily routine and new, unknown events. That does not mean that people on the spectrum are not creative (Prior & Ozonoff, 2007).