This set of notes begins with a reference to the analysis of motor skills and reflexes among infants as a possible indicator of Asperger Syndrome.
There is then raised some question whether the matter of exposure to mercury has really been resolved, with the implication that a diagnosis of ASD or autism could reflect a range of environmental triggers operating upon individual levels of susceptibility.
The next section provides more evidence about characteristic styles of verbal and non-verbal information-processing among individuals with autism, with the implication for careful planning of the presentation of material and monitoring of the comprehension and interpretation of the content.
The final section describes some anxiety over the means of fully eliciting the views and wishes of the young person with autism when it comes to planning provision and arranging transitions from one setting to another.
The work of Teitelbaum et al (2004) begins with some question whether there really are clear and unarguable criteria for Asperger Syndrome which has been deemed part of the spectrum of autistic disorders albeit perceived as a differentiable disorder in its own right.
These authors argue that relative ease of acquisition of language skills separates Asperger Syndrome from autism.
Asperger Syndrome may not be recognisable until relatively late in the child’s development – around 6 or 7 years of age – because of the absence of the severe language and associated social disabilities which serve to identify the child with autism whose diagnosis more typically occurs around the age of 3 years.
However, it is suggested that the Asperger child may be recognisable from allegedly characteristic abnormalities in motor style and performance, and that this motor pattern provides an early and valid means of distinguishing Asperger Syndrome both from autism and from normal developmental patterns.
The development of motor autonomy is seen as a central goal in the first year of life; and deficiencies in this respect can help to identify both the autistic and the Asperger child. The former may show a combination of motor and communicative deficits, while the latter may not stand out in terms of language weaknesses, but will share the pattern of motor deficit or delay.
The authors refer to the “ Eshkol-Wachman” movement notation which was developed as a means of recording dance sequences so that dancers can learn and rehearse the required steps and movements, and the choreography can be stored for use at any later revival. Thus, the notation is very detailed in recording movements.
This system has been used by the authors to analyse the videotaped movements of infants formally diagnosed with Asperger Syndrome.
In particular, the analysis focused upon mouth movements, patterns of lying down, getting to a standing position, sitting, crawling, falling, and reactions to being tilted.
It was found that deficits or anomalies were clearly identifiable in the infants diagnosed with Asperger Syndrome. Those observed in the Asperger sample but not in a sample of normally developing infants included …..
The authors concluded that defects or anomalies in motor patterns or reflexes are relatively easy to recognise and can be legitimately used as early warning indicators. When the motor development is observably delayed, or when infant reflexes either fail to appear or are maintained too long, there will be negative effects upon other aspects of behaviour, so that these motor anomalies can be used as early markers for abnormal neurological development of a kind characteristic of autism or ASD.
While recent and converging evidence has suggested that there is no risk from vaccines which contain the mercury-based preservative thimerosal, a study by a working group from the University of Arkansas (James et al 2004) has suggested that it may yet be premature to rule out some role for the effects of mercury in autism.
This group has identified a group of children who have a genetic mutation which may increase the predisposition towards developing the signs and symptoms of autism when exposed to mercury from the eating of fish or from other sources.
The risk results from the failure to produce sufficient quantities of glutathione, an amino acid involved in cell processes, including the metabolism of certain toxins.
The group went on to highlight a consistent difference between a sample of children diagnosed with autism and a normally-developing control sample of children in respect of all the indicators of the body’s ability to maintain an adequate glutathione defence.
They posed the question whether reduced antioxidant defence mechanisms mark out a group of individuals who are significantly sensitive to the effects of a range of environmental chemical toxins, and it is this sensitivity which may underlie the increases in the rates of behavioural and learning disorders.
The group stressed that this is a relatively small piece of evidence in a very large field and that there is still scope for debate over what is cause and what is effect.
Nevertheless, while acknowledging the considerable evidence for no link between routine immunizations and autism, it was suggested that the question of possible effects of exposure to mercury should still be included within ongoing studies of when and how the condition starts and of the (many) genetic and environmental contributions.
(The implication may support the view that cases of autism and ASD represent a multi-facetted and multi-causal condition where eventual diagnosis is a matter of a unique interaction between individual susceptibility, including genetic predisposition, and environmental experiences and pressures.)
Meanwhile, ongoing research at the Autism Research Centre of Cambridge University is highlighting the possible role of enhanced testosterone levels among children subsequently diagnosed with autism.
The investigating team, Knickmeyer et al (2004), has found that there is a link between the level of prenatal testosterone observed via samples of amniotic fluid and … 1. reduced eye contact among one-year old infants; 2. lower vocabulary at 18 months; 3. reduced communicative skills at 48 months … (all compared with typical performance among normally-developing children).
The research will be extended to determine whether an enhanced prenatal testosterone level is a valid marker or predictor of later diagnoses of specific language disorder or of ASD, with possible implications for early identification of risk and for equally early intervention or preventive strategies.
( One notes that, in a series of investigations concerned with the aetiology of dyslexia, there has been developed the hypothesis that high levels of testosterone are associated with slow growth of the left hemisphere which, in some severe cases, impacts upon language and communicative functions. The enhanced testosterone level is also found to increase the susceptibility to problems in the immune system.
[ However, again, the issue of causes and effects may still require unravelling.]
It is further argued that there are sex differences in hemispheric specialisation in that, among males, verbal processing is the more focused upon left hemisphere functioning. Among females, there is a greater degree of bi-hemispheric functioning in verbal processing.
One notes, too, the evidence for a tendency towards hemispheric asymmetry in favour of the right side rather than the more common left-favoured asymmetry among samples of boys with autism and ADSD [ and those with dyslexia ].
This susceptibility to limited communicative performance (and, thus, inhibited social interactions) may help to explain the greater incidence of autism and ASD among males; and one notes the current view [ as set out by Baron-Cohen and associates ] that some of the characteristics of autism and ASD could be seen as extreme versions of typically male behaviour.)
A series of studies at the University of Pittsburg School of Medicine has been investigating the cognitive capacities and weaknesses of individuals with autism and controls in order further to determine whether there is a typical profile that may be attributed to autism and ASD.
Firstly, Minshew and Goldstein (2001) examined the issue of intact or impaired memory functions in autism.
They administered a whole battery of tests of visual and auditory memory to a sample of high-functioning adolescents and young adults and to a sample of matched controls. Their hypothesis was that there would be indications of memory weakness in the autistic sample but that this would not be more evident in either of the sensory modalities; instead, the weaknesses would reflect a general problem with forming or using organising strategies.
An associated hypothesis was, therefore, that the memory impairment in autism would be more marked as the complexity of the memory task increased.
The results indicated that the two samples performed equally well on short-term memory and paired-associate tasks, but the members of the autistic sample performed significantly more poorly on a task involving learning a whole list, on immediate and delayed recall of a story, and on seeking to reproduce a complex geometric figure.
Performance on a maze learning task deteriorated progressively, compared to controls, as the complexity of the maze increased.
The authors concluded that their hypothesis was supported in that the sensory modality of the task was not a critical and discriminating variable, but what marked the autistic performance was a failure to establish any organising strategies and an inefficiency in new learning; a lack of capacity to use contextual cues in story of complex pattern recall, and a greater memory weakness according to the level of complexity of the material.
Information processing is confirmed as an area of key disadvantage.
( The concept of weakness in central coherence or in the ability to grasp the whole picture is reinforced; and there are implications for mainstream teachers in terms of the need for differentiated [ bit by bit, and repeated ] presentation of material even to older and higher functioning individuals with autism whose observable language skills may appear adequately fluent.)
Further studies by the same team include the following ……
Siegel et al (2004) investigated the commonly asserted view that there is a characteristic pattern of scoring on the Wechsler Intelligence Scale on the part of
(high functioning) individuals with autism, viz, verbal IQ lower than performance IQ with the lowest score on Comprehension and the highest score on Block Design. The authors noted that this pattern has been used as a means of further justifying an autistic diagnosis but held that the universality of this profile had not been demonstrated.
Accordingly, they administered the WISC and the WAIS to samples of rigorously diagnosed samples of children and adults with autism.
The analysis of the scores did not reveal the consistency of the verbal IQ lower than performance IQ pattern. Further, while the Comprehension and Block Design predictions were fulfilled, the size of subtest variability from the individual mean was small.
The conclusion was that individuals with autism can demonstrate a wide range of measured ability levels and patterns on these Wechsler tests, and it is not appropriate to talk in terms of some single characteristic profile pattern. Therefore, the advice given was that the use of IQ score profiles in the (differential) diagnosis of autism is not valid.
Goldstein et al (1994) had already shown that a typical autistic profile involved adequate procedural or “mechanical” academic skills (such as those involved in the completion of a number task), but there would also be some impairment of comprehension or interpretation of the outcomes. An answer can be produced, but what it means or how it may be applied are not necessarily recognised.
Their further study demonstrated a developmental aspect to this pattern in that, among younger (below around 13 years) high functioning individuals with autism, performance on tasks involving these mechanical skills and on at least some tasks involving complex interpretative skills was as good or even better than that observed among a control sample. However, with increasing age, this pattern changed in that the individuals with autism increasingly showed a disadvantage on tasks involving complex linguistic instructions. The pattern observed was of a gradual decline in the performance of autistic individuals compared to controls in terms of more demanding cognitive tasks, notably those involving interpretation and drawing implications or inferences, as well as those with a complexity of instructions.
Again, weaknesses in working memory and in information processing are implicated as critical for the functioning of individuals with autism.
A similar finding was produced by Minshew et al (1994) in comparing the performance of high-functioning individuals with autism against a control group matched for age, gender, socio-economic status and overall IQ.
As predicted, the two samples were not differentiable on tasks involving “mechanical” reading or spelling or computation. However, the autistic sample scored significantly more poorly when it came to comprehension of, and drawing inferences from, the material.
Further, the study by Minshew and Goldstein (1993) had already indicated that memory per se may not discriminate high-functioning autistic individuals from controls, but that the two groups could be separated when the memory task was made more complex involving the participants’ ability to cluster the material appropriately. The authors concluded that there was no support for an “ amnesic theory of autism ”, but that their findings were consistent with a theory linking autistic style to reduced neural connectivity and, thus, to deficits in the processing speed or capacity necessary for efficient organisation of information.
(A practical implication again highlights the likely dependence of children and young people with autism and ASD upon guidance by which to manage information or to organise the material presented into manageable and meaningful chunks which can be processed to become part of the longer term memory store.
The issue is not memory per se as much as having the material organised in such a way as to make it ready for memory storage.
The overall picture which emerges form this series of studies is that the individual with autism does not necessarily have any lack of the ability to attend to material presented, or to acquire the information, or remember it.
Problems arise when the tasks require more than a mechanical level of competence and when the required response involves comprehension of material which is complex or lengthy, or where verbal reasoning in the form of interpretation or inference is needed.
While experience and direct modelling of strategies would be likely to bring about some improvements in this information organising/processing capacity, it appears politic to maintain the view that much of the “core style” of autism may be resistant to change or that skills learnt in one setting may not generalise to other settings.
In other words, it is not so much the individual as the environment, including the classroom organisation and the manner of curriculum presentation, that requires supervision and monitoring to ensure that material presented [ and its implications and where it links to existing knowledge ] are understood and remembered.)
With regard to non-verbal processing, the work of Brosnan et al (2004) highlights the characteristic local rather than global style adopted by members of an autistic population when a visual stimulus is examined.
This style is differentiable from what might be considered typical among the population at large in the manner of processing visual material where there is a common global advantage.
For example, individuals with autism may be more competent than members of a control sample in dealing with the block design test or the embedded figures test because they focus upon individual components of the material and are not distracted by any tendency to examine the material as a whole. In the same way, they may be able to avoid being confused by visual illusions.
Thus, while the emphasis upon local instead of global processing can have some positive effects, it remains largely the case that this visual-processing style places individuals with autism at some disadvantage, given the common outcome of weak central coherence … ie, a failure to see the whole picture because of the focus upon (disjointed) details with consequent problems in gaining overall understanding and in planning.
Typically-developing individuals tend to operate according to the gestalt principle in that the whole is usually seen as more than the sum of the individual parts. This is illustrated by responses to an illusion where two circles of exactly the same size are presented. However, circle 1 is surrounded by larger circles, and circle 2 is surrounded by smaller ones, with the likely outcome that circle 1 is judged to be smaller than circle 2.
Happe (1996) explains the illusion by describing how all the circles become part of a whole-figure gestalt which brings about a shift in the participants’ perceptions of the component parts.
In a similar way, normal processes of face recognition are disrupted when “relational” properties are changed … for example, if the face is presented upside down, or if only part of the face is visible. However, individuals with autism may maintain their usual competence at face recognition under these circumstances because they operate at a local processing level, focusing upon details rather than the whole figure.
The implication is for some problems with coherence at a quite basic perceptual or attentional stage, and not just when dealing with higher-level challenges as involved in correctly rendering sentences containing homographs (“ There was a tear in her eye ” : “ There was a tear in his coat ”).
In their own study, the authors assessed samples of 10 year old children with autism and non-autistic controls matched for age and ability who were drawn from an MLD population. The tasks involved the presentation of sets of visual stimuli and observing how the children examined or organised the material.
For example, pairs of stimuli were presented …. I I I I I I I … and they were asked to identify the odd one out, with a view to determining any differences between the groups in terms of their use of gestalt principles of proximity, closure, etc..
The results indicated that the autistic sample made significantly less use of grouping than the control sample. Their manner of organising the stimuli in terms of meaningful groupings was no better than chance … unlike the control children who did consistently apply gestalt principles.
In other words, the autistic style involves an information-processing bias which is not only characterised by a global advantage but also by a failure to adopt gestalt grouping principles. Elements of a visual array are not seen as perceptually coherent units.
(The implication that one might draw is for a need to remain aware of these perceptual problems and avoid taking for granted that children with autism or ASD will draw information from visual sources including graphs or diagrams or maps. Where the information presented is simple, there may be no problem … such as a basic graph using columns to indicate the birth month of the children in a class … but more complex visual material may not provide the children with the information intended if they are required to examine how parts relate to each other …. such as reading a map to determine rapidly how to get from one point to another, or why population density differs from one part of a country to another.)
Recent and local cases where parents have expressed their wish for a move of their son or daughter with autism to a residential school or college have provided a reminder of the need for the rights and choices of that individual to be part of the overall set of data on which decision making will be based. The same need will apply in the case of a student whose parents are seeking a transfer from a mainstream school to a day specialist school for autistics.
The guidelines from the National Autistic Society (Code of Practice, Document 2) are concerned with managing the situation faced by parents when their autistic son or daughter reaches adulthood and has the opportunity to be admitted full-time to a residential establishment. However, similar anxieties or dilemmas may arise in the case of a younger person with autism for whom residential placement or specialist placement is being considered … often because of the parental feelings of being unable to manage the behaviour or to provide the level of care or supervision that is required.
While the above situation may evoke discussions about the best means of maintaining the least restrictive provision, and about the division between education and care (and whose responsibility it is to fund the residential element of the student’s placement), it still seems appropriate to ensure that he or she is aware of what is being considered and that any feelings are given voice.
In the case of a student with autism whose behaviour disturbance is severe and self-evidently beyond the resources of the parents to manage during the non-school period, even with access to available support, the need may be clear; but it prompts the question of who is to attempt to gain the student’s feelings.
In the case of the school student which prompted this set of notes, there is evidence of good progress socially and scholastically in the mainstream school, but the parents have found problems in managing behaviour and describe him as unhappy in the current school because he stands out from peers. The concern is that the boy himself has made no comments on this issue beyond his repeating the parental statement that a transfer is going to be arranged.
The NAS document argues that client self-advocacy must be promoted and encouraged even if the nature of the autistic difficulties in coping with choices, sharing a meaningful discussion, and facing the prospect of change, will make for some problems in the process of consultation.
Again noting that the NAS document is written about young adults, it still seems reasonable in the case of a child with autism or ASD in the latter stages of schooling to be involved in the decision-making process. Their suggestions include the possibility of arranging access to an independent person who will not have the vested interests that might apply to the parents, teachers, or LEA professionals; but there is also an acknowledgement that parents, or staff in many cases, have a continuity of contact with the individual which may well underlie an existing awareness of his or her feelings and aspirations.
These issues become all the more significant if the transfer is to a school where there is a residential facility and where the student may spend some evenings or nights at the school in order to share the clubs and activities available outside classroom hours. Even limited opportunities of this kind involve a considerable shift of responsibility from parents to residential staff, and could be seen as not that different from a care arrangement.
Meanwhile, there might be relevance in determining, in the case of a school-aged individual with autism, what the most appropriate arrangement will be at 16+ since this may carry implications for how best to prepare for the transition during the last year or two of secondary schooling.
These thoughts are penned in order to share some of the anxieties experienced by the present writer on attending reviews where opinions on the part of the adults, parents and professionals, may be firmly held, but it is not clear what are the true feelings of the student him or herself. The anxiety is enhanced when the views of the parents and staff may be equally sincere but point to quite different recommendations … perhaps reflecting their inevitably different perspectives and experiences.
One possible implication is that of extending the current policy of inviting the students to attend their reviews in terms of ensuring time (and perhaps establishing a specialist facilitator role) for a more organised system of encouraging or eliciting and presenting their perspectives, and ensuring that, where choices are involved, the students are maximally aware of the reasons why decisions are being faced and of the nature of the options.
* * * * * * *
Brosnan M., Scott F., Fox S., and Pye J. 2004 Gestalt processing in autism. Journal of Child Psychology and Psychiatry 45(3) 459-469
Happe F. 1996 Studying weak central coherence at low levels. Journal of Child Psychology and Psychiatry 37 873-877
James J., Goodman S. et al 2004 Gene mutation could link mercury to autism risk.
Report of the Environmental Working Group of the Food and Drug Administration. Washington : DC
Knickmeyer R., Baron-Cohen S., Hoekstra R., Raggatt P., and Manning J. 2004 The role of prenatal testosterone in development - description of ongoing research at the Cambridge Autism Research Centre.
Goldstein G., Minshew N., and Siegel D. 1994 Age differences in academic achievement in high-functioning autistic individuals. Journal of Clinical and Experimental Neurology 16(5) 671-680
Minshew N. and Goldstein G. 1993 Is autism and amnesic disorder ? Neuropsychology 7(2) 209-216
Minshew N., Goldstein D., Taylor H., and Siegel D 1994 Academic achievement in high-functioning autistic individuals. Journal of Clinical and Experimental Neurology 16(2) 261-270
Minshew N. and Goldstein G. 2001 The pattern of intact and impaired memory functions in autism. Journal of Child Psychology and Psychiatry and Allied Disciplines 42(8) 1095-10101
Siegel D., Minshew N., and Goldstein G. 1996 Wechsler IQ profiles in diagnosis of high functioning autism. Journal of Autism and Developmental Disorders 26(4) 389-406
Teitelbaum O., Benton T., Shah P., Prince A., Kelly J., and Teitelbaum P. 2004 Eshkol-Wachman movement notation in diagnosis : the early detection of Asperger Syndrome. Abstract : PNAS 101(32) 11989
© Mike Connor 2005.
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