Know What You Don’t Know – Part II

My last post Know What You Don’t Know may seem a bit abstract. Let me make it more concrete. Like last time, I am going to use a story to make my point. This time, the story concerns an 8 year old boy, who was referred to me for evaluation of poor school performance and temper tantrums. Let’s call him Billy Smith (not his actual name, and I have altered the history a bit to preserve the family’s confidentiality). Billy makes limited eye contact, and has an obsessive interest in the solar system. He prefers to play by himself, and has no close friends. Academically, he did well in kindergarten and first Grade, but lately he seems to be having trouble with reading comprehension. He has difficulty with transitioning between tasks at school, and at home he gets into frequent arguments with his father. Billy’s father is a software engineer. At work, Mr. Smith does everything “by the book.” At home, he expects his wife and son to follow all rules to the letter. “Billy is always focused on himself,” Mr. Smith declares during my interview with mom and dad. “He’s stubborn, and he needs to learn to obey his parents.” Mrs. Smith says nothing, but she looks unhappy.

After I finish interviewing Mr. and Mrs. Smith I send them back to the waiting room, and call Billy into my office. My evaluation includes assessment of “Theory of Mind” skills, and “Central Coherence” (the ability to see the big picture). Can Billy carry on a conversation? Does he get verbal humor? Can he figure out what’s going on in pictures? Can he make inferences from written material? Here is one of the passages I ask Billy to read:

The Boat

Henry goes to a large lake in the summer. Last summer a motorboat sank near his house. The boat had ten men in it. The man who was running the boat brought it very close to the shore when the water was low. The boat hit a big rock under water. The water came in very fast. All of the men swam to shore.

Billy reads the passage without difficulty. Then I say to him: “There’s someone in this story who might get in trouble. Who is it?” (People who are “neurotypical” get the answer immediately: The man who was running the boat. NT’s don’t have to think about it; the answer comes automatically. On the other hand, if you are on the autism spectrum, you may need to reason it out, step by step: “The boat sank. That was a bad thing. The man who was running the boat brought it very close to the shore when the water was low. That led to the sinking. Therefore, he is the one who might get in trouble.”) Billy is completely baffled by my question. “Henry?” he replies, hesitantly. Then “The ten men?” He simply can’t put the pieces together.

My diagnosis: Billy has ASD. His ASD has gone unrecognized until now, partly because academic tasks in kindergarten and 1^st grade are based on rote memorization. It’s only in 2^nd grade that there is a shift to inferential learning. This is why Billy’s grades have been slipping. Likewise, his difficulty with transitions at school and his argumentative behavior at home are due to cognitive rigidity rather than ordinary defiance. I see it clearly. Now, my job is to get mom and dad to see it.

I send Billy back to the waiting room, and call his parents back into my office. I begin describing my findings, but dad interrupts angrily: “I don’t see the point of any of this! What my son needs is more discipline!” Rather than debating dad, I decide to play a hunch. “Here’s a paragraph I asked Billy to read,” I say to dad, handing him the page about Henry and the boat. I’d like you to read it out loud.” After dad finishes reading, I take a deep breath and continue: “I asked your son ‘Who is it in this story who might get in trouble?’” Then I repeat the question directly to dad: “Who is it?” Dad looks up from the text and states softly “I don’t have any idea.” Mom’s jaw drops.

“Mr. Smith,” I tell him, “I believe you when you say you ‘don’t see the point.’ That’s because you have some of the same issues as your son. I recommend that you be evaluated by a psychologist or psychiatrist, to see if you have Asperger Syndrome or High Functioning Autism. If my hunch is correct, then getting a diagnosis confirmed in yourself will make a huge difference in your own life, as well as your son’s.” I glance over at mom. She is already putting the pieces together: All of a sudden, her husband’s rigidity and emotionally distant behavior make sense, as do his obsessive interests and insistence on following prescribed rules. He is not an uncaring tyrant; he is a good husband with Asperger Syndrome. With a diagnosis in hand, there is a lot that can be done via family therapy, cognitive behavioral therapy, and (possibly) medication, to reduce family strife and maximize Billy’s academic progress. Dad still doesn’t know what he doesn’t know, but with counseling he will eventually learn. Not only will this be helpful to him in his own life; it will improve his son’s prognosis.

That’s the advantage of knowing what you don’t know.

Continue to part III – Indistinguishable from Normal – Conclusion

Until next time.

James Coplan, MD is an Internationally recognized clinician, author, and public speaker in the fields of early child development, early language development and autistic spectrum disorders. Stay connected, join Dr. Coplan on Facebook and Twitter.