Interview with Dr Tony Attwood

Dr TONY ATTWOOD, a clinical psychologist based in Queensland, Australia, is widely ackowledged to be the world’s leading expert on Asperger’s syndrome.  Adam Feinstein spoke to him in Melbourne

ADAM FEINSTEIN:  Asperger’s syndrome has been recognised only relatively recently as a specific disorder. What do you think have been the major advances in our understanding of the condition over the past 30 years since Hans Asperger’s 1944 paper was translated into English?

TONY ATTWOOD: I think the main advances have come not from the research literature but from conversations and discussions with those who have Asperger’s syndrome, by reading not the scientific textbooks but their autobiographies. My greatest knowledge of Asperger’s has come from those who have it. Other great advances are the recognition of the challenges they face, and some way of helping them to cope. What may also be occurring is a change in attitude towards these attitudes and, I hope, a greater emphasis on their talents rather than their deficits.

ADAM FEINSTEIN  It used to be thought that individuals with Asperger’s syndrome had a normal command of language and that this, indeed, was one of the characteristics which distinguished Asperger’s from autism. We now know that the language used by people with Asperger’s is often stilted, not normal. I have spoken to Lorna Wing in the UK about the use of language in autistic children who, like my son, lost their speech, and I agree with Lorna that the nature of that language was non-social. My question is this: is the language used by people with Asperger’s resolutely asocial?  Is their obsession with talking about dinosaurs or lightbulbs or Winston Churchill a deliberate attempt to avoid meaningful social interaction?

TONY ATTWOOD:  You’ve asked many questions there. I’ll answer them one by one. The language profile in Asperger’s syndrome is different. Whether or not they were delayed in language when they were young children is, I believe, irrelevant. What is important is how they use language in a social context.  The art of conversation is not something in which they are naturally skilled. Also, they are not skilled in translating their thoughts into speech. And quite often, their thoughts may be visualisations or concepts which are not easy to convey in spoken communication but which may be conveyed by written or typed communication in e-mails, drawings, etc. But in a social setting, there are problems in the pragmatic aspects of language - especially social conversation. There can also be difficulties with regard to being somewhat pedantic, with rather odd prosody, and with not picking up the cues. But certainly, when I, as a clinician, socialise linguistically with someone with Asperger’s syndrome, it tends, from their point of view, to be somewhat artificial, contrived, laborious and clumsy. Yet, when you start talking about their special interests, then their eloquence, fluency and enthusiasm can be most captivating. So with speech, it depends on what you’re talking about.

ADAM FEINSTEIN:  In the case of those children who lost their language, some do begin to speak again. I have not seen this question asked before, so here goes. Do any of these individuals ever regain a sufficient level of language to warrant a diagnosis of Asperger’s syndrome? Has this ever happened?

TONY ATTWOOD:  At  present, we have not thoroughly examined the longitudinal development of those who have late-onset autism:  those who, as far as we can tell, have relatively normal development and then lose not only linguistic skills but social and play skills. Some of these children can - perhaps two, three or four years later - recover some of their speech and go beyond the level they had  reached before it started to disappear. We do not really know whether these groups have a distinct prognosis, but I do know that some who lose their speech may achieve speech later on and move into the description of Asperger’s syndrome rather than Leo Kanner’s classic autism.

ADAM FEINSTEIN:  On the vexed question of high-functioning autism versus Asperger’s syndrome, which continues to spark heated debate,  I may have misinterpreted a part of your talk here in Melbourne yesterday when you said that there was a simple cure for Asperger’s: you just leave the child alone in his room! My experience of meeting people with Asperger’s is that, on the whole, they do tend to want to make friends, and feel a degree of shame, even pain, that they cannot so. Would you agree?

TONY ATTWOOD:   What I meant by my comment on how to solve autism or Asperger’s was that, if you keep the person on his own, with no one to socialise with, to communicate with,  you allow the child to do what he wants in his own way. In other words, the symptoms of autism or Asperger’s syndrome are proportional to the number of people present and what they are doing. However, there are those with classic autism who may very much prefer to have a life of solitude, whereas there are others who, either by ability level or character, may choose to try to socialise with others. It is then that they experience such confusion and failure. This concerns me - because the psychological costs for such individuals can be enormous. Parents can be concerned that the isolated child wants metaphorically to build a bridge between themselves and others. But the description is that they crossed that bridge and there was no one there to meet or greet them on the other side. That is when they can become quite dejected, because they want to have friends, they want to  be part of a social group. They are aware of their difference, and this can lead to reactions of depression, denial, arrogance, anger - intense emotional responses.

ADAM FEINSTEIN:  In my experience, those with a diagnosis of high-functioning autism do not, on the whole, seem to have that same drive to make friends and so do not feel those intense emotions such as depression or dejection which you mentioned - or is that too simplistic?

TONY ATTWOOD:  One of the things that I notice is that those who were diagnosed with classic autism when they were younger - they had major problems with communication, socialisation and play - progressed to a level where they and others view them as an enormous success. They are now  able to achieve things which previously would never have been thought possible. So they are happy by what they compare themselves with. But those with Asperger’s syndrome who compare themselves with the neurotypical will have more depression and dejection. So quite often, those with classic autism who have progressed to high-functioning autism and success are happier, and people will see them as a success.

ADAM FEINSTEIN:  But you are well-known for stating that there is no really valid distinction between high-functioning autism and Asperger’s syndrome, aren’t you?

TONY ATTWOOD:  My view is that, if we are not careful, we are going to have an “autistic” view of autism. We are going to over-focus on the tiny details and miss the big picture. We are almost having an immediate look for differences, rather than similarities. I think that, at the clinical, behavioural level, and from what parents say, they are more the same than different. There may well be academic studies which suggest that there could be differences between the two groups on some aspects. However, I think that this is more of academic than practical interest, because when it comes to socialising, communicating, community integration, etc, there are more similarities than differences.

ADAM FEINSTEIN:  So you would disagree that those with high-functioning autism are less driven to make friends than those with Asperger’s syndrome?

TONY ATTWOOD:  I think that, when we are looking at drive for friendship in high-functioning autism and Asperger’s, it also depends on the individual’s personality. Some with very limited skills are desperate to relate to others. While others who have remarkable communication and social skills choose isolation, by their character. So we must look at the personality, as much as the diagnostic expression.

ADAM FEINSTEIN: Do you agree with Dr Rita Jordan when she said here in Melbourne this morning that there was a danger that, in our recognition of high-functioning groups with autism, we tended to ignore the autism among those with profound learning difficulties?

TONY ATTWOOD:  What happens is that there is always a vogue or trend in autism. In various years, there has been a sudden exploration of the “new biology,” as we moved away from the psychogenic model. Then we became entranced with the language model. Then we developed the social and cognitive Theory of Mind areas. Our newest area of exploration is Asperger’s syndrome. But we must not lose sight of the whole spectrum or continuum, and relatively neglect those who are more challenged by their autism - perhaps with fewer coping mechanisms. What I am hoping is that our knowledge of people with Asperger’s syndrome - because we can talk to them about their feelings and experience more eloquently - can then be of practical use to those who are less able to communicate. So I think it is worthwhile exploring that upper end of the autistic spectrum in order to be able to develop strategies for those who have greater problems.

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