In this four-part series Professor Tony Attwood reflects on a 50-year career in autism. In the first part of our series last week, Tony discussed autism in an historical context. In this next part he shares his observations on how different individuals cope with autism, and the various outcomes of these coping mechanisms. In the third part he describes conditions that commonly co-occur with autism, and in the final part he discusses prognosis in autism.
One of the central characteristics of autism, according to the DSM 5 diagnostic criteria, is a deficit in social communication and social interaction. The social and interpersonal aspects of life are a challenge to an autistic child or adult. So how does an autistic person adapt to these challenges? My extensive clinical experience suggests there are four potential adaptations based on personality and acquiring coping mechanisms: the introvert, the extrovert, the camouflaging and compensation.
The more easily recognized adaptation is that of the child who could be described as an introvert. The child, and subsequent the adult, actively minimizes or avoids social engagement, recognizing that social interactions are indecipherably complex, overwhelming, and stressful. This conspicuous adaptation, therefore, is to choose, where possible, to be alone to accomplish what you want to do without interruption, and not necessarily feeling lonely. The person’s energy is recharged in solitude, as being with people is at times bewildering and exhausting.
However, we are increasingly recognizing autistic children whose personality type is extrovert, being highly motivated to socialize. For these individuals, there are two potential adaptations that facilitate social engagement.
The autistic extrovert actively seeks social engagement. Unfortunately, due to difficulties with ‘theory of mind,’ autistic children and adults struggle to read the subtle nonverbal communication used in a social interaction that regulate and moderate the fluency, reciprocity and intensity of social engagement. Unfortunately, their social behavior may then be perceived as being intrusive, intense, or even irritating. A metaphor to describe this adaptation to autism is that of a driver who does not see the traffic signals (nonverbal communication) or abide by the traffic code (social conventions and context). They are unable to accurately read social situations and therefore criticized for behaving inappropriately.
While there is considerable motivation for social interaction and making friends, these experiences may nevertheless be ended prematurely by their peers. The consequence is that the autistic person feels bitterly disappointed that conversations, friendships, and relationships are short-lived, and social popularity remains elusive. When friendship is achieved, the autistic person can become possessive, idealizing their new friend with an intensity that is overwhelming. When the friendship or relationship ends, there can be intense despair and feelings of abandonment, betrayal, and of being misunderstood.
The autistic person who uses camouflaging is very aware of their difficulties in reading nonverbal communication and in making and keeping friends. With this insight, they are initially detached from their peers, but keenly observe their social interactions and the social behaviour of people in general. They seek to learn social ‘systems or rules and determine, interpret, and abide by those social rules. Their social abilities are achieved by intellectual analysis rather than intuition. Thus, effectively camouflaging their social difficulties. There is the creation of a social “mask.” We know that 70 per cent of ASD level 1 adults consistently use camouflaging in social situations. Research shows that autistic females tend to be better at camouflaging than males, and more likely to use this adaptation strategy in a wider range of social situations. However, some autistic males can use this adaptation.
The teenage autistic girl may have effectively camouflaged her autism, to “fly under the autism radar” and not have been considered for a diagnostic assessment with comments such as, “You’re too social to have autism.”. Every day at school (but probably not at home) she has acted the role of a typical schoolgirl, so much so that she should be awarded an Oscar for her social performance with her peers. She has a superficial sociability that is effective, but superficial and exhausting. She also has a lack of social identity, other than being the person that others expect her to be. Camouflaging can delay a diagnostic assessment for autism until the late teens or adult years which will also delay access to appropriate support and therapy.
There can be performance anxiety in social situations, as though she has been continually “on stage.” Like Cinderella at the ball, she can maintain the pretence for a while, but then becomes totally drained of mental energy and must return home to recover in solitude. She is likely to ruminate on her social performance in her bedroom and the high level of stress may evolve into an anxiety disorder or depression and self-harm.
The consequences of camouflaging autism can be a lack of knowledge of the inner and true self, with some adult women saying, “I don’t know who I am.” This may lead to a lack of self-identity, low self-esteem, and prolonged self-analysis. She recognizes that her friendships and relationships are based on deceit, where she has presented a “false” identity. This increases her feelings of deep inner loneliness. She yearns to find, and be able to be, her authentic self, but is aware that when her true self is revealed, she may be rejected and despised.
Psychotherapy needs to focus on the negative long-term consequences of camouflaging, encourage self-acceptance, and facilitate ways to explain the characteristics of autism to friends and colleagues so that others can accommodate and appreciate those characteristics to facilitate social acceptance and inclusion
A fourth adaptation to autism is to create a lifestyle that minimizes the characteristics of autism. The autistic girl may prefer the company of boys, whose social dynamics are relatively simpler to decipher than girls. Boys may be more accommodating of someone who is socially clumsy, but who clearly enjoys and is relaxed in their company.
Compensation can also be achieved by developing an interest and talent in science, the arts and computer games, becoming an author, artist, musician, singer, multi-linguist, scientist and games designer. Social eccentricities are accepted and accommodated due to being valued by peers who recognize and admire a particular talent.
Another compensation strategy is to develop an interest in fictional heroes and superheroes and to have friendships based on shared interests, such as cosplay and Comic-Con, providing defined and recognized roles and achieving an alternative persona. The autistic girl may seek social assimilation by studying psychology and avidly reading books on body language and friendship or a career that does not involve much social engagement, such as becoming a wildlife ranger.
Other compensation strategies can include engaging in part-time schooling and employment to reduce the effects of exhaustion and having a social network of friends and colleagues who have autism—that is, people who accept and encourage the person’s autism. There is a much-valued sense of connection and authenticity.