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Sharon 73 attention from

Sharon 73 attention from the physical world, as described in Chapter 3. These are the types of repetitive stereotyped behaviors and the restricted range of interests that are so characteristic of the disorder and may arise from weak central coherence or difficulties disengaging attention from objects that catch one’s interest. Sharon described other types of lapses in attention, but usually in a social context. “I could never maintain a narration or any form of conscious control over my language use while another person was present,” she said. She could always be alert and focused in the presence of physical objects, but this sense of awareness would leave her whenever she came in contact with another person. She simply could not focus her attention on people without considerable effort and then only momentarily. She felt like she was in a fog, not part of the real social world. What held her attention were the stones, the stuffed animals, the science fiction fantasies, and, more recently, problems of design. “I made a conscious decision to feel the world in a sensory way, to focus on the now. I craved alertness.” I thought her metaphor of being in a social fog was very evocative. Only when the responses of others were very pronounced or exaggerated could she see the outlines of a social interaction looming through the fog. It would lift momentarily, then descend again. At these times she had to use her considerable powers of logic to make sense of other people’s minds. * * * After three of four sessions, I had a lot of information about Sharon but no definitive conclusions. AS can be difficult to diagnose, especially in adults when there is no corroborating information about early child development. To make a diagnosis, I would have to rely on her developmental history and on her present predicament—the same foundation on which all children with ASD are diagnosed. There is no blood test or brain scan that will tell us who has ASD and who does not. In fact, Sharon’s story brought up virtually all of the peculiarities that can make diagnosing ASD challenging. One difficulty that I had with evaluating Sharon was that most of the adults with autism and AS I had seen were much more impaired than Sharon. They had few if any friends as adults, they had tremendous difficulty in finishing high school or college and even more difficulty finding and keeping a job. In spite of having many symptoms of AS, Sharon showed remarkably little impairment. She had completed high school, gone to college, and graduated with a degree in architec-

74 A MIND APART ture. She ran a successful business. She was happily married and was raising a perfectly normal and happy boy. She had friends and got along reasonably well with her family (well, at least as well as most people). Sharon had the symptoms but not the impairment. Was it possible to have one without the other? Could one have a pure deficit in TOM without a diagnosis of ASD? She had exquisite insight into her own problems in inferring the mental states of others. Did this insight allow her to develop compensatory mechanisms to overcome her difficulties? And did these compensatory mechanisms leave her with some AS symptoms but not the impairment? This possibility does raise two important points. The first is that a difference exists between symptoms and impairment. These often go hand in hand, but on occasion there is a marked disjunction between the two. There are some individuals with ASD who are quite impaired but have few symptoms . These individuals may have a later age of onset and may not have as many repetitive, stereotyped behaviors, because they either are quite developmentally delayed, are very young, or have what some consider true atypical autism. Other individuals with atypical autism tend to be higher functioning, to have some transient language delay but few repetitive, stereotyped behaviors. Because of their language problems, though, they still have a lot of difficulty communicating with others or doing well at school. Alternatively, there are other individuals who have many symptoms but manage quite well in the real world. This latter group tends to keep their eccentric interests to themselves or else share them with friends who have similar interests. These individuals have learned the difference between private and public and keep their eccentricities to themselves. They may go into their room after school and spend hours flicking small plastic tubes, staring at the reflections of a magic lantern on the wall (much like the child narrator, Marcel, in Remembrance of Things Past), or echoing conversations heard at school. Like Sharon, they recognize that they are different and take steps to minimize the impact of their symptoms on their functioning in the real world. Perhaps these symptoms are less severe in the sense that the person is able to exert some control over them. Many highly successful adults with autism or ASD are unable to lose their symptoms but are able to function quite well. In fact, I doubt that we can completely eliminate the symptoms of ASD through treatment—the lack of gestures and facial expression, the interests in unusual subjects. But we can help people with ASD improve their social skills, their communication skills, their ability to go to school and hold a job. People with ASD can go a