11 months ago



William 81 am as

William 81 am as confused as I am. In spite of this difficulty in carrying on a conversation, it’s remarkable that his grammar and vocabulary are excellent; he uses past tenses appropriately, his sentence construction is perfect—in fact, there is nothing wrong with the more formal aspects of his language. Yet I don’t have a clue what he is talking about. There is slippage between the words and the communication. The philosopher Ludwig Wittgenstein wrote that the meaning of language is a function of the “language game” in which it occurs, a function of the context of communication in social discourse. Words have no meaning outside their use. I know we are playing a language game, only the rules are William’s own invention and he either won’t, or can’t, share them with me. * * * I first saw William when he was four years old, some ten years ago. His parents asked me to give them a second opinion about his diagnosis. Along with his medical records, they brought in a diary they kept when he was an infant. The delight and joy they experienced as parents fairly jump off the page. Each accomplishment is recorded with pleasure and pride. “William sat up today,” “William took his first steps today,” “William pulled my hat down over my eyes and laughed.” One entry at eighteen months mentions that when the family was traveling in the car, he insisted on going to their usual station to buy gas rather than a new one, even though the new one was much more convenient. Reading the document, I searched for other hints and clues of early signs of ASD but found only the missing bits as potentially ominous. There was no mention of gestures or imitation, pointing or showing things of interest to his parents. No words appeared until eighteen months and no phrases until two years. There was no mention of seeking out other children with whom to play. This inclination to play by himself was brought to the parents’ attention by the nursery school staff when William was three years old. They recommended an assessment be completed as soon as possible. The first diagnosis by a pediatrician was autism, but this did not fit with the parents’ perception of what a child with autism was like, so they sought a second opinion. I saw him a little later. At that time, he was able to talk fluently but showed little inclination to do so. He seemed to understand everything his parents said to him, and he would point without any difficulty but still did not use gestures to communicate. There were also some exam-

82 A MIND APART ples of impairments in social reciprocity. He would smile at his parents, was cuddly, would come for comfort when hurt, and was upset when separated from his mother. But with other adults, he would not smile, he avoided their gaze, would look at people from the side, and often hugged other children inappropriately. His social interactions with other children were, in fact, largely limited to playing with his train set and allowing them to sit nearby. It was much more difficult to engage him socially in other play activities. At age four, there was still no evidence of imaginative play. William was very interested in toy trains and could play with them for hours, but the play consisted largely of repetitive movements of the cars, back and forth, without elaborating a story or making the tiny figurines get on and off the train. He loved to watch the water in the dishwasher, and even as young as age four he loved to travel on the subways, often remarking on the color of the doors. Later, in elementary school, he became intensely interested in elevators and especially the escalators in the subway stations. All the doors in the house had to be open, and he would sometimes walk down the hallways at school backward, presumably imitating the sensation of riding in a subway car. Cognitive testing done on a number of occasions consistently demonstrated that he was quite bright, had good nonverbal memory and motor skills, good word recognition and single-word comprehension skills, but more difficulty with complex comprehension of language and problem-solving tasks. If he had to tell a story from a picture or provide a solution to a puzzle, he would not be able to come up with an appropriate answer. This developmental history is fairly common among children with AS, a type of ASD that differs from autism in a number of ways. Age of onset is often somewhat later, and the social impairments are similar to, but less severe than, those in autism and are usually more apparent in interaction with peers than with parents. Children with AS can speak fluently and usually have age-appropriate grammar and vocabulary, but, much like children with autism who are able to speak, they have significant difficulties using language socially. Children with autism have similar problems communicating socially, but they also demonstrate delays in vocabulary and grammar as well. Finally, children with AS have intense, often bizarre interests and preoccupations that are somewhat more complex and involved than in autism. Asperger was a Viennese pediatrician who wrote a paper on “autistic psychopathy” in 1944, the year after Leo Kanner’s classic paper was published. Both authors borrowed the term “autism” from Eugen