Autism, Mental Health and Wellbeing

“Nature never draws a line without smudging it” - Lorna Wing

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  • Autism is a neuro-developmental disorder. Don’t believe me? Look it up. Autism is not mental illness, but rather a condition of a different trajectory of human development, no better, no worse than that which is typical and generally oberved throughout the population.
  • Autistic individuals find it difficult to identify with the attitudes of other people.
  • Autism may be mis-diagnosed as psychiatric disorders.
  • Where services consider the autistic person holistically, understanding the person’s development and developing relationships that move in sympathy with that person, a culture of wellbeing is more likely to flourish.

Autism is a neuro-developmental disorder. Don’t believe me? Look it up. You’ll find consistency in both global diagnostic systems, the International Classification of Diseases (World Health Organisation), and the Diagnostic Statistical Manual (American Psychiatric Association). But do we ever take pause to think about what that means? Autism is not mental illness, but rather a condition of a different trajectory of human development, no better, no worse than that which is typical and generally oberved throughout the population.

While behavioural indicators of diagnostic systems alert us to the possibility of autism, it is the diagnostic decision that puts those indicators in the context of the developmental history of the individual. The best diagnostic tools such as the DISCO (Wing et al., 2002), emphasise careful consideration of case histories of development. In the case of autism, the diagnostician looks for signs of early differences in instinctive responses to social signals such as those involved in joint and shared attention.

Autistic individuals express difference in something critical for typical early development, namely a capacity to structure self–other relations through the propensity to identify with the attitudes of other people. Therefore, in order to make sense of autism and typical development in relation to one another, it is necessary to posit that from early in life, the propensity to identify with others is a natural organising principle of social experience.

How then do we understand the autistic individual with their own unique atypical development if we do not at first understand the nature of typical development?  It is my contention that within service configuration we have failed to invest in our understanding of what is typical in human development and so are blind to identify developmental difference and what that means for the establishment and maintenance of relationships now and in the future.

It is tempting to respond simply to surface level behaviour, but to do so means to define behaviour in very narrow terms, and invite interpretations that are, compared against cultural norms, rather developmental. Interpretations that ignore the atypical developmental context of autism are prone to look for other explanations of behaviour. Diagnoses are constructs in which certain signs and symptoms are gathered into a meaningful whole, presumably something more than the sum of its parts. But of course, what is meaningful is continually shifting.

When services and professionals try to form meaning of behaviour within purely diagnostic constructs rather than understanding the developmental context of the person, they are at risk of adopting a reductionist biomedical paradigm that reinforces the myth that the best way to meet the individual’s needs is to use medication and biomedical intervention. Such intervention requires referral to psychiatric services. Referrals are frequently driven by behavioural presentations that are interpreted as irritability and aggression (RUPP, 2002), hyperactivity (RUPP, 2005), anxiety (Gadow et al. 2004, 2005), and depression (Vickerstaff et al. 2007; Sterling et al. 2008). However, whether these are co-occurring emotional and behavioural symptoms that simply represent associated features in people with developmental disorders, or are bona fide comorbid psychiatric disorders remains unclear (Frazier et al. 2001).

Equally important is to recognise the possibility of autism in those referred for the treatment of other psychiatric disorders. Several studies from various referred populations have noted the under-recognition of autism in individuals who initially come to clinical attention for the management of other psychiatric conditions (Sverd 2003; Gillberg 1992; Fombonne et al. 2004). This can frequently result in the accumulation of psychiatric labels before an individual receives a diagnosis of autism. Albeit that psychiatric diagnoses still rely exclusively on fallible subjective judgments rather than objective biological tests (Frances, 2013).

Perhaps nowhere in medicine is it more apparent than in the world of psychiatry that illness cannot exist outside culture. How a person perceives a symptom and how a society defines a disorder determines whether a physician ever makes a diagnosis and attempts a treatment (Frances, 2013). In the absence of an organisational and professional culture informed by an understanding of human development, behaviours are more likely to be interpreted within the same biomedical paradigm as the services that refer. The result is diagnostic inflation within groups of autistic people.

Labels such as obsessive compulsive disorder, oppositional defiant disorder, attention deficit hyperactivity disorder and mood disorders are commonly ascribed to autistic people, not to mention new constructs such as pathological demand avoidance syndrome that do not yet feature within the diagnostic criteria. As stated, the evidence that these are truly co-occurring psychiatric conditions is equivocal, yet as services refer for psychiatric assessment, so the risk of the individual acquiring yet another label increases, and the autistic person becomes trapped in a narrative of illness.

Ironically, as we culturally lean towards the mental illness narrative for those with developmental conditions, so do we simultaneously lean away from considering the physical dimension of health. Biases in our interpretation of behaviour can overshadow consideration of physiological causes, despite many criticisms of the Cartesian (mental/physical division) approaches to health and wellbeing.

There is increasing international interest in the concept of positive mental health and its contribution to all aspects of human life. The World Health Organisation (WHO, 2004) has declared positive mental health to be the ‘foundation for well-being and effective functioning for both the individual and the community’ defining it as a state which allows individuals to realise their abilities, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to their community. Central to this is the capacity for mutually satisfying and enduring relationships (WHO, 2001).

Where services consider the autistic person holistically, understanding the person’s trajectory of development and developing relationships that sensitively move in sympathy with that person, a culture of wellbeing is more likely to flourish.  This then is the antidote to diagnostic inflation, that promotes a culture of illness. allowing us to safeguard against our own biases.

References

Fombonne, E., Heavey, L., Smeeth, L., Rodrigues, L. C., Cook, C., Smith, P. G., et al. (2004). Validation of the diagnosis of autism in general practitioner records. BMC Public Health, 4, 5.

Frances, Allen (2013). “The new crisis of confidence in psychiatric diagnosis”. Annals of Internal Medicine. 159 (2): 221–222.

Frances, Allen (January 2013). “The past, present and future of psychiatric diagnosis”. World Psychiatry. 12 (2): 111–112.

Frazier, J. A., Biederman, J., Bellordcre, C. A., Garfield, S. B., Geller, B., Coffey, B. J., et al. (2001). Should the diagnosis of attention- deficit/hyperactivity disorder be considered in children with pervasive development disorder? Journal of Attention Disorders, 4, 203–211.

Gadow, K. D., Devincent, C. J., Pomeroy, J., & Azizian, A. (2004). Psychiatric symptoms in preschool children with PDD and clinic and comparison samples. Journal of Autism and Developmental Disorders, 34, 379–396.

Gadow, K. D., Devincent, C. J., Pomeroy, J., & Azizian, A. (2005). Comparison of DSM-IV symptoms in elementary school-aged children with PDD versus clinic and community samples. Autism, 9, 392–415

Gillberg, C. (1992). Autism and autistic-like conditions: Subclasses among disorders of empathy. Journal of Child Psychology and Psychiatry, 33, 813–842

Sterling, L., Dawson, G., Estes, A., & Greenson, J. (2008). Characteristics associated with presence of depressive symptoms in adults with autism spectrum disorder. Journal of Autism and Developmental Disorders, 38, 1011–1018.

Sverd, J. (2003). Psychiatric disorders in individuals with pervasive developmental disorder. Journal of Psychiatric Practice, 9, 111–127.

Vickerstaff, S., Heriot, S., Wong, M., Lopes, A., & Dossetor, D. (2007). Intellectual ability, self-perceived social competence, and depressive symptomatology in children with high-functioning autistic spectrum disorders. Journal of Autism and Developmental Disorders, 37, 1647–1664.

World Health Organisation (2004) Promoting Mental Health; Concepts emerging evidence and practice. Summary report Geneva; World Health Organisation.

World Health Organisation (2001) Strengthening mental health promotion Geneva; World Health Organisation;

Wing, L., Leekam, S.R., Libby, S.J. et al. (2002). The Diagnostic Interview for Social & Communication Disorders. Journal of Child Psychology and Psychiatry, 43(3), 303–325.

Michael McCreadieDr Michael McCreadie is a Health Psychologist who works with people with neuro-developmental conditions and/or acquired brain injury. He works in a range of health, educational and care settings in the UK, Scandinavia and Ireland. In addition to clinical responsibilities, Michael has substantial input to the ATLASS programme and a teaching remit within Strathclyde University. He is Director at AT-Autism.

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