Category Archives: By Tony Attwood

How does an autistic child learn?

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How does an autistic child learn?

Autistic children have an unusual profile of learning abilities that can often be recognised in very early childhood. Some pre-school autistic children have reading and numeracy abilities above the level of their peers. Such advanced literacy and numeracy abilities may have been self-taught through watching educational television programs, computer games and YouTube videos. There are autistic children who appear to easily ‘crack the code’ of reading, spelling, or numeracy; indeed, these subjects may become their special interest at school. In contrast, some autistic children have considerable delay in academic skills and an early assessment of learning abilities suggests the characteristics of dyslexia and dyscalculia. There seem to be more autistic children than one might expect at the extremes of cognitive ability.

Teachers soon recognize that the autistic child in their class has a distinctive learning profile, often being talented in understanding the logical world, noticing details and patterns and remembering facts, and the artistic world with a talent for drawing or music. However, the child can be easily distracted or distressed by sensory and social experiences, and when problem solving, appears to have a ‘one-track mind’ and a fear of failure. As the child progresses through the school grades, teachers identify problems with organizational abilities, flexible thinking, and group projects. End of year school reports often describe a conspicuously uneven profile of academic achievement with areas of excellence and areas that require remedial assistance.

It is extremely important that teachers and parents know the learning profile of an autistic child to improve his or her academic achievement. This is especially important as children usually have two reasons to attend school – to learn and to socialize. If the autistic child is not successful socially at school, then academic success becomes more important as the primary motivation to attend school and for the development of self-esteem and self-identity.

Verbalising and visualising

Valuable information on an autistic child’s learning profile can be obtained from formal testing using a standardized test of intelligence and tests of academic achievement. Standardized tests of intelligence have at least ten sub-tests that measure a range of intellectual abilities. Some sub-tests measure specific components of verbal reasoning, while others measure components of visual reasoning.

Some autistic children have relatively advanced verbal reasoning skills and may be colloquially described as ‘verbalisers.’ If such a child has difficulty acquiring a particular academic ability in the social and sensory interactive ‘theatre’ of the classroom, then his or her knowledge and understanding may be improved by solitary and quiet reading about the concept. If the autistic child has relatively advanced visual reasoning skills, a ‘visualizer’ then learning may be facilitated by observation of the teacher’s actions rather than listening to their instructions and learning from a computer screen. Learning from a computer screen significantly reduces any difficulties with social and conversational abilities. The ‘verbalisers’ may eventually be successful in careers where verbal abilities are an advantage, for example the legal professions or being an author, and ‘visualizers’ may be successful in careers such as engineering or the visual arts.

Attention

Psychologists divide attention into four components: the ability to sustain attention, to pay attention to relevant information, to shift attention when needed, and to encode attention – that is, to remember what was attended to. Autistic children appear to have problems with all four aspects of attention. The duration of attention to schoolwork can be an obvious problem but the degree of attention can vary according to the level of motivation. If the child is attending to an activity associated with his or her special interest, the level of attention can be excessive. The child appears to be oblivious of external cues that it is time to move on to another activity or to pay attention to the comments, requests and instructions of a teacher or parent. The amount of sustained attention can also depend on whether the child wants to give the attention to what an adult wants them to do. The autistic child may have his or her own agenda for what to attend to.

Even when the autistic child appears to be attentive to the task set by the teacher, he or she may not be attending to what is relevant in the material in front of them. Typical children can more easily identify and selectively attend to what is relevant to the context or problem. Autistic children are often distracted and confused by irrelevant detail, and they don’t automatically know what the teacher wants them to look at. They may need specific instruction at to exactly what to look at on the page.

Some academic activities require the ability to shift attention during the activity and focus on new information. Unfortunately, autistic children can have difficulty ‘changing track’ while engaged in a ‘train of thought’. There can also be problems with memory processes such that the recently learned information is not stored or encoded as well as one would expect. Autistic children may not remember what to attend to when they encounter the same problem again. This characteristic can affect social situations. Autistic children process social information using intellect rather than intuition and can have problems remembering what the relevant social cues are and changing their conversation ‘track’ when interacting with more than one person.

The autistic child often has considerable problems switching thoughts to a new activity until there has been closure, i.e., the activity has been successfully completed. Other children appear to have the capacity to pause a thought or activity and to easily move to the next activity. In the classroom, autistic children can resist changing activities until they have completed the previous activity, knowing that their thinking cannot as easily cope with transitions without closure. A teacher or parent may need to provide multiple verbal indications when an activity is going to change, perhaps counting down and if possible, allowing the autistic child extra time to finish the task.

Executive functioning

Autistic children and adolescents often have problems with executive function. Perhaps the best way to understand the concept of executive function is to think of a chief executive of a large company, who can perceive the ‘big picture’, consider the potential outcomes of various decisions, is able to organize resources and knowledge, plan and prioritize within the required time frame, and modify decisions based on results. Such executive function skills may be significantly delayed in autistic children and adolescents.

In the early school years, the main signs of impaired executive function are difficulties with inhibiting a response (i.e., being impulsive), working memory and using new strategies. The autistic child can be notorious for being impulsive in schoolwork and in social situations, appearing to respond without thinking of the context, consequences, and previous experience. By the age of eight years, a typical child can ‘switch on’ and use his or her frontal lobes to inhibit a response and think before deciding what to do or say. The autistic child can become capable of thoughtful deliberation before responding, but under conditions of stress, or if feeling overwhelmed or confused, can be impulsive. It is important to encourage the child to relax and consider other options before responding and to recognize that being impulsive can be a sign of confusion and stress.

Working memory is the ability to maintain or hold information ‘online’ when solving a problem. The autistic child may have an exceptional long-term memory and is perhaps able to recite the credits or dialogue of his or her favourite film but has difficulty with the mental recall and manipulation of information relevant to an academic task. The child’s working memory capacity may be less than that of his or her peers. Other children have a ‘bucket’ capacity for remembering and using relevant information, but the autistic child has a working memory ‘cup’ which affects the amount of information he or she can retrieve from the memory ‘well’.

Another problem with working memory is a tendency to quickly forget a thought. One of the reasons autistic children are notorious for interrupting others was explained by an autistic child who said he had to say what was on his mind to his teacher because if he waited, he would forget what he was going to say.

Impaired executive function can include difficulties with flexible thinking. Typical children can quickly react to feedback and are prepared to change strategies or direction with new information. Autistic children tend to continue using incorrect strategies, even when they know their strategy isn’t working, as they have difficulty conceptualizing different thoughts and reactions.

In the high school years, problems with executive function can become more apparent as the school curriculum changes to become more complex and self-directed, and teachers and parents have age-appropriate expectations based on the maturing cognitive abilities of age peers. In the primary school years, success in subjects such as History can be measured by the ability to recall facts such as dates. By the high school years, assessment in history has changed, and requires that the child shows ability in writing essays that have a clear organizational structure, and that he or she can recognize, compare, and evaluate different perspectives and interpretations. Autistic adolescents with impaired executive function have problems with the organizing and planning aspects of class work, assignments, essays, and homework.

There can also be problems with self-reflection and self-monitoring. By the high school years, typical children have developed the capacity to have a mental ‘conversation’ to solve a problem. The internal thinking process can include a dialogue, discussing the merits of various options and solutions. This process may not be as efficient in the thinking of an autistic adolescent as it is in typical peers. Many autistic adolescents ‘think in pictures’ and are less likely to use an inner voice or conversation to facilitate problem solving. The autistic adolescent may need the teacher or parent’s voice to guide his or her thoughts.

One strategy to reduce the problems associated with impaired executive functioning is to have someone act as an ‘executive secretary’. The child’s mother may have realized that she has already become an executive secretary, providing guidance with organizing and planning, especially with regards to completing homework assignments. The executive secretary (a parent or teacher) may also need to create a time schedule, proofread draft reports and essays, colour code subject books, encourage alternative strategies and create ‘to do’ checklists, with a clear schedule of activities and the duration of each activity.

Such close monitoring and guidance may initially appear to be excessive for an adolescent or young adult with recognized intellectual ability. A parent who provides the support as an executive secretary may be labelled as overprotective by school agencies and family members, but that parent has learned that without such support, the autistic child would not achieve the grades that reflect his or her actual abilities. We encourage a parent or teacher to take on this very important role of executive secretary. We hope that this will be a temporary appointment as the autistic adolescent and young adult eventually achieves greater independence with organizational skills.

Coping with mistakes

The learning profile of autistic children can include a tendency to focus on errors, a need to fix an irregularity and a desire to be a perfectionist. This can lead to a fear of making a mistake and the child’s refusal to commence an activity unless he or she can complete it perfectly. The avoidance of errors can mean that autistic children prefer accuracy rather than speed, which can affect performance in timed tests and lead to their thinking being described as pedantic. An autistic girl complained that her teacher frequently asked her to hurry up but said that if she did hurry up, she might make a mistake.

It is important to change the autistic child’s perception of errors and mistakes. Autistic children often value intellectual abilities in themselves and others, and young children can be encouraged to recognize that the development of cognitive ‘strength’ is like that of physical strength, in that the brain needs exercise on difficult or strenuous mental activity, that includes making mistakes, to improve intellectual ability. If all mental tasks were easy, we would not improve our intellect. Intellectual effort makes the brain smarter.

Adults will need to model how to respond to a mistake and have a constructive response to the child’s errors, with comments such as, ‘This is a difficult problem designed to make you think and learn, and together we can find a solution.’ It must also be remembered that while there can be a fear of making a mistake, there can be an enormous delight in getting something right, and success and perfection may be a more important motivator than pleasing an adult or impressing peers.

Cognitive talents

There are autistic children and adults who have cognitive abilities that are significantly above average and are sometimes described as gifted and talented. This can provide both advantages and disadvantages to the child. The advantages include a greater capacity to intellectually process and learn social cues and conventions. Advanced intellectual maturity may be admired by a teacher and winning academic competitions can lead to greater status for the child and school. Academic and artistic success can raise self-esteem and contribute to social inclusion; their social naivety and eccentricity can be accepted as part of the ‘absent minded professor’ or artistic genius image. However, there are disadvantages.

Autistic children are more socially and emotionally immature than their peers, which contributes towards their being socially isolated, ridiculed, and tormented. Having considerably advanced intellectual maturity in comparison to one’s peers could further increase social isolation and alienation. The child may have no peer group socially or intellectually in his or her classroom. Having an impressive vocabulary and knowledge can lead adults to expect an equivalent maturity in social reasoning, emotion management and behaviour; they may be unjustly critical of the child who is unable to express these abilities as maturely as his or her age peers.

We have recently recognised that the learning profile associated with autism can also include alexithymia, which can affect the expression of academic talents. Alexithymia is a difficulty converting thoughts into words. The autistic child’s conceptualization or solution perhaps to a mathematics problem may be extraordinary. However, while the autistic child knows their solution is perfect, they may have genuine difficulty explaining how they achieved that solution.

Summary

Autistic children and adolescents have a different way of thinking and learning. This can lead to academic talents and difficulties. Teachers and parents need to be aware of the autistic student’s personal learning profile and to modify the classroom curriculum to accommodate their distinct learning profile. This can include identifying learning talents and to recognise that autistic people can produce a new perspective on the problems of tomorrow.

We have been training teachers in recognising and supporting autistic students for the majority of our combined 80 years of specialisation in autism.

To learn more about this increasingly important area we encourage you to attend our next teacher training in autism broadcast via live webcast:

LIVE WEBCAST And Live In Townsville: Autism In School – 17 June 2022 – Attwood and Garnett Events 

Exploring autism 1971-2021

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Exploring autism 1971-2021

The historical context

Tony Graduating from The University of Hull in July 1973

Tony Graduating from The University of Hull in July 1973

In 1971, I had completed my first year studying psychology in England. During the summer vacation I became a volunteer at a special school in my hometown of Birmingham. It was at this special school that I first encountered autism as expressed by two young children. Russel was 7 years old and Sarah five years old. They were both agile and alert, but mute and preferred to engage in solitary play. Neither used gestural communication to replace their lack of speech and both were extremely sensitive to specific noises. They were frequently distressed by changes to their daily routine and the social, sensory, cognitive and communication experiences in the classroom and playground. They seemed in a world of their own, and other children were not invited into that world. However, I was determined to make a connection and to see the world from their perspective. Gradually and carefully, I became accepted, as a temporary but welcome visitor to their world.

The experience was profound emotionally and intellectually, and I decided that my career as a psychologist would be to explore and understand autism. In the autumn of 1971, I returned to University determined to read all I could on autism. There were only around a hundred published journal articles on autism, and perhaps two or three academic books and biographies written by parents of autistic children. Within a few weeks I had read all the relevant literature published in the English language. There are now over 7,000 journal articles on autism published each year and a corpus of research papers of over 70,000 studies of autism. Today I cannot keep up with the explosion of scientific knowledge on autism and tend to read the papers on the aspects of autism that intrigue me, and the papers of my colleagues and leading authorities on autism.

Changing concept of autism

In the early 1970s autism was conceptualized as an expression of schizophrenia that was caused by defective parenting and treatment was psychoanalysis of the child and their mother. However, during the late 1970s research studies and clinicians began to change this conceptualization to be replaced by autism being perceived as a neurodevelopmental disorder with a distinct profile of social, cognitive, linguistic, and sensory abilities that can be apparent in early infancy. This is the autism ‘signature’ that we seek in a diagnostic assessment and the core structure of our formal diagnostic instruments such as the Autism Diagnostic Observation Schedule or ADOS. My extensive experience as a diagnostician has led to supplementing the formal diagnostic instruments with activities to examine aspects of autism such as Theory of Mind abilities, the concept of self, alexithymia and interoception, and adaptations to autism that affect the clinical presentation and prognosis.

In the early 1970s our conceptualization of autism was that it was a rare but conspicuous and severe disability. The trajectory was for the child to attend a special school and eventually to be admitted to an institution due to high support needs in daily living skills and challenging behaviour.

During the 1980s we started to explore the range of expressions of autism and prognosis that included children and adults who were severely and conspicuously autistic in early childhood, but who acquired the ability to talk and converse fluently, had intellectual abilities in the average and above average range, and attended a typical school. They appeared destined to become independent of their parents and achieve full time employment and perhaps a long-term relationship. They had progressed to an expression of autism that was more subtle with a quite different prognosis. Lorna Wing in London recognized the progression in abilities to a profile consistent with the descriptions of autism by Hans Asperger in Austria rather than Leo Kanner in the United States. She first used the eponymous term Asperger’s syndrome in 1981 and her colleague and my PhD supervisor, Uta Frith, translated into English his original description of autism, based on the children he saw at his clinic in Vienna. I became a member of a small group of psychologists and psychiatrists in London exploring a new dimension of autism, Asperger’s syndrome. We discovered that there were children with the profile of abilities described by Hans Asperger that had never shown signs of severe autism in early childhood. There were two pathways to Asperger’s syndrome.

The original prevalence of autism was based on the conceptualization of a severe disability and was estimated at around one in 2,500 children. When we included Asperger’s syndrome in the autism spectrum and recognized the wide range of expressions of autism, the current prevalence according to the Centers for Disease Control in the USA is estimated to be around one in 54 children. Autism is becoming increasingly recognized by clinicians, schools, employers, and the public. A recent development is to have an autistic character in television programmes and films and there are many popular autobiographies written by autistic adults such as Temple Grandin.
There have been changes in terminology and diagnostic criteria over the last 50 years, as we increase our understanding of autism. The term Asperger’s syndrome has been replaced in the 2013 Diagnostic and Statistical Manual of Mental Disorders with the term Autism Spectrum Disorder Level 1. There are three levels of autism based on support needs. It is my opinion that we may change the terminology and diagnostic criteria, but the individuals remain the same in their daily challenges and abilities.

My recent research has included the design and development of screening instruments to identify the characteristics of autism in girls and women. The original gender ratio was 4 boys to each girl, but recent research indicates that the true ratio is 2:1. Girls and women can adapt to autism in ways that delay a diagnostic assessment.

Adaptations to 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 “camouflager”, and compensation.

The Introvert

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 Extrovert

The autistic extrovert actively seeks social engagement. Unfortunately, due to impaired ‘theory of mind,’ autistic children and adults have difficulties reading 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 Camouflager

The autistic “camouflager” 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 pretense 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

Compensation

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.

Co-occurring conditions

We now recognise that there is an association between autism and anxiety, with approximately 80% of autistic children and adults feeling mildly anxious for much of their day, and for most of their life. They often experience intense anxiety in specific situations, such as when there are changes in routine or expectations, uncertainty in what to do or what is going to happen, fear of imperfection and making a mistake and specific sensory experiences. There can also be anxiety in crowded places such as a shopping mall on a Saturday. Research has confirmed that an anxiety disorder is the most common mental health problem for autistic adults. Sometimes, the level of anxiety experienced may be perceived as actually more disabling than the diagnostic characteristics of autism.

Research and clinical experience indicate that approximately one third of autistic adults experience cyclical feelings of sadness and pessimism that can evolve into a clinical depression. There are many reasons why an autistic person may become sad and depressed. These include feelings of social isolation, loneliness, and not being valued and understood by family members and colleagues. Another reason for depression is the exhaustion experienced due to socializing, trying to manage and often suppress emotions, especially anxiety, and coping with sensory sensitivity. The person is constantly alert, trying to endure perpetual anxiety whilst suffering a deficit in emotional resilience and confidence. The mental effort of intellectually analysing everyday interactions and experiences is draining, and mental energy depletion leads to thoughts and feelings of despair.

Recent research has explored the association between autism and alexithymia, that is the ability to recognize or describe one’s own thoughts and emotions. An autistic person will have genuine difficulty converting their thoughts and feelings into speech. When asked why they may have done something, or to describe their feelings regarding an event, they may simply reply, ‘I don’t know’. This is not their being obtuse or evasive, but an expression of a recognized difficulty with self-reflection and self-disclosure of inner thoughts and feelings through speech. Psychological therapy for mental health issues will need to accommodate the profile of abilities and experiences associated with autism, such as alexithymia, the lifetime experience of extensive bullying and teasing, and sensory sensitivity. We now have psychological therapy manuals specifically designed for adults who have autism and I have been able to contribute with my colleague Dr Michelle Garnett to many of the manuals and therapy programmes. We have designed and evaluated individual and group programmes for anxiety and depression, to build resilience to bullying and teasing, and acquire abilities in the areas from love and romance to employment.

There is increasing evidence that autism is associated with specific learning disorders such as dyslexia and hyperlexia, attention deficit hyperactivity disorder, intellectual disability, and specific language disorders. Thus, the diagnostic journey does not end with confirmation of autism. Conversely, the diagnostic journey for autism may start with the accurate diagnosis of another mental or personality disorder and a detailed developmental history indicates the presence of autism. Research and my own clinical experience suggest that around one in four patients with an eating disorder, substance abuse, gender dysphoria and borderline personality disorder have a dual diagnosis. There is also an association between autism and Tourette’s disorder, sleep disorders and bipolar disorders. Clinicians in all areas of psychology and psychiatry need to be aware of the characteristics of autism in a patient’s developmental history and profile of abilities. When the diagnosis is confirmed, adapt their psychotherapy to accommodate the autistic patient who has a different way of perceiving, thinking, learning, and relating compared to other patients.

While we acknowledge the concept of autism plus, we also acknowledge the concept of autism pure. Around 15 per cent of autistic adults have no additional diagnoses and they often have a different prognosis.

Long-term outcomes

Over 50 years I have been able to maintain contact with autistic children through to their mature years and see retired individuals for a diagnostic assessment. Those who have achieved a diagnosis of autism late in life are often greatly relieved to know why they are different and can now perceive their life through the lens of autism. The diagnosis can help explain why they were bullied and teased at school, their difficulties in making friends and maintaining a long-term relationship and sensory sensitivity.

The majority have described an improvement in their mental health after the age of 50, not necessarily by treatment from health professionals and medication, but discovering strategies themselves through reading, the Internet and experimentation. We are also now exploring the concept of well-being and autism and surveys and clinical experience suggest that wellbeing can be achieved by having time in the day when they are not disturbed within their own private sanctuary, being able to excel in what they enjoy doing, and freedom from sensory pain. These are all achievable.

In my extensive clinical experience, I have known autistic children who have what we describe as autism pure, with no signs of a mood, medical or psychological disorder. By their early twenties they have gradually acquired social abilities to make and keep friends and relationships and achieve successful employment and financial independence. The social puzzle is finally solved. They still have the characteristics of autism, but at a sub-clinical level according to the diagnostic criteria. I estimate that this occurs in about ten per cent of patients on my clinic list. I am prepared to remove the diagnosis of autism, but only with the patient’s agreement and for their benefit. Our new conceptualization of autism is that for a few autistic adults there may be a delay in acquiring specific abilities, not an eternal absence.

Finally, over 50 years I have contributed to the growing literature on autism for professionals, parents, and autistic adults. My original book Asperger’s Syndrome: A Guide for Parents and Professionals was published in 1998 and has sold over half a million copies and been translated into 30 languages. I continue to write guidebooks on autism and books on therapy for anxiety, depression and emotion expression and regulation. There are now hundreds of books published by Jessica Kingsley Publishers in London on many aspects of autism such as catatonia, having an autistic partner and coping with being in prison and aging and autism.

Recently I have been able to provide professional and parent training through live and recorded webinars. These webinars are available at www.attwoodandgarnettevents.com and are a way of passing on my evolving exploration and understanding of autism.