Not Thinking in Pictures

The various types of autistic behaviors that I see in my medical practice are sometimes bizarre (self-mutilation), sometimes informative (below-the-tummy-rubbing indicating G-I disturbances), sometimes annoying (dropping on the floor and screaming is particularly so), and always interesting to observe. Occasionally, however, a patient presents with such an unusual combination of behaviors that it defines that individual as a category unto itself.

Temple Grandin wrote about her abilities in Thinking in Pictures. She described how language took a back seat to the images that she processed in her unique brain, and wrote that many ASD patients have similar abilities and brain structures.

Just to keep me on my toes, I met a 4 year-old patient this week who thinks in word patterns. Actually, he doesn’t seem to think in the neuro-typical sense, yet he appears to be connected to some of his surroundings. However, he processes the world in a completely unusual fashion. He makes fair eye contact with strangers and seems to communicate well with his mother. He is very well behaved and answers to his name. He “reads” everything – books, posters, signs, anything with words on it.  If there is a picture of a dolphin and the word “dolphin”, Jonathan points to the word and says it correctly. The picture is totally ignored. And, it doesn’t seem that Jonathan has any idea that the word and picture are related. Or what a dolphin is. This remarkable young man can read just about any word, and he can sound out those that he doesn’t recognize right away.

Echolalia is one thing. Practice with language. Scripting is another step in that direction. Complex repetition without any sign that there is comprehension is another level altogether.

One of my first ASD patients was an aggressive 11 year-old who could recite a half-hour TV show in, like, 15 seconds (his mother pointed out to me what he was doing). But, it took dozens of viewings to get that information. Jonathan can memorize the dialog of a video the first time, according to his Mom. From what I’ve observed so far, that’s pretty accurate.

Patterns are what seems to make the most sense to Jonathan. He can assemble a complex puzzle (>100 pieces, 6+ years) by himself, and he completes it in his own special way. Most of us would do the outside pieces first, then work toward the middle. This interesting child does “clumps” – putting patterns together until they make up the whole. But it’s the smaller patterns that he seems to appreciate, not the “big picture”.

Were it not for his wonderful Mom and family who have provided conventional interventions, I believe that Jonathan would have appeared similar to the “typical” autistic patient who I first saw in 1975 at Jefferson Hospital. That was a five year-old male, jumping up and down in a painted wooden crib, flapping away and totally unaware of his surroundings or the 20-or-so medical students who were observing him in his hospital room. At the time, the reported incidence was said to be “one-in-five-to-ten-thousand” children (which only meant that it was really rare since there were no Internet registries and few support groups). Those were the days when doctors told parents to put such patients into an institution with the other “retarded” children.

This child has several medical conditions, including G-I symptoms and allergies, which require attention. As we begin to get Jonathan on a more healthy path, I can’t help but wonder what will happen to some of his special qualities. There is a profound block somewhere in his processing that is, rightly so, his mother’s chief concern. I am fortunate that the family has sought my advice and allowed me to be part of their journey.

So little time, so much to learn. Stay tuned.

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