Richard Howlin, The Chelsea Center.
We live in an ambiguous world…aside from factual and computational trivia, most decisions we make in our everyday lives do not have intrinsically correct solutions.
The above quote may first appear as remote philosophical banter, yet its implication may lie close to the very heart of the autistic mind. Goldberg, an accomplished neurologist and former colleague of the late Alexandra Luria, is referring to a vitally important capacity in human psychology: the ability to adjust and adapt to the unpredictable and ongoing changes of the social world. The complex group of skills that support this vital function are referred to collectively as the “executive functions”. The significance of these skills in the developmental understanding of Asperger syndrome is the topic of the following discussion.
As children approach adolescence, the pathways of physical, cognitive and emotional function merge toward a new threshold of integration. While the course of child development is never linear, evidence suggests that children with Asperger syndrome find developmental transitions particularly challenging (Holiday Willey, (2003, Howlin, 2003). Prior to puberty, the child with Asperger syndrome has navigated the social landscape from a distinct and unconventional perspective. Even subtle autistic thinking qualities can significantly impact the ability to understand others. Difficulties in attentional regulation, coordinated motor expression and pragmatic language form common obstructions for the Asperger child, particularly in the world of early relationships. In conjunction with the more obvious social challenges, these deficits can also impact other important aspects of school success. For example, the need for strict routines, polarized thinking, and the insistent imposition of ones own perspective can directly affect classroom behavior and study (Szatmari et.al. 1994).
In investigating the thinking processes of high functioning autistic children, cognitive and neurobehavioral research is providing insights that may aid in our understanding of these distinctive Asperger processing idiosyncrasies. Of particular note, is the impressive similarity between difficulties associated with frontal cortex injury and the behaviors of many adolescents and adults with Asperger syndrome.
The cognitive processes most commonly associated with the frontal and pre-frontal regions of the brain are the executive functions. The executive functioning system (EFS) describes an important theory relating to the development and operation of metacognitive skills, including inhibition, purposeful thinking and initiation of action. Executive skills develop through childhood, growing in complexity and purpose. According to one theory, executive skills guide behavior by the representation of an “inner model”. Through this ability the child assumes increasing self control and awareness of action. In tandem with this evolving sense of agency, the executive system provides the basis for specific cognitive and social skills that help shape transition into the adult world. As is evident in Figure 1, these emerging executive functions of the frontal region contain many key abilities that are paramount to successful social adaptation. Unlike more typical forms of learning disorders, these abilities directly affect the formation of meaning and selfhood in social interactions.
As executive skills evolve, adolescence may form the most crucial phase in their development. The typical adolescent struggle between the growing demands of the social world and internal processing capacities is intensified in students with Asperger syndrome. Frequently, social and organizational demands increase dramatically by late Middle school. Common processing difficulties in Asperger syndrome such as perseveration and inflexibility may affect areas of reading comprehension and the completion of study projects. There can also be symptoms of increased rigidity, obsessive behavior and heightened social avoidance. (Howlin, 2003). The failure to develop adequate executive skills in the pre adolescent and adolescent period may play a formidable role in many of the difficulties faced by autistic spectrum adolescents during this period (Figure 1).
Behaviors Associated with the Development of Adolescent Executive Functions
- Self monitoring and accurate self appraisal
- Behavioral flexibility
- Learning from mistakes
- Time awareness
- Self organization
- Social judgment and appropriate social behavior
- Impulse control
- Successful regulation of attention
- Task initiation and completion
- Intrinsic motivation and drive
- Adequate working memory
Neurobiology, the Executive System and the Onset of Adolescence
In typical development, executive processing reaches a new and critical chapter during the adolescent period. In the vast majority of cultures, this is the period where the youth begins to assume adult duties and responsibilities. As a biological adult, the student is faced with new expectations in the preparation for adulthood. Neurological maturation responds by design to these demands. Most experts place the neurophysiologic center of this surge in the frontal and pre-frontal lobes of the cortex (Figure 2). At around the age of 12, the adolescent brain accelerates into high gear, pruning and creating new interconnections of neurons. Often referred to as the most evolved and “human” part of the brain, areas of the frontal cortex evolve through the developmental period into a vast operating center, integrating many different brain functions towards purposeful action. As noted by Goldberg (2001), in adulthood the frontal lobes assume the position of a conductor in a large orchestra, maintaining coherence and direction.
Studies of patients with frontal lobe injury have provided valuable insights into the complex nature of this network. Frontal lesions often result in pervasive deficits in planning and maintaining appropriate social responses. Adult patients often display difficulties choosing from alternatives in novel situations and organizing their time effectively. These “synthetic” brain functions may not be immediately identifiable and yet they reveal themselves in profound deficits in aspects of daily living. Individuals often become “concrete” in areas of social reasoning while curiously maintaining many of their fundamental and primary mental abilities.
The IQ performance remains typically unaffected, indicating intact memory and primary problem solving abilities. Yet, successful adaptation in the real world requires fluid and intuitive responses, a capability that cannot be compensated for by linear processing or factual knowledge alone. In describing the recovery of a patient with frontal lobe injury, Damasio, (1994), was initially impressed by the patient’s average to superior performance on a host of neuropsychological tests. Yet, as the patient attempted to return to his everyday life, a different picture emerged.
“The tragedy of this otherwise healthy and intelligent young man…..was that the machinery for decision making was so flawed that he could no longer be an effective social being” (Damasio,1994). This observation illustrates perhaps the most critical function of the executive system, its fundamental role in accurate social and self evaluation.
This development of the executive system lasts into adulthood and, in general, adolescents vary greatly in their ability to assume skills such as self control and social intelligence. Many of the difficulties faced by students with Asperger syndrome are consistent with symptoms associated with executive functioning impairment. Serious executive deficiencies are also common among several other developmental disorders, including Attention Deficit Hyperactive Disorder and Tourettes syndrome. Several childhood diagnoses share variations of executive impairments. One inherent difficulty
is posed by the variation found in many complex disorders such as Asperger syndrome. Such variations within this diagnostic category will naturally influence the kind of symptoms seen by diagnosing and treating clinicians. The initial assessment should encompass various domains of psychological functioning (ie the executive system) in order to screen for discrete strengths and weaknesses. This process of diagnostic “mapping” in Asperger syndrome will be introduced in Part 2.
The Impact of Executive Impairment in Asperger Syndrome
The following case of Robert is a characteristic example of the substantial role executive functioning impairments can play in Asperger syndrome. For this young patient, the tasks of emerging adulthood proved elusively challenging. His parents felt helpless as they watched his confusion in facing everyday challenges. Robert was first diagnosed at 10 years of age. His social difficulties increased during the high school period. Robert experienced significant academic performance problems for the first time in 10th grade.
Robert (19). A Window into Executive Functioning Impairment
An intelligent business student with Asperger syndrome, Robert was referred to my clinic because of difficulties with certain practical courses in college. These courses involved independent decision making and a degree of creative insight, which Robert found both annoying and arduous.
In high school Robert experienced some difficulties in completing homework and handing in assignments. With support, he was able to complete his final year and he graduated with a 3.4 grade point average. Neuropsychological testing revealed nothing significant, only some symptoms of mild ADHD. Robert’s IQ tested in the Superior Range. His scores on more subtle problem-solving tasks such as the Wisconsin Card Sort were all above average. Robert had taken the summer semester off to think over his school plans. It was at this time that he began working for his uncle’s sales company. After two weeks Robert’s parents requested a consultation. With Robert’s permission we arranged a meeting without Robert being present. The father began describing the observations and complaints that Robert’s uncle had reluctantly shared. Apparently, Robert had displayed numerous problems in various aspects of his simple manual work. He seemed to lack initiative, worked very slowly and was oblivious to the amount of work that other students were performing around him. His uncle had stated that if Robert had not been his nephew, he would have fired him after the first week. Each night, when asked about his day, Robert seemed very enthusiastic and pleased with his performance. He described his situation in positive terms. In my subsequent interviews, it was clear to me that Robert honestly perceived his situation in this way. He appeared incapable of gauging the social world around him and evaluating his own situation. .
The widespread occurrence of social, planning and self management problems in Asperger syndrome, strongly suggests underlying executive integration problems. I was first introduced to the powerful and elusive nature of executive skills in a series of clinical assessments I conducted during my graduate years in Europe. The young men, like Robert, demonstrated sound academic and intelligence scores, and yet
demonstrated profound impairments in daily living skills, such as socializing, planning, and managing their studies. These 16-20 year old students carried no distinct psychiatric diagnosis and yet since early childhood demonstrated odd characteristics and unusual hobbies and interests. I referred to them as having “eccentric features” and recommended a program of support in daily living skills. My supervisor at the time was suspicious of brain injury, but no such history existed in any of 6 the cases. It was these young men who fueled my interest in what later became known as Asperger syndrome . Today, some 25 years later, executive functioning theory is beginning to provide a deeper understanding of this syndrome. It is interesting to note that the all the students were referred for issues involving social adjustment and self management.
Studies have long supported a primary role for executive impairments in autism. (Russell, 2002 ). As described earlier, the resemblance of mild pre-frontal lobe symptoms and the behavior difficulties shown by young people with AS is impressive. Russell (2002), views executive processing as a primary inhibiting factor in a child’s ability to “mind read” and thus empathize adequately with the social world. A developmental scheme showing the early identification of EFS impairments and their changes through childhood to adolescence would be of significant value to parents and educators alike. Asperger syndrome can be characterized as a complex learning disorder, impacting diverse aspects of learning and primarily affecting the evolving executive processes.
In summary, executive functions form a key cognitive foundation in many important adaptive skills. Executive skills are first evident in early developmental capacities such as attentional regulation and behavioral inhibition. Adolescence surfaces an important transition period in the development and expansion of the executive system. Part 2 will examine intervention strategies stemming from a pragmatic clinical intervention scheme. The model centers on the growing self reflective capacity of the adolescent. Accurate self-reflection and purposeful action represent the most important executive achievements of early adulthood.
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