Not every child who struggles socially is autistic

One of the more heartening things that has happened in the last 20 years or so in child development/ education is a recognition of the range and irreverence of needs associated with autistic spectrum disorders. Children have benefited from more targeted intervention, and families have been helped to better understand their children’s perspectives and needs. It’s not perfect, but overall it’s a good news story.
One problem with this increased awareness, however, is that any child who struggles to interact socially with their peers has a good chance of attracting an autism-related label, either informally at school, or formally through a clinic. The trouble is that a lot of these kids DON’T have ASD, and mislabelling them can result in several harms.

Children with ASD struggle socially by definition, and this is thought my most people in the field to be to do with problems with understanding the thoughts, motivations and intentions of others, a skill sometimes known as mind-mindedness.
The trouble is that problems with mind-mindedness are only one of many reasons for social interaction problems. Think about meeting someone new: what will help the interaction to result in friendship? Well, a common language to start with, and both pitching communication at a level the other will understand. Both parties being in a receptive emotional state. Both able to sustain attention, not only on the verbal content, but also the non-verbal communication of the other. And, at some level, a pre-existing judgment that they might like each other. None of these are essential, of course, but each of them helps, and deficits in any of these aspects we’ll make friendship less likely. Importantly, none of these factors are to do with mind mindedness.
If we scale up from an individual interaction to the plethora of interactions that make up a child’s life, it makes sense that problems
with language, attention and cognition, as well as emotional and social problems may all make successful interaction with peers a struggle.
So when a child doesn’t make, or keep, friends all that easily, there are a number of reasons for this that might have nothing to do with autism.
Why does this matter?  There are concerns of course about over diagnosis, and inappropriate labeling. People like me get very fussy about categorizing developmental problems. But all of that in turn only matters because if we don’t know what’s going on, if we leap to conclusions and slap on an ASD label without careful thought or assessment, we are missing the opportunity to address the actual needs of this highly vulnerable group.
Let me give you one example. Raul goes to a local primary school, where he struggles with hyperactive and often aggressive behaviour and has few friends. The label of ASD traits has resulted in some harmless but largely ineffective interventions. Careful, holistic assessment leads to an old reference to domestic violence, a language impairment and mild ADHD, but no evidence of ASD. Support for mum to deal with the aftermath of DV, speech and language intervention, and ADHD strategies resulted in (slow) functional improvement.
So it does matter. ASD is important and complex, but it’s not the root of all peer difficulties.

In summary, for those who like bullet points:

  • These kids do have issues, just not ASD, and labelling them wrongly leads to inappropriate intervention, with missed opportunities fro therapy e.g. for anxiety, or dyslexia.
  • ASD is typically treated without drugs in the UK, but I have seen children get to the point of anti-psychotic medication before someone realises they might have the wrong diagnosis.
  • ASD has become less stigmatised recently, but it still interferes with a young person’s sense of self to be told they are a certain sort of person that they are not
  • Throwing the ASD label around willy-nilly makes it less meaningless and less effective as a guide for funding agencies and professionals- mislabelled children will not respond to standard interventions so people will lose faith in these, perfectly good, interventions in favour of the latest educational/ therapeutic fad.

What are the implications of this?

  1. No child should receive a diagnosis of ASD without a comprehensive look at other alternatives
  2. Having a clinic aimed solely at diagnosing ASD is dangerous
  3. Teachers/ social workers should not label children with ASD- it is enough to describe the pattern of behaviour and put in place sensible intervention pending full assessment.
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