ASPERGER'S VIGNETTES


COMEDIES and TRAGEDIES – CHAPTER 4


LOTS MORE COMEDIES IN THIS CHAPTER, FOLKS! I feel probably too many of the stories in Chapters 1 – 3 have been kind of “downers,” so I'm going to mostly present comedies in this chapter. BOBBY (9) was a super pocket hoarding problem child. He lived in a small house with his mother and grandmother located about 300 meters from his school. He had to walk to and from school every day. His 3rd grade teacher soon became used to him arriving with his pockets stuffed with all manner of junk he picked up along the road, so she made him empty his pockets every morning. He filled his pockets back up with more junk he found on the schoolyard every day, so she made him empty his pockets before he walked home. Bobby consistently arrived at home with his pockets filled up again. Grandma searched him and found old bottle caps, used matches, threads, small stones, grass, weeds, snails, and worms, among a constantly changing pantheon of items. Mom and Grandma brought him to see me due to their concern something must be seriously wrong with him since nothing they could say or do would make him stop. I soon discovered he had ADHD and treated him with Ritalin (this was 25 or so years ago), which helped him substantially in his academic work at school. But the Ritalin had no effect at all on the the junk that went into his pockets. When Mom and Grandma cut out all pockets, the junk was stuffed into his socks, or shoes, or boots, or pants, or underpants, or shirt – wherever. Despite the best and most intensive weekly 1:1 psychotherapy I could provide and all practical behavior modification efforts, Bobby always carried junk someplace cleverly hidden in his clothes. He had no idea why he kept doing this; he simply said “I have to.” We discussed adding other medications like “tranquilizers,” but that did not seem safe. In the end, after one year, we all faced reality and gave up and said “OK, put anything you want in your pockets.” Three weeks after “winning,” Bobby started stuffing only old bottle caps into his pockets. About three weeks later, he walked to and from school every day without putting anything into his pockets, and that was his status when I last met with him. MORAL OF THE STORY: We can't always “treat” some of the odd symptoms AD kids have. His Mom and Grandma and I had to accept a form of defeat, but we realized he was not harming himself or anyone else by stuffing all manner of items into his pockets or pants or socks or whatever. I correctly predicted Bobby would eventually cease this weird behavior. I incorrectly predicted how soon after we admitted defeat he would give up carrying all that junk around. TANYA (10) would never wear a shirt without a whale's portrait. Most of her shirts had logos like “Save the Whales!” She refused to color or draw anything but whales. When her teacher struggled to help her learn division, she had to invent problems like “If a pod of 32 whales decided to split into 4 smaller pods, how many whales would be in these new pods?” Tanya wouldn't read anything unless whales were an important feature of the book or article. Her Mom reported she had at least 20 stuffed whales on her bed. It was 1973, and neither I nor any of my colleagues had ever heard of anything like this. Asperger's Disorder in children was completely unknown in the U. S. then. AD was not listed as a diagnostic condition until 1994, although most child psychiatrists had seen some articles about it from the late 1980's on. Very thorough psychological testing was unhelpful. No manner of “talking” therapy was helpful at all. So I arranged to see Tanya annually primarily out of curiosity to see how she would develop. She eventually became less and less fixated on whales alone and became interested in other marine mammals, e.g. dolphins and seals. By age 13 she was studying a very wide range of oceanographic science. Her parents soon thereafter left the area but called to report Tanya was going to attend a special oceanographic camp in the San Diego area that summer. Evidently, we had all been correct in just letting her unusual development take its natural course. SEAN (6) and BARRY (7) were very similar. Sean was completely fixated on lawn sprinklers; he was an “expert” on all the various brands, their mechanics, the mathematical facets of their cycles, etc. His parents always knew where to look for him in any hardware or department store! Unfortunately, they lived in a small city where most residents regularly sprinkled their lawns. They could not drive past a working sprinkler without Sean throwing a mega-tantrum if they didn't stop and let him examine it. BARRY was completely fixated on pine cones: all pine cones. My office then opened out to a parklike lawn dominated by several large fir trees. As soon as Barry arrived at my office ZOOM ! He was out the back door and happily immersed in collecting and stacking and otherwise playing with dozens of pine cones. A carefully negotiated 3 large pine cones went home with him after each session. However, wherever his parents drove around town, his parents had to deal with the same fierce flip-outs Sean's parents did, and there were a LOT of fir trees in this town. No talking therapy, play therapy, behavioral treatment – NOTHING helped either one of these boys. Their parents simply had to set reasonable limits on how often and for how long they could stop and stick to their decisions. These stories both date back to the early 80's when there was no medication treatment for any aspect of AD (apart from the usually co-occurring ADHD which we treated then with Ritalin or Dexedrine). Fixations as severe and family-impairing as these can be treated with SSRI meds now. Since boys attended the same school, which featured large lawns and dozens of fir trees, their teachers, playground staff, and school administrators were nearly constantly engaged in chasing them all over the yard trying to set limits. It “seemed” cute, but hours and hours every day were consumed trying to manage them. In 2011, these two AD boys would be treated with a serotonergic medication to reduce the severity of their fixations. HELMUT (12) was the only child of two psychologists residing in Zurich, Switzerland. His parents attended a presentation I gave to the university psychology department in 1998. They approached me after the talk to ask if their son's behavior might be abnormal. His Mom explained his bedroom was crammed from floor to ceiling with small, interconnecting boxes and he would throw a “tizzy fit” if she moved anything. Since their house was nearby, I walked over there with them and recoiled in amazement upon (very carefully) walking into Helmut's room. There was a very small path providing access to his bed. Otherwise, every square inch was filled with floor to ceiling small cardboard box constructions, most of them painted. He had no explanation for why these boxes had to stay precisely in their place, but he was convinced they did and could never be moved. His history was perfectly typical of a child with AD. His parents had been taking him to a Jungian analyst for two years without any benefit, but my suggestion a SSRI medication would be useful was rejected. These parents were strongly adverse to drug Rx. This was very unfortunate, since Helmut had another serious AD symptom: He was completely convinced he was in love with a 13 year old girl in the complex, and she with him, but she simply did not know how to express it. Her parents became alarmed when Helmut was waiting outside her door day and night, sometimes followed her into her house, and refused to comply with both sets of parents' rules. He had to be sent to reside at a therapeutic boarding school many miles away. “Stalking” like this not common in AD patients, but it is not rare, either. I had to try to help school staff and parents deal with a more potentially serious case on another visit to an international school near Zurich two years later. BJORN (16) was one few Norwegian kids there. He had always been essentially friendless and very awkward socially, but the wonderful, dedicated faculty at this school worked hard to integrate him into many healthy school activities, and he met Helene (15) in a dance class. He immediately developed pathological attachment to her and attempted to follow her everywhere, including the girls' bathroom and residential areas. Helene strongly objected and Bjorn was repeatedly caught in compromising situations like hiding in a laundry room. NOTHING sufficed to persuade him to stop. Further, Bjorn was a big boy, well over 6' 2” and 220 pounds, and on several occasions when he was caught he “overly fondly” mishandled female teachers and staff members. My Swiss colleague and I very strongly recommended he be treated with a major neuroleptic, Zyprexa, but his parents were afraid of the relatively trivial side effects. Bjorn had to be sent back to a psychiatric treatment facility in Oslo (with his mother) while his father continued to work in his diplomatic role in Zurich for another year. Very odd and amazingly persistent STALKERS who are discovered to be bizarrely infatuated in or by some famous people, especially movie stars, are repeatedly caught, cited, put on restraining orders, and yet break these orders time again by invading their selected subject's yard, home, and bedroom. Usually these AD people are not interested or inclined to sexually assault their victim. What they are typically seeking is a sense of this person talking to them and caring about them. Far too often the AD folks who exhibit this pathology are misdiagnosed as having Schizophrenia. Girls are about 1/3 as prone to develop AD symptoms as boys, but they can be just as baffling and frustrating. Many years ago I tried to treat EMMY, (9), who had recently been placed in a very good foster home in a small town in another state. There were 3 younger girls and two older boys in the home. Soon after Emmy became familiar with her new family ALL the other kids complained she wouldn't stop playing with, or trying to play with, all the other children's fingers and toes. During recess and lunch hour at school, she “captured smaller kids (she was very big for age 9), removed their shoes and socks, and spent long periods playing with and even sucking on their toes. This, of course, “freaked out” the other kids' parents, and although a supervising aide was assigned to watch her she was often interrupted. Nothing her foster parents did had any effect on Emmy's behavior at home. (Oddly enough, she was very well-behaved in nearly every other respect. The “last straw” occurred when her foster siblings and parents discovered she had spend one “quiet” weekend cutting all fingers out of gloves, all the toes out of socks, and she had – in addition – cut all the fingers and toes off of all the (many) stuffed animals in the house! I had no idea what to do and referred her to an excellent child psychologist, who diagnosed Emmy as having Reactive Attachment Disorder as well as AD. This case dates back to many, many years ago to a bygone time when foster children could receive comprehensive 1:1 therapy and small group therapy by a good psychologist. Emmy improved dramatically in the next six months and was symptom – free by the end of the school year. +++ Please allow me to describe three cases which might sound a bit like AD but the diagnosis was different. BRANDON (10) lived a devout LDS family two hours from my office. His complaint was he could not stop thinking about having erections, which were discouraged in his family and church. The drive from his home to my office led him to pass at least 240 telephone poles, and anytime he saw a telephone pole he instantly experienced an erection. This was of course the case when he was riding or being driven from home to school, to and from scouts, to and from church, etc. It was never possible in “real life” to avoid seeing telephone poles. Equally obviously, it would have been professionally imprudent to try to give him some medication which would inhibit his developing an erection. Brandon had a severe case of Obsessive-Compulsive Disorder (OCD), and one of my psychological colleagues had become remarkably proficient in treating children who have OCD with so call “Exposure and response prevention,” also known as Cognitive Behavioral Therapy. After two sessions training Brandon and his mother precisely what steps to follow at our office, Tom (my psychologist) and Brandon and his mother were able to reduce and then eliminate ALL his symptoms simply using 30 minute phone calls. This is currently “the standard of care” in our profession. TANNER (8) lived in the same town as Brandon, and he was also obsessed with telephone poles! He also had OCD. His problem was different: he would become incredibly anxious and have to turn around and drive to my office all over again if the number of poles he counted on the way did not end in a multiple of four! (His mom soon figured out a route so that number was always 444.) However, this also applied to EVERY trip he took in a car – wherever! Tom employed the same treatment approach and Tenner was symptom free in two months. GABRIEL (7) was a cute little flying and bouncing tyke who had many motor and vocal tics, including squeaks and grunts. His mother and both aunts and two older cousins in this large, extended LDS family all had OCD, but Gabriel reported no such symptoms. I predicted (to his mother) Gabriel would very likely develop nasty obsessive thoughts with the next few months, and suggested he ask him about “nasty thoughts” every few nights when she tucked him into bed. Three weeks later I received a hysterical call from Gabriel's mother. He confessed he was having intense obsessional thoughts, the content being “I hate Jesus!” He had scrawled these words on dozens of small pieces of paper he kept hidden under his mattress, along with dozens or more crude drawings of stick figures being impaled complete with red coloring dripping from their anal regions. I explained morbid obsessions like these are common in ADHD children who have Tourette's Syndrome. This family lived far away, so I called in 25 mg Anafranil to be given before bedtime. I knew that would help right away, and when I saw Gabriel for follow-up a week later he bounded onto my lap, kissed and hugged, and said “Thank you” over and over again.