ASPERGER'S VIGNETTES


COMEDIES and TRAGEDIES – Chapter 2


 Impulsive verbal threats to harm or “kill” someone are common in untreated or undertreated AD children, in part because almost all boys and most girls with this condition also have Attention Deficit/Hyperactivity Disorder (ADHD), and in part because children who have AD have not developed the capacity to self-monitor and self-censor their comments in crucial psychosocial interactions. They often burst out with threats to “kill” after being teased by far more socially sophisticated peers. They do not actually, literally, mean “kill” in the sense of an actual intent to murder another child, a teacher, or any other person. They are simply expressing a wish they could somehow 'get back at' this individual.


JACK (11) was frequently teased by classmates partly because he was very small, and partly because he routinely spoke in a derogatory, condescending, critical manner to peers as well as to teachers. One day after being shoved and spit upon by a 6th grade classmate he muttered “I wish I could kill that kid!” A classmate overheard him and told the Vice-Principal what he said. Jack, who was always precisely honest, admitted saying these words when confronted by the Vice-Principal. He was suspended from school and soon thereafter assigned to an inner-city “Opportunity School.” Jack was terrified there and pled with a school psychologist to help him.


This school psychologist was a sensitive and capable young woman who immediately recognized Jack was completely different from any boy she had seen assigned to this school. His academic record revealed straight A's, Iowa achievement scores in the 99th % range, and no disciplinary problems ever before. She called his parents and insisted they take him to a child psychiatrist immediately. I met Jack on an urgent consultation basis two days later.


Jack appeared to be closer to 8 than his actual age of 11 ½. His expressive vocabulary included words more akin to those expected from a college student than a 6th grader. His manner of speech was typical of the prosodic inflections typically found in AD children and adults. After his parents confirmed he had never had a “real” friend, I asked them if he had any other unusual behaviors. His father immediately said: “He drives me nuts whenever I try to cook anything on the microwave!” It turned out Jack was fixated on precisely following written directions on items such as foods to be cooked in the microwave to the extent he would be hypercritical, furious, and refuse to eat anything which was removed as little as one second before or after the time designated on the package. His Mom worked late at her job, so Dad was the usual dinner-providing parent.


The Asperger's diagnosis, a couple of calls, and a brief written summary led to Jack being readmitted to his former school within a few days. I treated him and his parents with primarily educational and behavioral therapy, adding the SSRI Luvox to reduce his rigid fixations. This combination of treatment was almost immediately effective, and he was back to “perfect student status” immediately.


This is just the beginning of Jack's story. Almost all the rest is remarkably GREAT! He became a featured co-speaker at community and professional presentations I gave in a neighboring state and a valued assistant “peer therapist” for many newly diagnosed AD children and adolescents in my Clinic. I will tell more of his story later. Jack had a momentary “slip” when he was frustrated by a young professor in his second year of college. He muttered the “kill” word again, it was overheard, and the University “mental health team” descended on him with grave concern. This incident occurred shortly after the horrible Virginia Tech shootings! There were urgent calls and another report. Fortunately, the clinical staff at this university were sophisticated and capable professionals, Jack was contrite and effusively apologetic, and he was exonerated two days after his “slip.” ALL the rest of his story is absolutely a joy to relate.


NATE was 9 when I first met him, his mother Alice, and adoptive father Ben about 15 years ago. Some children who have AD are so severely affected a diagnosis can be made in minutes. The great Australian expert Dr. Tony Attwood describes cases like this. Nate's voice was raspy, grating, incredibly loud, screaming, and everything he yelled was like a lecture to me and his parents, except when he launched into astoundingly obscene threats, addressing his parents by their first names, and telling me and everyone within earshot in my office how Xxxxxx like these Xxxxxx should be executed by shoving Xxxxxx up Xxxxxx and setting their Xxxxxx on fire with a blowtorch. His mother had evidently refused to buy a video game he wanted on the way to the appointment.


AD is usually a genetic condition, so I was not completely shocked when his mother Alice responded in kind. Her voice was just as grating, raspy, nasty, and wrathful as her son. She also bellowed and screamed out obscene words I have never before or since in my entire career heard from a mother directed at her son. They were so loud my horrified office staff overheard essentially everything. None of us had ever heard a mother call her son vile, sexually explicit words like these. They continued ranting and raving at each other simultaneously for at least 10-15 minutes, never listening to each other at all. Ben sat quietly between them saying nothing at all. Nate was Alice's only child. Ben and Alice had been divorced for 5 years. They shared custody, trading off weekly.


This story will not be the least bit funny.


There is a myth often bandied about in our profession suggesting children are always truthful when they report being physically or sexually abused. Many experts who have had extensive experience with AD children (and adults) report these individuals especially are almost always explicitly honest and truthful. Jack was always precisely truthful. Adam was always honest in every respect. Most children and adults who have AD lack the sophistication and deliberate sneakiness to lie to doctors, Child Protective Service caseworkers, attorneys, judges, etc. Nate and his mother were exceptions.


Despite intensive 1:1 therapy and medication treatment, I was never able to help Nate stop calling his other parent and lying about being abused by the parent he was staying with that week. He knew the CPS emergency number by heart and often called caseworkers at this agency to report perceived abuse by parents or teachers. When exposed as having lied to me and/or others, his response was always “I must have misspoken.” Nate openly celebrated and in a sense reveled in whatever grief he caused both parents. He hated them both for having divorced each other.


His Mom, Alice, detested Ben for being happily remarried. Shortly after their divorce, she began to call Ben late many evenings and “ventilate” at him, often threatening to kill him. When he remarried, Alice also often threatened to kill his new wife, her parents, and even his new 9 y/o stepdaughter. These calls sometimes occurred after Nate called her (when he was spending the week with Ben) and complained about Ben or his new wife abusing him, e.g. by sending him to his room without dessert when he threw a tantrum and spit in his stepmother's face because he didn't like the food he had been served for dinner.


Ben soon learned to never answer when Alice called, but he recorded her messages on his voicemail. The threats were constant, finally leading to a Family Court judge ordering Alice to be evaluated by an eminent forensic psychiatrist, who – amazingly – found nothing wrong with her! He also speculated Nate was being very capably parented by both Mom and Dad, but never interviewed Nate.


Eventually a ferocious, extended custody battle ensued, and Alice won primary custody. Now she had no relief from trying to cope with a (then 13 y/o) angry AD / ADHD boy full time in addition to a demanding work schedule. She soon found many ways to clash in a variety of incredibly offensive ways with her employees, drawing complaints to a federal agency, and lost a legal battle against them. Several months thereafter she did physically abuse Nate, whereupon CPS took custody and sent him to live with a relative Alice hated. One month later while her federal case was back in court she called both adversarial U. S. attorneys late at night and left raging messages on their voicemail threatening to kill them. Later that night she called the judge and left a message on his voicemail repeating her threat to kill these attorneys. A jury subsequently found her guilty of seven major felonies, and she was sentenced to 10 years in a federal prison for each felony.


*** This case was a catastrophe in part because Nate had been evaluated by several well – qualified psychologists and psychiatrists before I first met him, all failing to Dx AD despite his flagrantly obvious Sx, so he and his parents never had a prior opportunity to work together and help Nate and each other work on strategies to deal with his many problems. Alice herself had been seen and evaluated by three very good clinical psychologists and two excellent psychiatrists several years before I first met her. They all failed to make a Dx of AD. None of these respected professionals ever met with Alice and Nate together. This was THE MOST IMPORTANT OPPORTUNITY to actually see and help understand their conjoint pathology.


Nate's perception of having the power to destroy both his parents (and antagonize school personnel) proved untreatable. He was dismissed from every important, excellent private school program in the region, sometimes for threatening to harm or kill peers, and sometimes because he falsely claimed he was being abused by school staff. He eventually alienated everyone who tried to help or care for him by constantly lying about being abused. Alice actually readily accepted my Dx of her having AD, but could never fully cooperate with her therapist, and took prescribed medication erratically. She always felt superior to everyone else and fully justified in whatever she said or did to Nate, her ex-husband, his new family, her employees, and ultimately to any “stupid” attorneys.


In my experience it is always crucial to Dx and treat children who have AD as young as possible, and also to try to Dx and treat any AD-affected parent as soon as possible as well. Once the parents of AD children have split up, which almost all do by or before the child is 11 or 12, effective Rx becomes very difficult or sometimes impossible.


I will close out this chapter with a humorous vignette.


EDWIN was an amazingly tiny 10 y/o when I first met him, weighing only 45 lb. He looked closer to 6 or 7 than 10. I was amazed when his mother told me his pediatrician had been prescribing 0.1 mg Clonidine 3 x per day for him. Clonidine is an old antihypertension medication which has calming features, but is also very sedating, and rarely if ever given to children since 1990 except as a sleep-inducing bedtime medication. Edwin and his mother had recently relocated and were seeking the services of a child psychiatrist because he had become increasingly angry and disruptive at school. As Edwin played with magnetic toys on my office floor I asked his mother when he had last been seen by his pediatrician. She answered “A few weeks ago.” Edwin immediately stated, in the most critical, derogatory, and pedantic manner imaginable “I last saw Dr. XXX three months and 10 days ago.” He add the date and time of the visit.


Clonidine can generate bradycardia (a very slow pulse rate), so later in this session I helped Edwin climb up onto my exam table and bent over him so I could listen to his heart with my stethoscope. After a few seconds he sniffed, pouted, and said:


“Does one attend to one's personal oral hygiene?”


I immediately realized he had detected the odor of smoke on my breath. His mother yelled “He is always saying nasty things like that!” I responded by asking “Does one detect an offensive odor on my breath?” Edwin then said “Yes, the odor of cigarettes. I hate it when my Mom smokes and then wants to kiss me!”


I am much more careful about (not) smoking before I see children these days!


Please go on to Chapter 3. There are many more vignettes I will discuss there, including one of the most entertaining and dramatic ever: Colin's “threatening” story.