Many concerned parents have asked me if their seemingly highly sensitive child (HSC) could really be autistic or have Asperger syndrome. Sometimes a teacher or doctor has suggested it. Others have been told that the entire trait of sensitivity is just a mild form of one of these disorders, the higher functioning end of the “autistic spectrum.”
This article is not meant to supply you with the full details of autistic spectrum disorders. The new name for all of them that was adopted by the American Psychiatric Association’s fifth edition of the Diagnostic and Statistical Manual. To find all of the criteria you can go to some very good websites (for example, http://www.cdc.gov/ncbddd/autism/hcp-dsm.html).
How is HS mistaken for these disorders?
Let’s go back to our three possibilities in the first FAQ. I do not know how it happens in the consultation room or doctor’s office, but I know many professionals have at first (or still) viewed HS as merely some mild autistic spectrum disorder. Some simply equate them. This is mainly because both HSCs and those with the disorder are bothered by overstimulation. Plus both may withdraw from social activities and stay in their rooms on the computers, watching movies, and so forth.
About overstimulation, two new criteria, not there in the past, are under B: Restricted, repetitive patterns of behavior, interests, or activities.” There are four criteria for this, but these might be confusing, especially the third and fourth:
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).
- Hyper- or hypo reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
So those on the autistic spectrum have hyper reactivity, but also hypo reactivity at other times or in other situations. This is due to problems in properly processing information social and otherwise. They fail to sort it out, so it is all there, all the time, or totally shut out. In contrast, HSPs and HSCs process information very carefully. We can become overstimulated if there is too much for too long, but we do not become fixated in an extreme way or unable to shift to other stimuli according to the needs of the moment. Above all, we can read social cues, unless we are overaroused in the moment by being overstimulated. Below are the first criteria from DSM V, which have not changed much or at all from their last description.
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.
Can you say that more simply?
Okay. Sometimes—not always—children with an ASD show acute sensitivity to noise, touch, or other sense modalities. Others are impervious to what most people would find uncomfortable, even to serious pain. Sometimes sensitivity and ASDs are confused because the child with an ASD may have little or no ability to regulate emotions, and sensitive children, too, are more emotional than other children. But with ASDs, these behaviors are due to incorrectly processing perceptual stimulation all the time, not just when overstimulated.
For a good sense of ASD from the inside you might enjoy The Curious Incident of the Dog in the Night-Time, a novel by Mark Haddon, who works with autistic children. He writes the story from the viewpoint of an autistic boy. Among other things, this child is intensely, miserably sensitive—but in a far different way than HSPs describe themselves. Remember, HSPs process information more thoroughly and thus gain more meaning from their observations. Our states of overstimulation arise from too much to process at once. Those with an ASD are always processing the wrong things and always experiencing chaos unless they are able to shut themselves off from the world entirely.
In brief, you can best sort out sensitivity from ASDs by keeping in mind two differences. First, social perception—HSPs are generally more skilled at observing what’s going on in a social situation, even when they are not joining in. Second, HSPs have intense imaginations and varied interests rather than narrow preoccupations.
What if it is Autism Spectrum and Not HS?
Being clear about this in children is especially important, as the earlier you begin treatment, the better the outcome. An astounding 3.4 children out of 1,000 have an ASD. Even taking into account that there is more knowledge about ASDs and so more diagnoses of them, the increase goes beyond that. We do know these disorders are often genetically based—researchers have found a number of different genes that can produce ASDs. For example, most but not all of the genes put boys more at risk than girls. Besides genes that are inherited, ASDs can also be caused by a gene mutation. (There is a suspicion that the increase in ASDs could be caused by one or more of the zillion chemicals we are all ingesting these days.) The variety of genetic pathways accounts for the wide range of behaviors seen with these disorders (strange fixations, astounding memories for details, etc.), but in all cases the brain is thrown off of its normal development because the growing child’s brain is misusing the sensory information it is receiving and that it needs for normal development.
The tendency to be very sensitive to stimuli and easily overaroused is easily confused. I have two grand-nephews with an ASD, one a grandchild of my sister and one of my brother. When I first saw them as toddlers, in each case they were visiting as part of a longer trip, and I assumed they were HSCs who were overstimulated by travel. Clearly I am no expert myself at making the diagnosis, although I like to think that now I could do better, having seen them in action. But no one who loves a child or their parents would want to think about autism, even when the child in question will eat only exactly three kinds of food or is happy for twenty minutes merely watching a bicycle wheel spinning.
Nor do we want the reverse, of course—sensitive children being mislabeled because they are observed to be socially withdrawn at school or in a strange social situation.
How to find out for sure?
A parent with even a suspicion that something is odd should get a professional evaluation involving several specialists (pediatrician, speech therapist, psychologist, etc.) who make observations at home and at school as well as in their office. But be sure at least one has experience separating a normal but extreme temperament from a disorder, which means he or she should be an expert in children generally, not just those with ASDs. And do mention whether the problem is worse when your child is tired or has been in an overstimulating environment, or if there is stress at home, or some major changes going on that might cause anxiety in an HSC, even if not in another child. Especially confess if you are having marital problems or fit some DSM diagnosis yourself, including substance abuse. HSCs are very affected by such things, so that, again, they could meet the criteria of severe, sustained, pervasive impairment in social functioning without having an ASD.
In some cases, you know if it’s sensitivity or an ASD because the signs were present from birth. In other cases, the onset of an ASD occurs suddenly, around 1 or 2. Sudden or not, ASDs usually become obvious to others when the child is around 18 months to 2 years. It is essential that treatment begin early if there is a real problem. So start asking questions as soon as you begin to suspect that something could be wrong—if speech is delayed, for example, or your child is behaving very oddly. Don’t be in denial or think this is just high sensitivity. Find out.
Adults with Autism Spectrum Disorders
Adults can be especially confusing, as they can function very well. When I happened to be on a week-long group backpacking trip with a man with Aspergers (he only told us about this at the end), it took some time to realize there was something different about him. I recall best that his normal ten-year-old son (they’d been sent out for a male bonding experience) was in agony from trying to carry a pack too heavy for him. His father told him it was because he had packed too much. This was surely the case, but Dad showed no sympathy or even annoyance. It was not about teaching his son a lesson—that would have involved some complex social-emotional negotiations. He was clueless about how to resolve this beyond next time seeing his son had a lighter pack.
Something clearly had to be done, so my husband carried the boy’s pack on steep climbs. The father expressed no surprise or gratitude. He was a very nice man, a nurse by profession, and a good one when I was injured on the trip. At that point I wondered if he really was an HSP. But when he told us at the end, I saw the difference because he could talk readily about his problem, and the fact his marriage had ended because his wife could not stand his lack of emotional empathy. With that information, there was no way that he could be confused with an HSP, except perhaps by his acute awareness that he was different, which made him very sad. He could experience his own emotions, but he could not read the signs of the emotional experiences of others.
The Unsocial Man—Sensitivity or Asperger Syndrome
Even autism professionals can have trouble sorting out sensitivity from men with Aspergers because both can lead to social withdrawal or poor social skills. Again, as yet there is no way yet to make a certain diagnosis looking at brains or genes, so one has to look beneath these behaviors—being socially withdrawn and unskilled—to the underlying reason. Men with either issue may have, as boys, holed up in their rooms to work with computers, read, or watch TV. As teenagers they may not have dated due to fearing rejection for being a nerd or seeming less manly than the boys getting the most attention. Then they may have chosen careers such as engineering or accounting in which they could avoid the discomforts of socializing. But again, those with Aspersers lack social skills because they cannot perceive what is going on and never could very well.
HSMs might do all of the above for several reasons. One is not fitting the masculine stereotypes in our culture. Another is having been more affected than others would have been by social traumas such as rejection or betrayal. Yet another reason is that they want to avoid over arousing emotional encounters with strangers or in groups merely because they have learned that in these situations they become too overstimulated to function well. So they focus instead on what they do best (for which they are often paid well, too).
Whatever the reason for social withdrawal, their families often want some explanation for all of this that they can understand in simple, scientific language. Why did he always retreat to his room as a boy? Why he is still not married? Everyone may be relieved to find a biological explanation, an ASD, especially since it absolves the parents of any blame. Alas, such a diagnosis also reduces the hope of changing, of developing stronger social connections with practice.
There are ways, again, to sort this out. Suspect an ASD if the problem was noticeable even in infancy, and as much at home as at school. Are the social problems now due to a real problem with recognizing social-emotional cues, such as a bland response when others would have empathy? On the other hand, suspect sensitivity if only other people are concerned, or if there is a reasonable explanation behind the behavior—the desire to reduce stimulation, a history of social traumas, or a wish to avoid working or living in environments that require boisterous or highly competitive behavior, which is most of our culture. Remember it also could be neither an ASD nor sensitivity if the man withdraws due to serious wounds from previous social rejections. In all of these cases except an ASD, the man might have rusty social skills, leading to more social anxiety, and then even less confidence in social situations and more and more withdrawal, all while fully aware of social cues. If anything, these men see too much. Research has found that shy people usually know very well what is happening and how to behave in a social situation—watching a video they can identify or suggest good social behavior—but they perform poorly in the actual situations due to low self-confidence.
On the other hand, some adults decide they are highly sensitive when they actually do have an ASD. They want to find a normal explanation for something that is not normal. Again, there is no blood test or other way of diagnosing ASDs, so if you are unsure, read all that you can about them and then try to decide for yourself (you being the person who probably knows you best). Pay particular attention to how others remember you in childhood. If still unsure, get a professional evaluation from someone who will consider all of the possibilities. If one person says you have Asperger’s, get a second and a third opinion. You want the truth. Don’t be afraid—there’s help for adults with ASDs. But none of us can begin to change until we know from where we are starting.
I said this in Psychotherapy and the Highly Sensitive Person:
The mistake [seeing them as being on the autistic spectrum] is usually made with sensitive men (since these disorders do appear more often in men), who are especially prone to withdraw emotionally due to not fitting the masculine stereotypes in our culture. They still need to prove themselves in some way, have social contacts, and support themselves, so they often enter into nonsocial professions, such as certain types of engineering and technology innovation, where they can meet these needs while usually avoiding over arousing emotional encounters. When a man or his family members seek a non-blaming explanation for why he always retreated to his room as a boy and still has not married, they may find it in a biological explanation involving the “low end of the autism spectrum.”
On the other hand, men with undiagnosed Asperger’s Disorder might well come to therapy thinking or having been told that they are highly sensitive as an explanation for why they feel they do not fit in [the second error, saying it HS when it is not]. You can do the differential diagnosis by closely observing patients’ actual social empathy with the therapist (after a few sessions to become comfortable) and by how they describe their relationships with others. In their history, the question is whether their low sociability is the result of trouble with social-emotional cues, commented on by themselves or others, or is it due to fear of rejection. One study (Cartwright-Hatton, Hodges, & Porter, 2003) found that even shy children usually know well how to behave in a social situation (watching a video they can identify or suggest good social behavior), but perform poorly due to low self-confidence.
I think I am on the autistic spectrum and am also highly sensitive.
My mentor on temperament, Jan Kristal, who went over every word of The Highly Sensitive Child, insisted that everyone has a temperament separate from any disorder or innate developmental challenge, even those with brain damage and intellectual disabilities—not that I am equating that with those on the autistic spectrum, who are often exceptionally intelligent in many ways. So yes, it seems that one could have both.