OAARSN Book Review
Autism: preparing for adulthood, by Patricia Howlin
Routledge, London and New York, 1997. 294 p. Figures, tables, references, index.
Patricia Howlin, who won the 1997 NASEN Special Educational Needs Book Award, is Consultant Clinical Psychologist and Senior Lecturer in Psychology at St Georgeís Hospital Medical School in England. She decided to focus on adults because most of the existing literature was about autism in children, and to concentrate on more able adults because there was so little published advice about to understand and support their needs. Difficulties in communication and social interaction and with obsessive and ritualistic behaviours persist through adulthood of people with autism, whatever their functioning level. More able adults are usually well aware that they are different, feel frustrated that they are unable to make use of their special skills, and experience acute emotional distress. Society tends to be much less sympathetic with adults who seem more mildly disabled and to have unrealistically high expectations of them.
The authorís aim is to foster understanding of the fundamental deficits of autism and the impacts these can have on the lives of affected adults. Chapter 2 reviews follow-up or longitudinal studies of autistic children as they became adults, especially those regarded as more able or "higher-functioning." Understanding autism is generally limited to how the triad of impairments affects behaviour, and strategies are various forms of behaviour modification. Beyond references to autism as genetic, there is no exploration of the what and why of any dysfunctions. Readers may be disappointed that there is no mention of gastronintestinal disorders or special diets, or sensory integration dysfunction and strategies, or neurological and movement disorders, and that facilitated communicating is summarily condemned. But we should remember that Howlinís book must have been completed in 1995-96 and that there have been very substantial advances in research into neurodevelopmental factors in autism during the past five years.
Each of the remaining chapters begins with explaining an area of difficulty and ends with discussion of strategies that can be used to overcome or minimize the impairments. No magic cures are proposed and Dr Howlin is very sceptical about the claims of particular intervention programs to be the answer to autism. Strategies can be adapted to the individual needs of adults with autism and those who support them.
In the chapter on "Problems of Communication," comprehension difficulties, problems in spoken language and in dealing with abstract concepts, and lack of reciprocity are noted. Suggested strategies are to: increase understanding and decrease inappropriate speech; help to improve the communication skills of other people; remove uncertainty; reduce attention to inappropriate speech but recognize the importance of obsessional speech; teach alternative skills; talk about emotions and abstract concepts; and increase general communicative ability by whatever means.
Impairments in social functioning are pervasive and profound for all adults with autism. Temple Grandinís image of being "like an anthropologist on Mars" is well known. Therese Jolliffe, a postgraduate student with autism who is often quoted by Howlin, writes that "life is bewildering, a confusing, interacting mass of people, events, places and things with no boundaries... People do not appreciate how unbearably difficult it is for me to look at a person." The author notes the almost universal problems with peer relationships and understanding friendship, failure to share or understand and respond appropriately to othersí feelings or emotions, failure to interpret social cues, and "mindblindness." She suggests: teaching the rules of social behaviour through clear and simple guidelines from the earliest age possible; helping with more complex social understanding and how to respond to othersí social cues; modifying the demands of the social environment; supporting to deal with loneliness; and making use of existing skills to encourage social interaction.
Obsessional and ritualistic behaviours are interpreted as often crucial ways of keeping fear and anxiety under control. Strategies to cope with these include: addressing the underlying causes; cognitive and behavioural techniques of desensitization; introducing alternative and more acceptable behaviours; keeping obsessions out of sight; making contracts, compromises and rules; enlisting the help of others; support in predicting and dealing with change; relaxation; distracting and thought stopping; developing and encouraging other activities; and using obsessions creatively.
There are also chapters on education for adolescents with autism, further educational provision, coping with and finding employment, psychiatric disturbances in adulthood, legal issues, and problems with sexual relationships.
In the last (brief) chapter about "Fostering independence, " Howlin comments on changing expectations and attitudes by others, the problems of lack of self-drive and initiative, the need for flexible and individualized living arrangements, and the need to experience various options in order to exercise choice and self-determination. She concludes that there is no one ideal form of provision for people with autism. A wide range of different environments is needed, and it should also be possible for individual adults to change their living environments as their needs or skills change. She offers a few basic guidelines (p. 265), which we think apply to all adults with autism.