Autism And Mentalization

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Hello and welcome back.
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This is Kim Lee from the Children's Consultancy.
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In the last episode, we talked about the relationship between detention deficit hyperactivity disorder and mentalizing or mentalization.
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And I omitted to qualify this term ADHD because if instead of thinking of ADHD where the H stands for hyperactive, we also have to consider that type which is different.
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There is the inattentive attentional difficulty and the hyperactive variety.
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And sometimes patients present with a combination of both.
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That doesn't substantively change what it is that I'm talking about, but I think it's an important qualification.
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And so in this episode, I want to talk about something different, but connected, because it once again has to do with the way in which mentalization evolves, but also those factors that might compromise it.
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So I'm going to talk about mentalization and autism.
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And the question here is: do autistic children or children with autism struggle to understand minds?
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And for many years, psychology has answered that question with a very confident yes.
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But science, like people, evolves.
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And perhaps it's time to ask a better question.
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Not can people with autistic difficulties mentalise, but do people with autism and those who don't have those kinds of minds understand each other differently?
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Because this distinction matters.
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For decades, autism was viewed largely through the lens of deficit.
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And researchers such as Simon Barron Cohen contributed enormously to our understanding of autism and developed what became known as the theory of mind.
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Now, theory of mind refers to the ability to appreciate that other people have thoughts, feelings, beliefs, and intentions that may differ from our own.
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Early research suggested that people with autistic difficulties found aspects of this really quite difficult.
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And undoubtedly many experienced challenges in social communication and understanding.
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But since then the picture has become far more nuanced.
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And what's become increasingly clear is that mentalization is not a single skill that someone either possesses or lacks.
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It's influenced by language, emotion, context, stress and relationships.
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And importantly, by whether the people involved understand one another.
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Now Damian Milton introduced an incredible concept called the double empathy problem.
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And his argument was both simple and profound.
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So perhaps people with autistic difficulties do not fail to understand non-autistic people.
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Perhaps it is they who fail to understand autistic people instead.
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However, this results in the misunderstanding flowing in different directions or flowing in both directions.
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So two people may possess empathy and curiosity, but communicate it in quite different ways, and that changes everything.
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It's important to say that difference and deficit are not the same thing.
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Many children with autistic spectrum difficulties understand feelings deeply.
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Some feel emotions with extraordinary intensity, they possess compassion, loyalty, and sensitivity.
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But they may process social information differently.
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They may prefer clarity over ambiguity, literal meanings over implied meanings, and predictability over certainty.
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And this is really important because how another person experiences, processes that experience, and then communicates or responds is subject to a whole series of invisible mechanisms.
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Now, because much of human communication relies on assumption, hints, facial expressions, unwritten rules, nuance, well, misunderstandings can occur.
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So imagine arriving in a country where everybody speaks your language but uses entirely different meanings and customs.
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A perfect example of this was when I was on a lecture tour in America, and I was lecturing at the University of Michigan, and in my innocence, I was going to do something, some diagram work or something, on the blackboard or chalkboard, and I quite innocently asked if anybody had a rubber.
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When the audience stopped politely laughing, somebody pointed out to me that using a contraceptive to clean the board was not how they did it in that country.
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I think I said something else for like, well, you probably wouldn't, you would see it that way, but you know, we've been around a bit longer.
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But the point here is that when people use the same terminology without different with different meanings, then confusion is likely to set in.
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And if this is consistent, you it's exhausting.
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It creates anxiety and misunderstanding.
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Now, many people with autistic difficulties describe exactly this experience.
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They hear the words, they hear the language, but the meaning isn't clear, it's not received in the way it's intended.
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But this is an exhausting experience of constantly trying to translate a world that often seems unclear.
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And when we feel confused or unsafe, mentalization becomes more difficult for everyone.
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And this is why stress is so important.
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Children with these difficulties frequently experience a world that's overwhelming.
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Sensory overload and social uncertainty, unexpected change, demands, masking, trying to fit in and trying not to get things wrong.
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And really trying to understand what everybody else seems to understand effortlessly.
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Now, these experiences place enormous demands upon the nervous system.
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And when the nervous system becomes overwhelmed, mentalization will collapse.
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It's not unique to autism, it happens to all of us.
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The difference is that individuals with autistic difficulties may spend far more time managing environments that feel confusing, unpredictable, or overstimulating.
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And parents often describe situations where their child appears highly empathic one moment and entirely self-focused the next, and it's bewildering.
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But the explanation may not be about a lack of empathy, it may be overload.
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Because when the brain becomes overloaded and overwhelmed, survival takes precedence over reflection.
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So mentalization narrows, perspective taking becomes harder, and emotional regulation becomes compromised.
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So children may become rigid, literal, demanding, withdrawn, or explosive.
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Not because they don't care, but because they really are struggling to cope.
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Another misunderstanding concerns eye contact and emotional expression.
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Many people assume that if somebody does not express emotions in familiar ways, those emotions are absent.
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But emotional experience and emotional expression are not the same thing.
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Some autistic children show love quietly, express empathy differently, need more time to process feelings, or communicate emotions through actions rather than words.
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And this brings us to perhaps one of the most important principles in supporting such children.
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Mentalization begins with curiosity, not assumptions or labels, but curiosity.
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So instead of asking why are they so difficult, we begin asking what might the world feel like from their perspective.
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I do this every day with patients, and I'm not suggesting it's easy.
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I don't always come up with answers, but the curiosity remains open.
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So we don't assume that it's defiance.
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We wonder about anxiety.
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Instead of interpreting withdrawal as indifference, we wonder about exhaustion.
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Instead of expecting conformity, we become curious about communication because every child wants and needs to be understood.
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And children with autistic difficulties are no exception, in fact, more than many.
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They need adults who can remain curious when misunderstandings arise.
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Adults who are willing to ask, what am I missing?
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What sense does this behavior make?
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What are they trying to communicate?
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Because mentalization is not about reading minds perfectly, it's about remaining open to the possibility that there is always more to understand.
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And that understanding doesn't arise from certainty, it arises from curiosity and humility, from the willingness to accept that two people can experience the same world in very different ways.
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Neither is wrong, they're simply different.
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And when difference is met with curiosity rather than judgment, relationships flourish.
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In our next episode, we turn our attention away from diagnoses and towards families themselves because some family environments may really help children develop mentalization and others, albeit unintentionally, can undermine it.
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And nowhere is this more evident than in everyday life conversations that happen around the kitchen table.
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A final note is this as a clinician, I regard myself as needing to be multilingual.
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And I say this because it is back to that example of being in a different country where people speak your language, but they ascribe different meanings.
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I cannot assume that what I am hearing or seeing means the same thing as what is intended.
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I have to understand that everybody who I work with has their own language, their own meaning, and their own way of communicating what that might be.
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Therefore, I have to remain open, not because I'm trying to get it right and ensure I understand everything.
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Quite often I will say, when you say this, does that mean this or or do you think me do you mean something else?
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I'll I'm trying to have them help me understand.
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And this is incredibly powerful.
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There is no judgment.
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I'm seeking clarification to make sure that the child or young person, and indeed the parent and I have a shared understanding.
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Thank you for listening.