Doctor's Review: Medicine on the Move

March 23, 2017

Kim Peek is the real Rain Man.

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Autism at the start of understanding

The role of “Autistic savants” from mystery to insight

Jedediah Buxton, born in Derbyshire, England, in 1707 measured everything. He accurately measured the area of the town he was born in simply by walking around it. He counted the number of steps that dancers took at town dances and the number of words uttered by actors at plays. He couldn’t write, but when the Royal Society tested his mathematical abilities in 1754, they found that he could calculate numbers up to 39 figures.

Buxton may be the earliest recorded example of an autistic savant. These days, savants with autism perform feats with a modern flair. Stephen Wiltshire, for instance, known as “the human camera,” can create ink drawings of city skylines in perfect detail after a single helicopter fly-over. What hasn’t changed much is the mystery that surrounds both autism and the savants the condition sometimes produces. Recent discoveries suggest that autism may result from a combination of genetic and environmental factors. Some scientists even believe they have figured out how to manipulate the brain to make temporary savants of us all. Still, autism remains a puzzle yet to be cracked. The attempt to do so, however, has yielded some curious insights into how our brains work.

Spectrum struggles

The Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) 2013 conflation of multiple terms used to describe various autistic disorders into a single term — autism spectrum disorder or ASD — can be bewildering. Rett syndrome, childhood disintegrative disorder and Asperger syndrome, while they are considered autism spectrum disorders, are distinct from autism, though boundaries between diagnostic categories on the spectrum can seem arbitrary.

A person who is “on the spectrum” can be without language or motor skills and require lifelong care, exhibiting a fanatical need for sameness, relentlessly repetitive behaviours and even bouts of violence.

These “low-functioning” individuals require an enormous amount of energy, an exhausting journey for parents who seek the best treatments for their children and fear what will become of their offspring should he or she outlive them. A case in point is that of Kim Peek, the real person on whom Dustin Hoffman’s character in the film Rain Man was based. Peek relies, for his well-being, entirely on his father, now in his 80s. “It’s a 30-hour-a-day, 10-day-a-week job,” says dad.

While some autistic savants — like celebrity professor Temple Grandin, who has made dramatic improvements to slaughter house design and lectures widely on “thinking in pictures” — can be very high-functioning, having savant capacity often appears in people with low-functioning autism.

The thread that holds the diagnosis together across the spectrum is a triad of symptoms: impairments in verbal and non-verbal communication; persistent deficits in social interaction; and restricted, repetitive behaviours, interests or activities. This preoccupation with details and the uncanny ability to perceive governing patterns or systems is what fuels the autistic savant mind.

Autism’s first case

The first person ever to be diagnosed with autism — “Case 1… Donald T” — was a savant, so named in 1943 by Johns Hopkins professor Dr Leo Kanner. At a young age, Donald Gray Triplett of Forest, Mississippi spent most of his time engaged in what are now considered typical autistic behaviours: spinning blocks and plates, and repeating strings of unrelated words. But as an older child, his fixation with math acquired savant proportions.

When a visiting mind-reader and hypnotist spent a night with the family and discovered their son’s genius for multiplying numbers in his head and his perfect musical pitch, the performer wanted young Donald to join his act. His parents would have none of it. They had made a supreme effort to integrate him into normal life, including getting him to attend classes at the local school where he was a celebrity for his reputed ability to count the number of bricks in a building just by glancing at it. Truth be told, it later came out that he just made up the number, an unusual feat for someone with autism since people with autism don’t tend to lie. He was a special case on so many levels.

When the family travelled to Boston to see Dr Kanner, Donald, age three, displayed all the characteristics of autism that are well-recognized today. He showed “no apparent affection” for human beings and had several obsessions including pictures of the US presidents and the letters of the alphabet, which he enjoyed reciting in reverse order. To all intents and purposes, he appeared to have withdrawn “into his shell,” to “live within himself,” as his father described in a detailed letter to Dr Kanner.

The term autism refers to this apparent retreat into self, coming from the Greek word “autos” meaning “self.” “Autistic” was first used in 1911 to describe a symptom of schizophrenia wherein patients seemed averse to social interaction. Dr Kanner applied the term to the new set of behaviours he observed in Donald.

Part of what makes social interaction so challenging for those on the autism spectrum is their acute ability to track individual details in a hyper-literal way combined with their inability to grasp generalized concepts, such as those required to initiate and nurture relationships with others, the reason they often appear wooden or distant. Rather than not perceiving enough in the world around them, they perceive too much to be able to sort through it. Retreating into their obsessions gives them the peace they need to focus and function. Only by breaking down niceties into distinct, formalized steps are they able to function in a social context.

The brains behind it

What makes it possible for the brain to remember songs after hearing them once, learn a language in a week, or name the day of the week of any date from any time in history at the drop of a hat? Some scientists suggest it is this supreme, obsessive focus, which is unmitigated by “the tyranny of the prefrontal cortex.”

The prefrontal cortex, which has recently been shown to exhibit consistent damage in the brains of autistic children, is the region of the brain in charge of executive functions like predicting consequences, focusing attention and examining emotions. The prefrontal cortex brings together the data gathered by the various disparate parts of the brain and configures it to form a cohesive picture. It looks at the big picture and ignores details like counting fallen toothpicks, as Dustin Hoffman’s autistic savant character in Rain Man does.

When the prefrontal cortex is damaged, however, the brain is free to obsess. “Acquired savants” offer evidence that this theory may be true. Like characters in a bad daytime TV drama, a blow to the head really has turned some individuals into overnight artistic geniuses or prodigious musicians.

Painter Jon Sarkin was a chiropractor who dabbled in art. After suffering a brain hemorrhage and a stroke, he suddenly became obsessed with painting and even found that he needed to paint to stave off debilitating nervous tension. Derek Amato, a 39-year-old failed businessman who had dabbled in music in high school, smashed his head on the bottom of a swimming pool while diving for a football and thereafter found himself with a surprising ability to play piano.

In 2003, an Australian scientist named Allan Snyder raised eyebrows by suggesting that he could recreate the conditions that led to acquired savantism by suppressing the activity of the prefrontal lobes using a non-invasive machine called a transcranial magnetic stimulator (TMS). The device employs a magnetic field generating coil to stimulate small regions of the brain. Snyder had read that certain people undergoing treatment with a TMS to slow down specific regions of the brain during brain surgery suddenly exhibited isolated pockets of genius-like mental ability. He was familiar with acquired savantism and was intrigued.

Snyder set up a test, in which subjects were asked to draw a cat from memory before, during and after having their prefrontal lobes stimulated by the TMS machine. He claimed that the cat drawings showed much more detail and realism post-TMS, suggesting that dimming down the prefrontal cortex freed up the part of the brain used in drawing to access the wealth of remembered details that were stored there. Experts were skeptical about Allan’s assertion that the drawings improved, but were more convinced by another test. Using transcranial direct current stimulation (TDCS), subjects were asked to connect a set of nine dots by drawing three lines without lifting the pen. Before treatment, none of the participants could complete the test; afterwards, 40 percent could.

The sci-fi minded will perhaps envision a time when we can selectively amplify sections of our brains to increase our mental powers at will. But for those on the spectrum, a more significant advance would be that the insights about savantism provide new and better ways for those affected to be understood by “neuro-typicals” — that’s the rest of us.

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