Warning: This post is somewhat rambling, being a collection of observations and musings of mine over how AS/NLD relate to frank brain injury.
As some people on here might know, I recently got my first job as a speech pathologist in a rehab hospital. My caseload includes people with all sorts of problems, from Parkinson's Disease, to strokes, to brain injury, to dementia, etc.
I've read in the past how similar some of the symptoms of Right Hemisphere Syndrome (caused by damage to the right hemisphere, such as a stroke or traumatic injury) can be to NLD, and also AS. After all, NLD is often considered a "right hemisphere disorder," and sometimes AS has been described in the same terms. This topic has been discussed on this board before, and since I have a few patients right now with right hemisphere damage (3 strokes, 1 traumatic brain injury), I thought some people here might be interested in my observations in the similarities and differences between NLD and AS as proposed developmental "right hemisphere disorders" and right hemisphere syndrome caused by brain injury (being careful not to provide any identifying information about these patients of course). I have NLD by the way (dx'ed 2 years ago), but not AS.
One difference of course is that patients with Right Hemisphere Syndrome (RHS) can have severe left neglect (ignoring the left side of their body as if it weren't there) and also left-sided hemiparesis/hemiplegia (weakness/paralysis on the left). NLDers don't tend to have the severe manifestations of neglect and hemiparesis, however some have problems with left side inattention and weakness (not sure about AS). I actually myself have a weak left grip (10th percentile in my left, versus 65th percentile in my right), and visual inattention which is worse on my left side.
One of the major symptoms of RHS is a deficit in pragmatics- one of my stroke patients who has classic RHS makes no eye contact at all, he speaks in a monotone, and his affect is flat. People with NLD, and especially those with AS, often have difficulties in these same areas (although some Aspies actually have voices which are over-inflected).
None of my right hemisphere stroke patients have any difficulty with impulsivity however, which can be an issue with AS/NLD/ADHD, although they definitely do have problems with executive functioning. They also don't seem to have issues carrying on two-way conversations, the way Aspies and some NLDers do. Now, take this with a grain of salt because one thing I've found in my month of work so far is that I have problems spotting this kind of difficulty (gee, wonder why). The other therapists tend to rate patients' "social interaction" scores lower than I do, and a couple of times have been shocked that I thought a patient was functioning normally when apparently their social skills were very inappropriate. Yeah, it's something for me to work on.
My right-sided traumatic brain injury (TBI) patient on the other hand *definitely* has communication problems, specifically with confusion and confabulation and "cocktail party speech". For anyone who doesn't know what confabulation is, basically it means that your brain makes things up. I say "your brain," because it is not conscious, and the person actually believes these falsehoods are true. For instance, if I asked a brain injury patient what he has done that day, and he said, "I drove to the theater to see a play," that would be confabulation. My TBI patient has this in spades. He also has "cocktail party speech," which is rambling, tangential, and includes a lot of talking without saying anything (like smalltalk at a party). NLDers and Aspies are both frequently described as having cocktail party speech. His speech is also highly formal and often uses fairly "advanced words" that most people don't commonly use in speech- that may be more related to him as person than his brain damage however, as I doubt average joes who sustain brain injuries suddenly start talking like university professors- I'm not sure what he was like premorbidly though or what his career was. He doesn't always use these words correctly though, and his speech content is fairly empty (again, NLD speech is often described this way).
Here is an example with my TBI patient. We were working on a short-term memory exercise, and I read off four words ("elephant," "stone," "squirrel", and "sofa"), and then asked him which were the animals. His response (paraphrased):
Patient X: "Well, I suppose that you said something about a small animal, a small animal packed in, one which could fit in a pack. An animal, which is a pack..."
Me: "Do you mean a pachyderm?" (in case you don't know, elephants are pachyderms- since his speech does tend to be formal and pedantic I thought he might have thought elephant= pachyderm, and gotten stuck on that)
Patient X: No, no, a pack. An animal which can be packed, a small animal, perhaps one which can fit into a backpack...."
[around here I repeated both the instructions and the words, which he took no notice of, continuing on in the same vein, so I decided to be more direct]
Me: One of the words was "elephant." Elephants are pachyderms, so I thought that might be what you meant."
Patient: (angrily) Yes, I KNOW that elephants are pachyderms. I know what an elephant is. That is not what I meant...." etc etc
I wasn't able to make myself understood, so we ended up switching activities to one more appropriate (his level of confusion varies depending on fatigue, and this was near the end of the session), but anyway, I hope you see what I mean about lots of talking without much content. Also he exhibits major perserveration, which should be obvious from this short exchange. Most of my patients have problems with perseveration though, especially when they are tired.
One last thing about right hemisphere damage is that it causes "anosognosia," which means that patients are unaware of their deficits. For instance, I have a right hemisphere stroke patient with severe left neglect and visual processing problems, in addition to having no use of his left arm or leg, who insists that if staff would let him, that he could drive home right away and go back to work as a wood-chipper. I know that some auties/Aspies are not aware of their difficulties with communication, but I don't think it works the same way.
Anyway, basically the purpose of this post was to discuss some AS/NLD-like characteristics that I've seen in patients with right hemisphere damage. Since I am aware that both AS and NLD are thought to be related to abnormalities in the RH, I find my RHS patients very interesting to work with. I will say however that although a list of symptoms of AS and RHS might look similar (minus the special interests, stimming and routines- it's mostly the communication style which is similar), I get no sense of "Aspieness" from these patients. I'm in no way an expert, but I knew several dx'ed Aspies in college (and some others I suspected were Aspies), and I also worked in a school for kids with autism for 5 months, and there's an "air" of Aspieness/autism. It's a qualitative difference in interaction. It's nothing I would be able to quantify, but anyway, none of my patients have it. It's just that right hemisphere damage appears to cause some problems with communication (especially nonverbal) and also some cognitive deficits which seem similar to the communication styles and deficits of some people with AS and NLD.
I hope I didn't offend anyone with this post by the way- I realize some people think of Aspies as having neurological differences only, and not deficits, and I realize that I didn't address any of the strengths/advantages of AS/NLD, though certainly a number exist. Speaking from the stand-point of NLD though, I *definitely* have some significant deficits in nonverbal communication and also some processing problems (although I have typical NLD strengths as well), so again, no offense meant.
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Not all those who wander are lost... but I generally am.
08 Feb 2009, 10:13 am
