68 Autistic Disorder

Name: Arnie Grape

Source: What’s Eating Gilbert Grape? (movie, 1993)

Background Information
Arnie Grape is a Caucasian male who is 17 years old and is close to turning 18. He does not go to school and spends most of his time with his older brother, Gilbert. Arnie appears to be mentally disabled or developmentally disabled. When Arnie was born, the doctor said he would be lucky if he lived to the age of 10 and when he turned 10, the doctor said he could die at anytime. He has repetitive speech, which it seems as if he is listening but then turns around, and does the same things over again. He engages in very dangerous behaviors but is not aware of how dangerous his behaviors are. For example, he climbed up the water tower in the town and was dangling off the side of the ladder laughing the entire time not knowing how serious the situation was. Arnie lives with his mother, brother, and two sisters. He is very close to his older brother because Gilbert takes care of him. His mother, Bonnie, who has not left the house in seven years, became morbidly obese and depressed when her husband committed suicide. His two sisters, Amy and Ellen, take care of the chores and do all the cooking. Arnie is very friendly to other children in his town but it does not appear that he has very many friends because they do not understand his ways of communication, although there were many children at his eighteenth birthday party. There is an instance when Arnie will not go into the basement because he said “dad is down there” and then he does a hanging motion. Arnie does not appear to take any medication or see a regular physician or psychologist. His feelings are easily hurt because he does not fully understand what people are saying to him. Arnie does not appear to have any goals other than trying to survive.

Description of the Problem
Arnie kills a grasshopper by cutting its head off in the mailbox and a little while after he kills it he gets very upset at himself and is sad that the grasshopper died. He has certain hand movements that he constantly does. He puts his hand to his mouth a certain way when he is in an uncomfortable situation. He has eye twitches and he blinks quite often. Arnie is always running off and hiding from Gilbert or climbing the water tower. Gilbert knows where Arnie is hiding but plays a game and pretends that he does not know Arnie is up in the tree and he thinks Gilbert has no idea where he is. When other people get hurt or when Arnie says mean things to others he thinks that it is very funny and usually laughs hysterically. He is arrested for climbing the water tower and when they put him in the cop car, all he is worried about is the cops turning on the lights and sirens. He is not able to take care of himself. For example, Gilbert puts Arnie in the bath and tells him that he is a big boy and can wash himself. Gilbert leaves and comes back the next morning to find Arnie still in the bathtub. Arnie repeats everything that people tell him to do and what they say in general. After the bathtub incident, Arnie is afraid of any kind of body of water. He gets very upset and starts to hurt himself when he tries to wake his mother and she never wakes up.

Diagnosis
The diagnosis for Arnie Grape that fits most appropriately is Autistic Disorder (299.00). To be diagnosed with Autism Disorder criteria A, B, and C must be met:

1. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):

(1) qualitative impairment in social interaction, as manifested by at least two of the following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
(d) lack of social or emotional reciprocity
(2) qualitative impairments in communication as manifested by at least one of the following:
(a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c) stereotyped and repetitive use of language or idiosyncratic language
(d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
(3) restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole body movements)

Arnie meets the criteria for deficits for three out of the four in section one, as described in the section of “Description of the Problem”. Arnie does not meet the criteria in (c) because he was always trying to talk to people and make friends with them. Arnie meets all the criteria for section two because he repeats every word a person says to him, he is not able to carry on a conversation with anyone, and he does not seem to have any imaginative friends. He does not meet the criteria in section three listed under (b) because he does not have any specific rituals. Arnie meets the criteria for (a) and (c) because he was obsessed with taking care of a cricket and kept it in a jar and he constantly made the same hand movements when he felt uncomfortable in a situation.
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

1. Social interaction

2. Language as used in social communication

3. Symbolic or imaginative play
Arnie’s history was not given prior to age three but one could conclude that he had delays in all three areas prior to age three.
C. The disturbance is not better accounted for by Rett’s Disorder or Childhood Disintegrative Disorder.
Arnie was born with his disorder and has had it his whole life. The doctors did not expect him to live long but he did and everyone called him a miracle child.
Accuracy of Portrayal
The average person watching this movie would probably think this individual is mentally disabled. They would see that he needs a caretaker constantly, that he is not able to communicate well with others and that he is unaware of the outside world around him. These symptoms could be confused with mental retardation or a mental disability. To be specifically diagnosed with autism all the criteria above have to be met. Arnie met all the criteria so if an individual was familiar with or educated on autism they would be able to see an accurate portrayal of autism. This movie lets people see the different types of autism. The types of autism that are usually shown in the media are children who are quiet, reserved and do not talk to anyone, but Arnie was the complete opposite. He was loud, tried to speak to everyone, and was not afraid of most things. Throughout the entire movie, no one talked about Arnie’s disorder nor did they label what he had been diagnosed with at birth. What’s Eating Gilbert Grape? was an accurate portrayal of an individual with autism.

Treatment
First, a full medical and psychological evaluation would be given to Arnie. Arnie would need to be put in a stable setting. Currently he lives with his mother and siblings but his mother is unable to take care of him. He needs an individual to take care of him full time and that individual needs to be specialized in how to take care of his needs. He also needs an individual to work with him on his communication skills, yes, he is past the developmental stage of language, but having that daily practice could help him greatly with his language skills. Arnie also needs behavioral treatment therapy so that he is able to understand how to act in certain situations. He needs more support from his family, everyone needs to be interactive in his treatment and give a helping hand

Name: Mandy (Amanda)

Source: Fly Away (movie, 2011)

Background Information
Mandy is a 16-year-old Caucasian female who lives at home with her mother Jeanne. Jeanne makes sure Mandy has a consistent daily routine and tries to teach her day-to-day responsibilities. Mandy seems to be making slow progress and then other days she regresses, especially when her mother is not as attentive to her needs. Mandy’s mother is a single mother who works from home to be able to provide constant care for her daughter. Her father Peter comes to visit occasionally but is not consistently there. He loves his daughter and tries to interact with her, but cannot seem to without becoming overwhelmed and angry. Mandy goes to a school for the mentally disabled; however, she does not like the staff and is always acting out to be able to go home. She takes medication twice a day, and has doctor visits regularly. She has a difficult time coping with certain situations and does not know how to control her emotional impulses. Her mother has to hold her and tell her to breathe before she will calm down. Sometimes the outbursts are so bad there is nothing and no one that can control or sooth her. Jeanne also uses singing to calm and refocus her daughter. Mandy is very responsive to this technique and it gets her back down to a controllable level. This is the only form of positive coping shown. Mandy’s weaknesses are her short temper, and violent outbursts. This makes it almost impossible for her to be out in public or in a social setting.

Description of the Problem
When a situation arises that a normal 16 year old could handle, she seems to react like a young child. Mandy repeats anything said to her, displaying echolalia. Mandy also has outbursts of aggression. Her aggressive behaviors include biting, pushing, punching, yelling, and running away from her mother. She has overly dramatic emotional swings during these outbursts, where she is very enthusiastic or very upset. While Mandy is experiencing these fits, she becomes physically abusive with objects, throwing them at walls and other objects around her. After the outbursts Mandy encounters, she feels sympathetic only to her mother. She is the only person that she will apologize to for her behavior.
In addition to the above outbursts, almost every night while she is sleeping she yells out, “Mandy’s a bad girl, I hate myself!” Her mother will then have to comfort Mandy. When Mandy is in public, her emotions are erratic; she is very enthusiastic or extremely angry. She is not concerned with the reactions of people around her or how her behavior impacts others. She has no impulse control and immediately acts on how she feels. She begins to feel the need for some social interaction, but due to lack of knowledge on how to do so, she is angered by this emotion as well. Her interest in the opposite sex becomes more apparent and at one point in the film she asks her mother if she will ever get married. This shows her longing for human interaction and her capability to understand social interactions. Physically, Mandy’s hands are disfigured and are constantly curled. She walks on her toes primarily, and she rocks whenever she feels anxiety.

Diagnosis
Autistic Disorder (299.00) is the criteria that Mandy fits in the DSM-IV diagnostic system. The patient must meet criteria for category A, B, and C to be diagnosed with Autistic disorder.

• A) A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3):
  • Qualitative impairment in social interaction, as manifested by at least two of the following:
    • Impairments in social interaction may include the following:
      • Pronounced deficits in non-verbal social behavior
        • Lack of eye contact
        • Facial expressions
        • Body posturing
        • Gesturing
      • Lack of age-appropriate peer relationships
        • Possibly interacting with parts of people
      • Absence of spontaneous attempts to share interests or pleasure with others
        • Not pointing to or showing things to others
      • Lack of social/emotional reciprocity
        • Lack joint attention
        • Fail to share actively with other’s activities or interests
        • Act as if unaware of the presence of others
        • Select solitary activities
  • Qualitative impairments in communication including both verbal and nonverbal communication, as manifested by at least one of the following:
    • Delay or absence in spoken language
      • not compensated for by attempts to communicate nonverbally
    • Inability to converse appropriately with others regardless of the presence of speech
    • Odd, stereotyped, repetitive uses of language
    • Absence of imaginative or pretend play
    • There is also a great deal of variability in communication.
      • Ranging from the absence of expressive or receptive language to fluent speech with semantic/inappropriate social uses.
      • Echolalia is the repetition of a phrase heard in the present or the past.
        • Occurs in up to 75% of individuals with PDD who are verbal
          • This characteristic is a cardinal feature of autism.
      • Receptive language continues to impair social communication in that individuals have difficulties in understanding abstractions.
        • Echolalia and receptive language are not utilized in a functional communicative fashion by those with autism.
• Restricted and stereotyped behavioral patterns require at least one of the following criterion:
  • Restricted interests that are abnormally intense
    • Can range from cars and trains to numbers and letters
    • Inappropriately intense or odd in their content
    • Rigid adherence to routines or rituals
    • Repetitive motor mannerisms
      • Opening and closing doors
    • Preoccupation with parts of objects
      • May become overly interested in moving parts of objects
    • Compulsive behaviors
      • Lining up objects in a specific way
      • Slight alterations in routines can cause behavioral outbursts
    • Motor stereotypes
      • Hand or finger-flapping
      • Rocking
      • Spinning
    • Non-specific motor abnormalities
      • Toe walking
      • Unusual hand movements or body postures
    • Continuous course for those with autism however, school-aged children may show improvements in social, play, and communicative functioning, which ultimately can improve further intervention
• B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years:

  1. Social interaction

  2. Language as used in social communication

  3. Symbolic or imaginative play

• C. The disturbance is not better accounted for by Rhett’s Disorder or Childhood Disintegrative Disorder.

There would be no difficulties in diagnosis for Mandy as being autistic. She meets criteria in A, B, and C. Pertaining to the previously stated problems, Mandy is clearly autistic.

Accuracy of Portrayal
Most people who watch the film would label Mandy as having a mental disability. The average person would not know the criterion that depicts autism. Mandy clearly can be labeled as autistic because she meets all of the above criteria. Most films that portray individuals with autism show them as quiet and socially distant. This movie shows an individual with an extreme case of autism and does a very good job showing how hard it is to live with this disorder. The movie did a good job showing the daily hassles for the family members and how it affects the individuals self esteem. People watching this film got a truthful insight on the life of an individual with autism and would learn about the disorder through the film and Mandy’s character. Fly Away was an accurate portrayal of an individual with autism.

Treatment
First, Mandy would undergo a full medical and psychological evaluation. She would need to be put in a stable environment and be able to express some sort of responsibility and self support. Mandy lives with her mom and has a good support system but at her age Mandy needs to be able to do things on her own without some supervision and her mother is not trained properly to be able to provide that. Currently she lives with her mother. She needs to have a specialized worker that can help her but not treat her like a child. Developing her self sufficient skills will help her be able to control more of her emotional responses and better understand social interactions. She also needs an individual to work with her on her communication skills. Even though Mandy is past the developmental stage of language, but having that daily practice could help her greatly with her language skills. Mandy will also need behavioral treatment therapy so that she is able to understand how to act in certain situations and control her violent outbursts. With behavioral therapy, more developed communication skills, family support and more accountability Mandy will be able to better cope and function with her disorder.