Distinguishing autistic-like behaviors from Autistic Disorder

By Darold A. Treffert, MD

This website gets many “I have a son or daughter who…” questions, usually inquiring about the presence and implications of savant-like behaviors, often ‘splinter skills’, in children, adolescents or adults. Occasionally these behaviors present as a rather startling precocious ability to read words in very young children, well beyond that expected at the child’s chronological age, coupled with an intense fascination with letters or numbers. In spite of this intense preoccupation and ability with words, there are, correspondingly, significant problems in understanding verbal language. Comprehension of that which is masterfully read is often poor, and thinking is concrete and literal. There is difficulty with, and paucity of, abstract thinking. There may be some behaviors and symptoms commonly associated with autism spectrum disorders as well including echolalia (repeating rather than initiating conversation), pronoun reversals, intense need to keep routines (obsession with sameness), auditory or other sensory hypersensitivity, specific intense fears, strong auditory and visual memory, and selective listening with the appearance of suspected deafness.

This combination of precocious reading skills accompanied by significant problems with learning & language is called hyperlexia.

The literature on this topic is really quite scant, beginning to appear only a recently as 1967. Some of these children, most of whom have learned to read before age 5 with little or no training, have this precocious reading ability combined with language difficulties (in spite of accelerated reading ability) and display significant difficulty in social relationships. These children come to speech and language disorder clinics with a variety of diagnoses such as “autism, behavior disorder, language disorder, gifted, precocious reading ability seen often as rote learning, splinter skills or savant idiosyncrasy” according to one such clinic, the Center for Speech and Language Disorders in Elmhurst, Illinois.

Usually parents of hyperlexic children, when they inquire of this web site, have had their children go through numerous evaluations, with various confusing and contradictory diagnoses applied ranging from Autistic Disorder to Pervasive Developmental Disorder, Asperger’s Disorder, Attention Deficit Disorder or language disorder, for example. In other instances there is no diagnosis applied except “precociousness.” Controversy exists as to whether hyperlexia is a serious developmental disorder such as autism, or whether it is in fact a speech or language disorder of a distinct and separate type, or, in some cases, simply advanced word recognition skills in a normal (neurotypical) child especially when not even the sometimes accompanying ‘autistic-like’ symptoms are present.

While the literature to date is not a great deal of help in making the distinction between hyperlexia being an autistic/PDD spectrum disorder, or a separate, distinct language disorder. It appears that in the latter instance it appears the prognosis overall is quite good. According to Phyllis Kupperman and her co-workers at the Center for Speech and Language Disorders clinic, when the children were first seen at the clinic at age 2 or 2 ½ they had difficulty understanding language. They may use a few words but often they are echolalic. Their behavior looks autistic. However they found these children emerge out of that autism, although they may retain some aloofness or antisocial or oppositional behaviors. But over time the aloneness and self-stimulating behaviors decrease dramatically as language comprehension and expressive language improves. By the time many of the hyperlexic children are in the first or second grade many of the ‘autistic’ behaviors have diminished and while remaining aloof, the children do begin to socialize more. In short, they emerge significantly from their ‘autism’, if in fact it was Autistic Disorder at all.

An article entitled “Reading Skills in Hyperlexia: A Developmental Perspective” by Kate Nation of York University is another source of information on this condition (Psychological Bulletin 125:338-355, 1999). The lengthy article is a comprehensive review of the literature to that date. One section of the article examines the relationship of hyperlexia to developmental disorders such as autism. The author concludes that hyperlexia, while present in some children with Autistic Disorder, is not specific to Autistic Disorder or confined to that condition. Instead, hyperlexia can be seen in non-autistic persons, many of whom, however, do have autistic-like symptoms and behaviors.

As a clinician, and as a monitor of correspondence and e-mails via the savant syndrome website, I would define hyperlexia as having three forms:

Hyperlexia, type I

This are very bright, normal (the appropriate word nowadays is neurotypical) children who simply read early to the amazement of their parents, grandparents, teachers, peer and parents of their peers. Often one or both parents have read often and patiently to their children. Very early the child begins to ‘read’ the book, which is actually rather prolific memorization of the book triggered by the words and pictures on the pages themselves. Soon however the child is actually ‘reading’ the words in the book, rather than just memorizing them, and that reading ability can then be transferred to other books. The child is a precocious reader at that point and is reading at a first or second grade level in pre-school, kindergarten or even before. At some point, of course, most of the other children in the class catch up as they begin to read. This group of hyperlexic children is what I call early, or precocious readers. They are bright, neurotypical children.

Hyperlexia, type II

This is a group of children who have hyperlexia as a ‘splinter skill’ as a part of an autistic spectrum disorder. They read voraciously usually with astonishing memory for what they read, often accompanied by other memorization tasks and abilities, sometimes linked with number or even calendar calculating skills. These ‘splinter skills’ are seen along with, and in the midst of, the characteristic language, social and behavioral symptoms seen in autistic spectrum disorders. They usually carry a diagnosis of autistic disorder, Asperger’s disorder or pervasive developmental disorder (PPD/NOS) for example. These cases include the several sub-types of autistic disorder such as classic early infantile autism, early onset autism or late onset, regressive, autism to name several.

In this group it is the hyperlexia as a splinter skill that raises the ‘savant syndrome’ questions. Clinical presentation, course of the illness and prognosis are those seen in autistic spectrum disorders.

Hyperlexia, type III

This is a less frequently recognized, and probably less frequent form of hyperlexia overall. These children also read early, often show striking memorization abilities, and sometimes have precocious abilities in other areas as well. They may have autistic-like behaviors, but, in my experience, they do not have Autistic Disorder. For example, they may show unusual sensory sensitivity (to sounds or touch or taste). They may not seek, or may even avoid, affection, but usually they are more social, more outgoing, more interactive and less withdrawn than children with Autistic Disorder. They do tend to make eye contact and can be very interactive with persons close to them. There may be fascination with, or intense insistence on, routine and resistance to change. These children seem quite bright, inquisitive and precocious in some areas overall. Interest in, and mastery of, reading coupled with memory powers memorization is conspicuous and often quite amazing. There may other autistic-like symptoms or behaviors as well. But these symptoms and behaviors, prognosis ultimately shows, are indeed 'autistic-like'and are not Autistic Disorder as such. Over time the autistic behaviors and symptoms fade and, as it turns out, these children then are quite normal (neurotypical) for their age.

These are children who ‘outgrow” their autism, or, more accurately in my view, did not have Autistic Disorder or any of its variants to begin with. The prognosis for these children is in a word, excellent and I have followed now a number of such cases via correspondence where the outcome has been just that—excellent.

The point of this posting on hyperlexia on this website is not to exhaustively discuss the disorder. Rather it is to point out that when precocious reading ability and extraordinary fascination with words presents itself in a very young child, especially when accompanied by other language or social problems that might suggest an autistic spectrum disorder, a comprehensive assessment by a knowledgeable professional or team familiar with the differential diagnosis of the various forms of hyperlexia is indicated.

Several parents who had inquired on this site about their child with accelerated, savant-like precocious reading ability, obtained considerable help, and relief, when, in those particular instances, the diagnostic and treatment approaches consistent with the above were followed. Especially grateful were parents when it turned out their hyperlexic child was in group III above with autistic-like symptoms rather than Autistic Disorder. But parents in group II were also helped, and relieved, when directed to knowledgeable resources in their community when hyperlexia was a presenting sign or behavior. Hopefully, as the literature continues to evolve on hyperlexia, there will be more clarification regarding the classification of hyperlexia into its component sub-groups, and then even more resources will emerge for comprehensive evaluation and then application of appropriate treatment principles to these individuals.

In the meantime I continue to solicit information from parents about more cases, particularly in group III, above, so I can share those stories that have turned out so well, as reassurance, with other parents who are in the beginnings of a search for the appropriate diagnosis and treatment regimen for their child.

Hyperlexia is not the only circumstance in which the distinction between autistic spectrum disorders and autistic-like is important. If that distinction can be made correctly, parents can be spared the worry attached to the fear that their child may be ‘autistic’ or ‘asperger’s’, for example. In my view sometimes such diagnoses are made prematurely, or too casually with unnecessary worry and fear.

There are other conditions where “…-like” would be an appropriate designation and distinction. For example some patients on certain medications may have “Parkinson-like” side effects but do not have Parkinson’s disease. Or certain medications, or conditions, can be accompanied by “Alzheimer’s-like” signs and symptoms, often reversible, but not be actual Alzheimer’s Disorder. And 50% of persons with savant syndrome do not have autistic spectrum disorders as the underlying disability. Rather they have a variety of other disorders upon which the savant syndrome skills and abilities are superimposed. Many of these persons, with organic brain syndrome or other disabilities can have autistic-like behaviors (hand flapping, rituals, etc.) but they do not have autistic spectrum disorders.

Often, as elsewhere in medicine, particularly in puzzling cases, it is best to let the ‘natural history of the disorder’ emerge before applying a definitive diagnosis or ‘label’ that can have important, lasting consequences. Treatment can still be applied to target symptoms, but parents or others can, in those cases, be spared the unnecessary worry and fear that can accompany certain diagnoses prematurely applied.



For more information, please contact:
Darold A. Treffert, MD
St. Agnes Hospital, Fond du Lac, Wisconsin
Clinical Professor, Department of Psychiatry
University of Wisconsin Medical School, Madison
Personal Web site: http://www.daroldtreffert.com
e-mail: savants@charter.net