subject

Submitted June 4, [redacted], for [redacted] (supervisor) approval and signature.

Referral: Subject's self.

Background information: Subject is a [redacted]-year-old [redacted] who presented in The Examiner's office at the urgent and repeated request of Subject's spouse's best friend. This best friend seems knowledgeable, having been a patient his whole life due to paraplegia secondary to congenital spina bifida, and is deeply trusted by Subject's spouse. Subject seeks adequate explanation for Subject's turbulent history and current social, vocational and emotional challenges, particularly that which Subject described as "an omnipotent, ever-present feeling like I am an alien on the wrong planet" [paraphrase].

Data sources: A targeted clinical interview was conducted by The Examiner, PhD, clinical psychologist specializing in the care and guidance of Asperger's and autistic patients. Collateral interviews with Subject's spouse and Subject's biological parents were conducted via telephonic communication [non-recorded]. When The Examiner reported to Subject that Subject's female parent spoke for the majority of the interview, Subject expressed surprise and said, "That is very unusual" [paraphrase].

Additionally, the following assessments were administered by The Examiner:

Records review: No records were provided to The Examiner at any point.

Purpose: Because Subject has been informed directly by peers, family members, and co-workers, as well as through experience, that Subject's way of being in and thinking about the world diverges significantly from the norm, a careful and comprehensive examination of Subject's selfhood/concept of selfhood, as well as narratives from selected informants, was conducted. Subject's sensitivity (sensory and emotional); expecting people to mean what they say literally; robust preference for order; fixations on objects/people/ideas others, particularly in her peer group, do not concern themselves with (e.g., looming global problems, local injustice, personal slight or injury); difficulty with shallow/routine social contact were all cited by Subject's spouse's best friend as warranting diagnostic attention. Subject concurred with the list, stating, "Those, plus more, are all true. And that does make me feel like an alien, but I also don't know if I want not to be."

Detection of the presence of an autism spectrum disorder requires close observation and interrogation of a subject's developmental history and patterns of behavior. The most common developmental concerns include delayed language acquisition; atypical social responsivity; sensory and somatic hyper- or hypo- sensitivity; nonspecific medical problems; and difficulties related to attention, eating and sleeping. Stereotyped behaviors, rote motor mannerisms, and unusual or restricted interests onset later in childhood.

Collated and edited report of [Subject]'s backstory: Subject is a first-born. Subject's female parent did not use drugs or alcohol during gestation. Subject's female parent went into preterm labor at 29 weeks, which scared her to death, and was given labor-prevention medication until Subject was born vaginally at 37 weeks, "beautiful and perfect, loved and adored," Subject's female parent said [direct quote].

Subject's parents reported Subject's immediate and intense difficulties with sleeping and emotional regulation; "these persist to this day," Subject says [paraphrase]. Subject's female parent was so exhausted by Subject's lack of regular sleep that she reported hearing voices. Subject's parents had to rotate dressing Subject each day because Subject's tantrums were so overwhelming. "This was easily resolved," Subject reports. "As soon as I was verbal, I demanded to be dressed only in purple. This, too, is largely still true today" [paraphrase]. Subject loved the park; when it was time to leave, Subject would shriek as if being abused and resist both parents physically.

Major developmental milestones were met easily, for the most part. Subject's female parent recalled Subject had some difficulty learning to roll over, stating [direct quote], "[Subject] would grunt and [Subject's] face would turn red. Such a contrast to [Subject's] sister, [Subject] was mad and frustrated." Subject also had trouble learning to ride a bike and kick a soccer ball; Subject remained unsure about which side of the plate to swing the bat from in softball. "This," Subject says, "is also easy to explain. I was left-handed, but every time I picked up a crayon or pencil with my left hand, my mother would take it out of my left hand and put it in my right hand. I don't blame her. It's just what her mother did to her, but, as a result, I never got confident with either hand. I can now write with both hands, it's just equally illegible" [paraphrase].

Subject acquired language early and employed it often. "The only time I would stop talking was when I fell asleep, usually in the middle of a sentence. This talking wall is still present, triggered by anxiety or discomfort. Though I don't stay asleep for long, I can fall asleep anywhere, anytime—movies, the shower, in the middle of fights with [spouse], walking across a busy street —and when I do, I sleep like a fire hazard" [paraphrase].

"Even [Subject's] play was serious," Subject's female parent reported. "[Subject] would line up LEGOs according to color and then size, and plastic animals according to the patterns on the rug or carpet." Subject reports this to still be true today, only with books and clothes. "And LEGOs," Subject states. "I still play with—and by that I mean organize—LEGOs" [paraphrase]. Subject is a deeply auditory learner. "I would be able to tell by the time [Subject] was in first grade if they'd had a sub that day," Subject's female parent reported [direct quote], "because [Subject]'s reports of what they learned that day included direct quotes from the teacher and they would be in a different inflection or cadence than how [Subject] normally relayed the day at school." Subject confirms. "If I've heard a song or seen a movie once, it's in there forever [taps right pointer finger to right temple]. I'm probably the only person who still has people's phone numbers memorized" [paraphrase]. Subject was also very good at recontextualizing funny quotes from movies into everyday life and retaining their humor.

Subject loved books, being read to, and making [Subject]'s own books, including intricate, detailed drawings. "All of that, with the exception of that last item, is still true," Subject says [paraphrase]. Subject struggled to learn to play Subject's male parent's female parent's baby grand piano. "It's hard to do different things with each hand simultaneously," Subject reports [paraphrase]. "I have inherited this piano. I just have to figure out how to get it and me in the same geographical state in our respective single pieces." Subject took private saxophone lessons and marched in the high-school and college bands. Subject taught Subject's self the flute. Subject would go through distinct phases of interests—the Beatles, the Back to the Future series, dolphins—and would want to redo the entire decorating scheme of Subject's room and wardrobe to match her fixations. "When I love something, I fully commit," Subject says [paraphrase].

"The flip side is also true; when I hate something, I repel it" [paraphrase]. When prompted by The Examiner for examples, Subject provided: being interrupted, not completing [Subject]'s to-do list each day, and having schedules or plans change, particularly with little or no notice. Having no routine at all was and is intolerable. "Hugs seemed to be as well," Subject's female parent reported [direct quote]. "I would attempt to hug [Subject] and [Subject]'s eyes would go wide and [Subject]'s whole body would stiffen. Like [Subject] did when [Subject] felt a clothing tag on [Subject]'s skin or when the seams of [Subject]'s pants or socks weren't hitting the same place on [Subject]'s body every time."

"But I'm not uniformly overly sensitive," Subject says. "Taking tests always made me crazy. I could hear a failing light bulb buzzing like a crazy bee and I could hear all the pens writing, but I can't tell if there's too much garlic in my food. I can tell if there's too much ginger, but all beer tastes and smells the same to me. I'm overwhelmed by people talking at the same time, but it takes me so long to register that something's hot that, by the time I react, I've burned myself. I'm extremely sensitive to language and how words are used. I am not approximate in my use of language; I am exact and literal, and that's how I listen to others, which a friend recently pointed out was odd since I'm a poet" [paraphrase]. Subject turned Subject's gaze toward the window, perhaps in a continued effort to avoid The Examiner's eyes. "But then, 'odd' is the reason I'm here, isn't it" [paraphrase]. Subject answered this question by the way she asked it.

Where Subject's black-and-white tendency really gets Subject into trouble, Subject reports, is with people. "I made my first friend in kindergarten, before we each got our final sibling, and, though this friendship ended a few years ago, eight months before my wedding, I still miss it. I think of [redacted] every year on [redacted]'s birthday. I still have the meeting minutes from our Garth Brooks/Colorado Rockies/NSYNC club, which held regular meetings from 1994-2000 in either of our closets. [Redacted]'s entire house was so messy you couldn't see the floor, which turned my skin into stinging ants. I tried to help [redacted] clean once; I only got a corner of [redacted]'s room clean, but it was the most organized, sparkling-clean corner that house had ever seen" [paraphrase].

When Subject learned in kindergarten that not all children were going to like Subject or one another, Subject experienced notable emotional deregulation. Each time a friend would move away or a kid would decide not to play with Subject at recess, Subject would need iterative processing. "Subject was an emotional roller coaster as a child; at some point I simply had to get off," Subject's female parent stated [direct quote]. "Subject remember that day," Subject reports. "Subject had just discovered that trees could die. Subject was three and inconsolable. It was around that time Subject started having dreams where the world was being covered in oil and everything was trapped underneath it. Subject would wake up just before Subject suffocated" [paraphrase].

Subject's male parent stated, "Subject would bring home strays—animals, kids from single-parent homes or absent-parent homes—all the time" [paraphrase]. Subject explained that Subject did that because Subject knew what it was like not to fit in. "Could have been the weird behavior," Subject's female parent stated [direct quote]. "[Subject] would pretend to be an animal, mostly a dog. [Subject] was still doing this—at school—in 5th grade!" Subject's parents had no knowledge of whether Subject was teased at school for this, or bullied in general; Subject made no comments in the course of the interview or testing procedures that could be directly related to this.

Adolescence was rough, Subject's parents concurred. "For everyone involved" [direct quote]. Subject did well at school. "Not like top-ten-in-Subject's-class well," Subject states [paraphrase], "like top-ten-percent-well. Subject could never figure out how everyone else was so smart. And it was a big deal to be smart, not just in Subject's family, but to Subject's self, too. Subject still, over a decade after graduation, remembers Subject's class ranking because it wasn't high enough (29/707). Seemed like the only thing Subject had a chance at being good at" [paraphrase]. Subject participated in swim team in the winter, after marching band season was over. "[Subject] should have been born a fish," Subject's male parent said [direct quote]. "He means that Subject is graceful and beautiful in the water, not that Subject is competitive," Subject explained [paraphrase]. "Subject is not. Subject's not good enough to be and Subject has no spi