The Triad of Impairment in Autism Revisited
191
Andrew Cashin, MHN, NP, Dip App Sci, BHSC, GCert PTT, MN, PhD, and Philip Barker, RN, PhD, FRCN
TOPIC: The triad of impairment referred to at
present in the autism-related literature is a
behavioral triad. This paper extends this thinking of
the triad of impairment to the triad that underlies the
behavioral manifestation. The real triad of
impairment.
PURPOSE: This paper considers the thinking and
information processing style of autism and takes the
next transitional step in understanding the triad of
impairment.
SOURCES USED: Contemporary literature on autism
and information processing.
CONCLUSIONS: Exceptional pioneering work in the
late 1970s gave rise to the concept of the triad of
impairments as the central plank of the construct of
autism: impaired communication; impaired social
skills; and a restricted and repetitive way of
being-in-the-world. This clear articulation of the
structures of the phenomena allowed a new way for
professionals and families to see and understand
autism, and to relate to those with autism. Like the
evolution of many concepts, this was a transitional
idea. The original triad of impairments described the
behavioral manifestation; the actual triad of
impairments is at the level of cognitive processing.
The actual triad of impairment is static and
ubiquitous unlike the variable and fluctuating
behavioral manifestation. The actual triad of
impairment in autism is visual as opposed to
linguistic processing, impaired abstraction, and lack
of theory of mind. The actual triad is central to all
diagnosis that together makes up the autism
spectrum.
Search terms: Asperger’s Disorder, autism,
cognitive processing, nurse therapy
doi: 10.1111/j.1744-6171.2009.00198.x
© 2009 Wiley Periodicals, Inc.
Journal of Child and Adolescent Psychiatric Nursing, Volume 22,
Number 4, pp. 189–193
JCAPN Volume 22, Number 4, November, 2009
jcap_198 189..
Andrew Cashin, MHN, NP, Dip App Sci, BHSC, GCert
PTT, MN, PhD, is Professor of Nursing, Southern Cross
University, New South Wales, Australia; Philip Barker,
RN, PhD, FRCN, is Honorary Professor in the School of
Nursing, University of Dundee, Director Clan Unity
International, Fife, UK.
Introduction
Central to the construct of autism is the triad of impair-
ment (Wing & Potter, 2002). Impaired functioning in the
areas of communication, social skills, and behavioral
flexibility are central in the diagnoses of Autistic Disorder,
Asperger’s Disorder, and Pervasive Development Disorder
not otherwise specified (atypical autism), which comprise
the construct of autism. The impaired functioning is identi-
fied through behaviors classified in these three areas. This
serves the surveillance function of health care well in terms
of identification of autism, and monitoring personal
functioning over time, but does little to inform therapy.
The triad of difference in cognitive processing of informa-
tion, the actual triad of impairment underpins, or is caus-
ative of, the behavioral manifestations of the traditionally
recognized triad. This triad of cognitive processing differ-
ences is more informative in how to work with and con-
struct therapy for people with autism. The actual triad of
impairment in autism is better described as visual as
opposed to linguistic processing, lack of abstraction and
lack of theory of mind.
Phenomena such as autism do not exist as things waiting
to be discovered (Schutz, 1932/1967). Phenomena when
described in a way that resonates meaningfully with experi-
ence are articulating patterns of experience of being-in-the-
world. These descriptions are not immutable but often are
transitional steps through which understanding is refined
(Weeks & Ward, 1988). The original evolution and articula-
tion of the triad of impairment was exceptionally important
as it formed the basis for a clear recognition of autism as
a pattern of recurring behavior to allow diagnosis. This
allowed people to see the behaviors, and with the broadening
of the construct afforded when DSM-IV included Asperger’s
Disorder in its 1994 revision (DSM-IV), this appeared to lead
to a much publicized increase in diagnosis of people with
autism (Wing & Potter, 2002). Such description as the triad of
impairments is of great importance as it provided an easily
189
The Triad of Impairment
recognizable and classifiable structure. Recognition of some-
thing prior to the acquisition of an individually meaningful
structure is rare. There are many examples that point to this
through history but few are as intriguing as that described of
when indigenous peoples did not recognize ships because
they had no concept of such things. “The Fuegians, whom
Charles Darwin visited from the Beagle, were excited by the
sight of the small boats which took the landing party ashore,
but failed to notice the ship itself, lying in anchor in front of
them” (Polyanyi, 1951, p. 19). The traditional triad of impair-
ment, now perhaps more correctly a square with the
acknowledgment of sensory sensitivities, is of great use in
diagnosis and recognition but tells us little in how to con-
struct intervention to support the person with autism. The
triad incorporates behavioral descriptions that are dimen-
sional as opposed to categorical and individual impairment
that fluctuates depending on the external pressures to which
the person is exposed (Berney, 2000; Cashin, 2005).
The Traditional Triad of Impairment
Impaired Communication
The impairment in the area of communication exists
across a broad spectrum. The impairment affects both
verbal and nonverbal communication. In a small minority,
this impairment can involve the complete absence of verbal
language. The range extends through a continuum to
people with hyperlexia who have more subtle difficulties.
For those with speech prosody, the variance of pitch and
tone is often impaired. Variance in pitch and tone of speech
is a tool of communication, as this is the basis upon which
intonation is varied. Impairment in this area is not only in
the use of intonation but interpretation of other people’s
use of it. Many people with autism have a monotone quality
to speech. The lack of abstraction ability makes for great
difficulty in interpretation of homograms based on the
context within a sentence such as tear. An example being
difficulty distinguishing an understanding of the difference
between she had a tear in her eye, or conversely a tear in
her pants. Nonverbal communication, or the development
of facial expression, is not innate. Facial expressions are
learnt. People with autism often have a restricted range of
expression that comes across as pallor (Cashin, 2005). This
restricted range again restricts communication, as it is a
receptive and expressive restriction.
Impaired Social Skills
Communication of course is heavily interrelated with the
impairment in social skills. The social skill impairment
centers on the difficulty interpreting communication and a
theory of mind or mentalizing deficit, or lack of competence
in folk psychology (Baron-Cohen & Wheelwright, 1999).
Theory of mind is the ability to form a theory about what
190
other people are thinking and feeling. Again, a continuum of
impairment may exist from no awareness that other people
have separate thought processes and the assumption that all
people think the same things as the individual, to an under-
standing that other people have their own thoughts and feel-
ings which are a mystery and can only be interpreted with a
great degree of difficulty, if at all. This is a restriction in the
ability to put one’s self in other people’s shoes and make a
guess at what they are thinking and feeling. Social impair-
ment is the source of much anxiety, particularly for adoles-
cents (Attwood, 1998).
Impaired Behavioral Flexibility
It is unclear whether this lack of flexibility is a result of the
marked communication and social skills deficits or is related
to the origin of the deficits (Cashin & Waters, 2006; Priven,
Harper, Palmer, & Arndt, 1996). What is clear is the presence
of a restricted and repetitive range of interests and activities
and at times stereotypic behavior (American Psychiatric
Association, 2000). People with autism do not deal well with
unexpected change and have a marked preference to do
things in an ordered and, at times, ritualistic manner. This
can range from people who cannot tolerate any change of
routine up to people who can adjust their routine with fore-
warning and support to deal with the associated anxiety. The
restricted range of interests is often manifested in obsessions.
These would appear to serve the function of mediating
anxiety (Grandin & Scariano, 1996) as in Obsessive–
Compulsive Disorder but are less often ego dystonic and
there is less fear of catastrophic consequences if the behaviors
or ideas are not engaged in (Baron-Cohen & Wheelwright,
1999). The development in this area of the triad is of interest.
Often in young children with autism, stereotypic behaviors
are present. These behaviors are often rocking, twisting, flap-
ping type behaviors that appear to have no clear social com-
municative function. For those with autism and a co-existing
intellectual impairment, these behaviors can persist into
adulthood. For those with autism and average or above intel-
ligence, these behaviors tend to decline in intensity and fre-
quency around the age of 3 or 4 years and are replaced by
obsessions. These are age-appropriate obsessions such as an
intense interest in Bob the Builder or Thomas Tank that is all
consuming and repetitive. About the age of entering school,
for boys, this obsession is often replaced by dinosaurs fol-
lowed by the galaxy and then is extremely varied. Girls are
quite different in their presentation. This difference is worth
noting as many diagnostic schedules and interviews rely on
the absence of pretend play and the obsessions of girls with
autism mimic pretend play closely. Girls in preschool and
into the schools years are often obsessed with an animal and
spend much time repetitively acting out being the animal to
the extent of drinking from cat and dog bowls, refusing to
speak but meowing or barking, etc. This obsessional behavior
JCAPN Volume 22, Number 4, November, 2009
is distinguished from pretend play based upon its repetitive
and exclusionary quality. While stereotypic behaviors
decline, motor tics often remain. Blinking and head shaking
are common. These are disturbing for the person but like all
tics are often a very useful barometer, that can be viewed by
clinicians, of current anxiety levels.
Many diagnostic schedules and interviews rely
on the absence of pretend play and the
obsessions of girls with autism mimic pretend
play closely.
The Cognitive Processing Triad of
Impairment in Autism
Rolling off lists of potential behaviors that characterize the
triad reveals less than a foray into the underlying cognitive
processing style that would appear to characterize autism. As
with all people, the array of possible behavioral variants is
unlimited and fluctuates but what remains consistent in
autism is a unique way of being based on a unique cognitive
processing style. The triad of cognitive processing difference
is ubiquitous and static as opposed to variable and fluctuat-
ing. This cognitive processing style is neither normal nor
abnormal, but rather a feature of autism and has perhaps best
been described as not neurotypical (Gray & Attwood, 1999).
In terms of our rudimentary understanding of how people
think that has evolved through the centuries, it would appear
that in broad brush terms there are only two main processing
styles, those with autism and those without autism. Of
course there is variance within both groups in terms of rela-
tive balance between visual and auditory processing for
instance and preference for attending to visual, auditory, or
tactile stimuli, but this variance occurs within two main pro-
cessing styles. The processing style of autism is characterized
by the triad of linguistic as opposed to visual processing,
impaired abstraction, and a theory of mind deficit.
Visual Processing
People with autism are visual processors as opposed to
linguistic processors of information. This is an impairment as
the majority in the population process information differ-
ently. The neurotypical platform of processing is one of lin-
guistics; thought is based on a form of personal language or
mentalese (Pinker, 1997). People with autism are relatively
more visual processors of information (Grandin, 1995, 2000).
Linguistic processing lends itself to the formation of concepts
JCAPN Volume 22, Number 4, November, 2009
and an integrated body of knowledge about the world not
facilitated by the more exact visual processing.
Impaired Abstraction
Neurotypical people are blessed with what Aristotle
described as the great gift of abstraction (Gadamer, 1966/
1976). People with autism did not receive this gift and have a
marked deficit in this area (Scott, Clark, & Brody, 2000).
Abstraction is the gift that allows neurotypical beings to
linguistically categorize their interpretations, which consti-
tute their information about the world in an ordered fashion
based on like and similar concepts. This unified base of
knowledge of the world has been likened to a personal
in-head filing cabinet (Cashin, 2005). Neurotypical people
are self-referential; to make sense of incoming stimuli they
pull information in and relate it to what is in this filing
cabinet, their interpretations about the world (Burnette et al.,
2005). This unified base of knowledge is critical in recogniz-
ing the world, as illustrated with the Fuegians and the
Beagle. There is a strong central coherence in the way infor-
mation is processed that is dependent on context and indi-
vidual interpretations of the world. People with autism have
poor abstraction abilities and hence have great difficulty
forming a unified base of knowledge about the world. Infor-
mation is stored on the basis of visual, as opposed to linguis-
tic code, and stored in chunks in the order received without
being unified with past experience based upon the quality of
being alike or similar (Scott et al., 2000). People with autism
are not constructionists in terms of thought and have weak
central coherence.
Impaired Theory of Mind
Another great gift of which people with autism were
deprived is that of theory of mind. Theory of mind can be
described as the basis of empathy. The innate knowledge that
others have a mind in a similar fashion to the individual, and
on a self-referential basis, taking the cues in and forming an
interpretation based on the unified base of knowledge, the
individual can make a guess at what other people are think-
ing and feeling. This is an intentional category, intentionality
signifying that it is something we can attend to or take notice
of (Lauer, 1967). Theory of mind ability allows neurotypical
beings to regulate communication and social contact.
The combination of an ever expanding unified base of
knowledge about the world and theory of mind allows neu-
rotypical people to adapt in an ever-changing social world.
Of course, to adapt requires flexibility of thought and behav-
ior. The neurotypical individual when confronted with novel
stimuli can reach into their unified base of knowledge and
bring forth the successful behavior from the closest or most
likely circumstance. The neurotypical individual then has
behavior to try and for a short while anxiety subsides. If the
behavior is successful, adaptation has occurred and more
191
The Triad of Impairment
worldly knowledge is added to the personal database. If the
behavior is not immediately successful, anxiety may rise but
the behavior can be modified until successful. The database is
added to in such a case by not only a new context, but also a
new behavior. Though we often claim it, it is rare for a neu-
rotypical person to not have a clue even though the first
behavior tried may be a long way off the mark. For those who
store information visually, who don’t have a unified base of
knowledge but rather chunk style learning, when confronted
with a novel situation, which may be a familiar situation in a
new visual context, they may in fact have no behavior to try
and not have a clue. Anxiety rises and the only way to control
it is to engage in a flight or fight response. Autism does not
affect what some people would call temperament or person-
ality, so some people with autism lean predominantly toward
internalizing and some to externalizing. Externalizing in
autism often means behavior related to taking control. This
taking control may be through tantrums or application of
rigid ritualistic ways of doing things to avoid any novel
stimuli or situation. Internalizing may well be to engage in
obsessional pursuits or thought. It is of interest that an
element of personality disorder is often the pattern of people
continuing to trial nonsuccessful behaviors to cope without
adaptation and a neurosis has been described as a form of
shut-upness (May, 1967). The neuro-processing style of
autism in a world dominated and structured by neurotypical
processors clearly predisposes people with autism to anxiety
to the degree of that experienced in recognized psychiatric
disorders, and the need for assistance to adapt and cope.
Autism does not affect what some people
would call temperament or personality, so
some people with autism lean predominantly
toward internalizing and some to
externalizing.
Of course, the neurotypical processing style while
extremely efficient in managing the endless bombardment of
stimuli experienced in the world can at times limit new and
unique ways of viewing the world (De Bono, 1985). The
unified base of knowledge can be a trap in regard to creativ-
ity as it can restrict what is seen as possibility (again, refer to
example of Fuegians). Some people with autism, such as
Temple Grandin, have revolutionized areas of human
endeavor based on the ability to see the world as an endless
succession of novelty. The ability to explore detail in each
192
encounter that is not rounded off by reference to experience
has some benefit but comes at a great cost to the individual
(Grandin, 2000; Grandin & Scariano, 1996).
An understanding of the actual triad of impairment in
autism informs the psychiatric nurse’s approach to therapy.
The ability to work with a person to construct a new reality,
as done in the work of therapy, is reliant on the nurses’
understanding of the person’s cognitive processing style
(Cashin, 2008). The nurse cannot therapize the person with
autism into a different neurotypical cognitive processing
style, hence treating the autism (Cashin, 2009). The nurse can
work with the person on the problems of living using talking
therapy as long as this therapy is based on an understanding
of the cognitive processing style, or the actual triad, inherent
in autism. Therapy must be utilized that is sensitive to the
person’s lack of abstraction ability and theory of mind. The
nurse needs to be aware of the primary visual mode of infor-
mation processing, visually augmenting where possible each
step of the process.
Case Study
Warren is the only child of Peter and Mary. Although
exhibiting “unique behaviors” since the age of two, Peter
and Mary had little contact with other children, they inter-
preted the behavior as gifted. They often boasted to friends
about the length of, and precision of, the lines of toy cars
Warren would create. They saw him as a perfectionist as he
would tantrum if anything was out of line. When Warren
dictated the family routines, and maintained them through
staunch tantruming, this was attributed to giftedness. His
apparent nonresponsiveness to their feelings dismissed in a
similar way “the odd little Professor.” Warren was referred
to the Child and Adolescent Mental Health Nurse Practitio-
ner by preschool staff who observed similar behavior at
preschool with teachers and peers and feared that the
behavior represented more the triad of impairment of
autism. The lining up and routines were seen in an alternate
light to giftedness by preschool staff and the nurse practi-
tioner, that being a restricted and repetitive way of being in
the world. His lack of response to his parents, and now
peers, were seen as impaired social skills. His lack of verbal
exchange, and reliance on tantruming to manipulate the
world, were seen as impaired communication. Peter and
Mary were devastated and after exploring “why Warren,”
and the lack of comfort afforded by the little knowledge of
causation of autism, they moved to “what does this mean?”
They wrestled internally as to whether to privilege their
original interpretation or accept the interpretation of autism.
Describing the original triad of impairment other than
helping parents see the rationale for the competing inter-
pretation provided little guidance to helpful strategies to
intervene. What was helpful was to describe the real triad of
JCAPN Volume 22, Number 4, November, 2009
the cognitive processing differences. This allowed Peter and
Mary to not only learn discrete skills such as use of visual
augmentation and development of social stories but also
develop confidence in the ability to design their own
Warren-centered interventions. Instead of learning decon-
textualized skills, they learnt context-based knowledge.
They realized a social story does not have to be perfect in
form but needs to work. Working, they realized, was based
on providing information to Warren about the world in a
way he could use. They needed to be aware that he did not
have abstraction and had difficulty generalizing. It was
important to realize that his reliance on routine was a way
of navigating a confusing world. As Warren aged, Peter and
Mary felt confident they could reposition from providers of
the information in partnership with school staff to teachers
that would enable Warren to extract and structure the infor-
mation he needed to navigate the confusing socially
demanding world.
While the original telling of the triad of impairment
in autism was extremely helpful in identifying and moni-
toring the progress of the people with autism it was a tran-
sitional step. The actual triad of impairment rests at the
level of cognitive processing. Understanding the cognitive
processing deficits allows the construction of intervention
to support people with autism (Cashin & Waters, 2006).
Further to this, it explains why existing interventions such
as social stories (Gray & Garand, 1993) are so effective. This
transitional step in thinking allows expansion of our pro-
fessional bubble of perception (De Bono, 1985). Formally
accepting expansion of a concept allows it to enter our
thinking and be factored into our vision of the phenomena,
in this case autism (De Bono, 1985). Incorporating recogni-
tion of the cognitive processing deficits into diagnostic
schedules may allow us to move beyond observation of
behavior, that is variable and context specific, to more exact-
ing testing designed in such a way to eliminate the con-
founding variable of testability. The actual triad of
impairment in autism is visual processing, impaired
abstraction, and impaired theory of mind.
The actual triad of impairment rests at the
level of cognitive processing.
Author contact: andrew.cashin@uts.edu.au, with a copy to
the Editor: poster@uta.edu
JCAPN Volume 22, Number 4, November, 2009
References
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text revision). Washington, DC:
American Psychiatric Association.
Attwood, T. (1998). Asperger’s syndrome: A guide for parents and pro-
fessionals. London: Jessica Kingsley Publishers.
Baron-Cohen, S., & Wheelwright, S. (1999). Obsessions in children
with autism or asperger syndrome. Content analysis in terms
of core domains of cognition. British Journal of Psychiatry,
175(November 1999), 484–490.
Berney, T. (2000). Autism—an evolving concept. The British Journal of
Psychiatry, 176(January), 20–25.
Burnette, C., Mundy, P., Meyer, J., Sutton, S., Vaughan, A., & Charak,
D. (2005). Weak central coherence and its relations to theory of
mind and anxiety in Autism. Journal of Autism and Developmental
Disorders, 35(1), 63–73.
Cashin, A. (2005). Autism: Understanding conceptual processing
deficits. Journal of Psychosocial Nursing and Mental Health Services,
43(4), 22–30.
Cashin, A. (2008). Narrative therapy: A psychotherapeutic approach
in the treatment of adolescents with Asperger’s Disorder. Journal
of Child and Adolescent Psychiatric Nursing, 21(1), 48–56.
Cashin, A. (2009). The person with a diagnosis of autism. In P. Barker
(Ed.), Psychiatric and mental health nursing: the craft of caring (2nd
ed., pp. 303–310). London: Hodder Arnold.
Cashin, A., & Waters, C. (2006). The under-valued role of over-
regulation in autism: Chaos Theory as a metaphor and beyond.
Journal of Child and Adolescent Psychiatric Nursing, 19(4), 224–230.
De Bono, E. (1985). Conflicts. A better way to resolve them. London:
Harrap.
Gadamer, H. (1966/1976). Man and language. In D. Linge (Ed.),
Philosophical hermeneutics (pp. 59–69). Berkeley, CA: University of
California Press.
Grandin, T. (1995). Thinking in pictures. New York: Doubleday.
Grandin, T. (2000). An anthropologist on Mars (A. Georget, Director).
In Gloria Films (Producer). New York.
Grandin, T., & Scariano, M. (1996). Emergence labelled autistic. New
York: Warner Books.
Gray, C., & Attwood, T. (1999). The discovery of Aspie criteria by
Attwood and Gray. The Morning News, 11(3), 18–28.
Gray, C., & Garand, J. (1993). Social stories: Improving responses of
students with autism with accurate social information. Focus on
Autistic Behaviour, 8, 1–10.
Lauer, Q. (1967). The other explained intentionally. In J. Kockelmans
(Ed.), Phenomenology. New York: Doubleday and Co.
May, R. (1967). Psychology and the human dilemma. New York: D. Van
Nostrand Company.
Pinker, S. (1997). How the mind works. New York: W.W. Norton and
Company.
Polyanyi, M. (1951). The logic of liberty. London: Routledge and Kegan
Paul.
Priven, J., Harper, J., Palmer, P., & Arndt, S. (1996). Course of behav-
ioural change in autism: A retrospective study of high-IQ adoles-
cents and adults. Journal of the American Academy of Child and
Adolescent Psychiatry, 35(4), 523–529.
Schutz, A. (1932/1967). The phenomenology of the social world (G.
Walsh & F. Lehnert, Trans.). Evanston, IL: Northwestern Univer-
sity Press.
Scott, J., Clark, C., & Brody, M. (2000). Students with autism character-
istics and instruction programming. San Diego, CA: Singular
Publishing.
Weeks, D., & Ward, K. (1988). Eccentrics. The scientific investigation.
Glasgow, UK: Stirling University Press.
Wing, L., & Potter, D. (2002). The epidemiology of autistic spectrum
disorders: Is the prevalence rising? Mental Retardation and Devel-
opmental Disabilities Research Reviews, 8, 151–161.
193