Autism

   This term refers to either a symptom of schizophrenia or, more commonly, a developmental disorder in children beginning in the first 3 years of life. In children, the brain disability involves a qualitative impairment in social interaction, significant impairment in communication, and behavior that is often rigid, obsessional, and ritualistic.

   The term "autism" (der Autismus) was coined by Eugen Bleuler in 1910 in an article on "Schizophrenic Negativism" in the Psychiatrisch-Neurologische Wochenschrift (p. 185f ). In his 1911 book, Schizophrenias, Bleuler amplified that autism was a basic symptom of schizophrenia involving the inability to distinguish an internal phantasy world from reality. "We term autism the loss of contact with reality together with the relative and absolute predominance of an interior life" (Schizophrenien, p. 52). In his later Textbook of Psychiatry (Lehrbuch der Psychiatrie), published in 1916, Bleuler abandoned the term "autism" because it had created too much confusion about "egoism" and substituted the term "dereistic" thinking: whenever the patient’s fantasy world conflicted with reality, it was the fantasies that received preference: "The laborer who’s engaged to a princess is simply no longer a laborer but ruler of the world or some other grand figure" (quote from eighth ed., p. 24).

   Yet, in his original Schizophrenia book in 1911, Bleuler allowed that autism could occur in non-schizophrenic individuals as well, especially children: "There is a normal style of autistic thinking, that takes no consideration of reality and is guided by emotions [Affekten]. The child plays with a piece of wood that one day is a baby for him, another day a house" (p. 305).

   In 1943, Leo Kanner (1894–1981), a psychiatrist at Johns Hopkins University who is considered the father of child psychiatry in the United States (he wrote the first American textbook on the subject, Child Psychiatry, in 1935), described in the journal Nervous Child "autistic disturbances of affective contact." "The outstanding, ‘pathognomonic,’ fundamental disorder is the children’s inability to relate themselves in the ordinary way to people and situations from the beginning of life. . . . There is from the start an extreme autistic aloneness that, whenever possible, disregards, ignores, shuts out anything that comes to the child from the outside" (p. 242). Kanner emphasized that they were not feebleminded but had "strikingly intelligent physiognomies. Their faces at the same time give the impression of serious-mindedness." He noted their "astounding vocabulary" and "good intelligence." The disorder further entailed elaborate repetitive routines. It was caused, said Kanner, by a chilly home environment: "In the whole group, there are very few really warmhearted fathers and mothers. . . . Even some of the happiest marriages are rather cold and formal affairs" (p. 250). Kanner dwelt upon how some of the children had been constrained to recite from the "Presbyterian Catechism." (In a personal communication, Gabrielle A. Carlson, director of child and adolescent psychiatry at Stony Brook University, suggests that Kanner may have been seeing genetic similarities and misattributing the resultant child to the coldness of the parents rather than to the genetic contribution.) Kanner later termed the condition "early infantile autism." Kanner’s observation about cold parents got the field off onto the wrong foot for many years. Yet, many of his observations were accurate.

   Meanwhile in Vienna, pediatrician Hans Asperger (1906–1980), who remained unaware of Kanner’s work, was describing in 1944 in the Archive for Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten) virtually the same condition but calling it "autistic psychopathy." "While people normally live in a continuous reciprocal relationship with the surrounding world, constantly reacting to it, for these ‘autistic’ [children] these relationships are grossly disrupted, contracted. The autistic child is only ‘he himself’ . . . not a living part of a larger organism that continuously influences him and is influenced by him" (p. 84). Asperger described avoidance of eye contact, an unnatural almost caricatural mode of speaking directed not at the listener but off into the distance, and an intelligence marked often by startling originality yet substantially learning-disabled. The author was also struck by the artistic creativity of these children.

   Asperger’s contribution (it was his Habilitation), published in German in the final years of a long war, went virtually unnoticed abroad until 1981, when English child psychiatrist Lorna Gladys Wing (1928–)—then at the Social and Community Psychiatry Unit of the Maudsley—decided to baptize as "Asperger’s Syndrome" a population of children with many of the characteristics that Asperger had described. She took issue with Asperger’s description of the group as creatively gifted: "It would be more true to say that their thought processes are confined to a narrow, pedantic, literal, but logical, chain of reasoning." She also doubted his assessment that many patients were of high intelligence: "Those with the syndrome are conspicuously lacking in common sense." In her view, "Asperger’s Syndrome" was a helpful term for "explaining the problems of children and adults who have autistic features but who talk grammatically and are not socially aloof" (p. 124). (This was not exactly the population that Asperger described.) Her paper, appearing in Psychological Medicine, suggested that Asperger’s syndrome and "typical Kanner’s autism" were situated somewhere within a "triad" of problems affecting early child development that involved (1) "absence or impairment of two-way social interaction," (2) impairment of linguistic comprehension and of language, and (3) impairment of imagination, substituting rituals instead.

   Psychoanalyst Bruno Bettelheim (1903–1990), director of the Orthogenic School at the University of Chicago, created a boomlet for the concept of autistic children as badly damaged by concentration-camp–like trauma—above all in his 1967 book, The Empty Fortress. (See PSYCHOTHERAPY: milieu therapy [from 1925].) In 1992, Christopher L. Gillberg (1950–), professor of child psychiatry at the University of Goteborg, Sweden, proposed in the Journal of Child Psychology and Psychiatry the term "disorders of empathy" for a spectrum of autistic-like conditions that included autism and Asperger’s syndrome.

   In DSM-I (1952) and DSM-II (1968), "autistic thinking" appeared as a symptom of schizoid personality. (DSM-I: "As children, they are usually quiet, shy, obedient, sensitive and retiring.") "Infantile autism" entered DSM-III in 1980 under the class of "pervasive developmental disorders." Among its essential features were disturbed ability to communicate and to respond to others, in addition to "bizarre responses to various aspects of the environment"—all occurring within the first 30 months of age. Many of the children had mental retardation as well. In the Manual, it was described as "very rare." Alongside infantile autism was a second diagnosis—"childhood onset pervasive developmental disorder"—that sounded a good deal like previous definitions of autism ("profound disturbance in social relations and multiple oddities of behavior") and was also "extremely rare."

   DSM-III-R in 1987 considerably expanded the number of symptoms that would qualify someone for the diagnosis of autism, requiring 8 out of a possible 16. Autism, the guide said, was "merely the most severe and prototypical form of the general category Pervasive Developmental Disorders" (p. 34). In this edition, childhood onset pervasive developmental disorder became folded into autism, thus widening considerably the scope of autism.

   DSM-IV (1994) arrayed a number of pervasive developmental disorders, including "Childhood Disintegrative Disorder," "Asperger’s Disorder," and "Autistic Disorder." "In most cases, there is an associated diagnosis of mental retardation," as described in the Manual (p. 67). These additional diagnoses had the effect of again narrowing the scope of autism, yet raising awareness of the concept of an autism spectrum.