However, the history of autistic disorders stretches far back into the mists of time, long before Kennerīs and Aspergerīs insights (Brauner and Brauner, 1986). Some versions of the myths of changeling children, left in place of real human babies who had been stolen by fairies, sound remarkably like children with autism. The legends concerning the followers of St Francis of Assis include stories of one Brother Juniper, who was barely innocent and lacking in any social intuition or common sense (Frith, 1989). At the time, his oddity was considered to be due to his saintliness, even though t often exasperated the other brothers. Nowadays he would have been diagnosed as having Aspergerīs syndrome.
In factual history, scattered examples of individuals with autistic disorders can be found. The most famous is the story of Victor, the boy found living wild in the woods of Aveyron in south central France at the end of the eighteenth century. J.M.G Itard (1801; 1807; Lane, 1977), who devised methods of educating the boy, describes his behaviour in detail and there can be no doubt that Victor was autistic and fitted into Kanner 1 s syndrome.
Accounts of persons, who had one remarkable skill at a much higher level than their other abilities and whose behaviour was very strange, can be found in the literature (Treffert, 1989). Langdon-Down, who is most famous for his writings on Down-s syndrome, in 1887, lectured on these individuals, many of whom would now be diagnosed as autistic savants.
Despite some very vivid descriptions by some writers of what we now know to be autistic behaviour, no one saw any connections among the individual cases until the last half of nineteenth century. Then Henry Maudsley (1267), after whom the Maudsley hospital was named, suggested that children with very strange behaviour could all be classified as suffering from childhood psychosis. This was, at first, greeted as a shocking idea because t disturbed the romantic notions about childhood current at the time. However, Maudsleyls idea gradually came to be accepted. Psychoses were, at that time, considered to be due to physical causes affecting the brain.
In the- first half of the twentieth century, workers in the field of abnormal child development began to try to define sub-groups within so-called childhood psychoses. De Sanctis (1906; 1908), and Heller (see Hulse,1954), describes children who seemed to develop normally for a time and then lost language, social and other skills. Margaret Mahler (1952) describes children who insisted on clinging to their careers but without any real feeling .-and who had other abnormalities of behaviour. Potter (1933) wrote about children whom he said had a childhood form of schizophrenia. Earl (1934) describes a group of adolescents who were mentally retarded and who developed behaviour he called catatonic but which had major similarities to severe autistic behaviour.
Kanner (1943) was one among this group. He wrote his classic description of young children who were socially aloof and indifferent, who were mute or had echolalia and idiosyncratic speech, were intensely resistant to change in their own repetitive routines, and who had isolated skills in visuo-spatial or rote memory tasks against a background of general delay in learning. He emphasized their attractive, alert, intelligent appearance. He thought that his form of autism was unique and different from any other disorder in childhood. Asperger (1944; Frith, 1991) was also one of this group of workers. He described older children and adolescents who were naive and inappropriate in social interaction, who had good speech but used t for monologues on their own special interests, had poor intonation and body language, were absorbed in their circumscribed interests, and often had poor motor co-ordination. They were of borderline, normal or superior intelligence but often had specific learning difficulties.
Jaraes Anthony (1958,a;b) a child psychiatrist, discussed these attempts at defining sub-groups. He pointed out that, although there were some differences, all the sub-groups that were suggested overlapped with each other to a very great extent. He said there were not enough symptoms to go round among all the authors who wanted to name a syndrome.
It is interesting that, out of all the workers writing in this field, Kanner and Asperger are the only ones whose names have become generally well known throughout the world. Kanner was the first to have his work widely recognised. Asperger achieved this status in the English language literature much later than Kanner, though his work was known earlier in mainland Europe. The reason why these two authors work had continued to capture interest is probably because each describes the children they saw in vivid detail. The children come alive from the pages of their papers.
Although the twentieth century gave us the concept of autism and autistic disorders, t also gave a darker twist to the story. The theories of Freud and of other schools of psychoanalysis were developing in Europe during the early years of the century and became strongly influential on the USA during and after the Second World War.
Leo Kanner (1949) suggested that genetic factors played a part in the causation (an insightful guess in the light of recent research) but was influenced by the psychoanalytic theories that had taken such a hold upon the psychiatric profession, especially in the USA. He suggested that the children's condition was also due to being reared by cold, detached, humourless, rigid parents who were perfectionists, caring for their children like --attendants caring-for a machine. He noted that almost all the parents he saw had academic qualifications and professional occupations. He thought that the children were potentially normal and of good intelligence but were emotionally damaged. He firmly believed that there was no physical pathology in the brain. Kennerīs ideas about the parents of autistic children were accepted uncritically by psychiatrists. Many, perhaps most people in professions in contact with autistic children, such as other branches of medicine, nursing and teaching, also adopted these ideas. Even parents themselves were indoctrinated by the prevailing theories.
The results were devastating. Many parents were overwhelmed with guilt and families were split by attempts to assign blame to one or other partner. Some families spent large sums of money on psychoanalytical treatment for their children. If they improved over time, the therapist took the credit. If there was no change or a deterioration the parents took the blame. The children suffered because they were not given the type of education and help' they needed. I have been unable to find any single attempt at scientific evaluation of such treatment in the years when psychoanalytical theories were at their height, up to the end of the l95Os. Nor was there any study of the natural history of autism when no treatment was given - an essential basis for evaluation of methods of intervention.
Fortunately not everyone had faith in the theory of the emotional causes of autism. Some workers recognised the large overlap with mental retardation (now referred to as 'learning disability' in the UK). Some were interested in the abnormalities of language development. others felt that the neuropathology should be explored.
The champions of the emotional theories had dismissed the possibility of any physical abnormalities in the brain because no specific lesions had then been revealed. Looking back now, t seems remarkably arrogant of anyone to assume that the techniques available in the 1940s and 195Os for examining the brain could never be improved. It is of interest that, in 1932, Critchley and Earl had describes tuberous sclerosis, a condition in which recognisable brain pathology occurs. The behaviour pattern in this condition is, in a large proportion of cases, that of typical autism, though in most cases associated with mental retardation. In the metabolic disorder called phenylketonuria, if t is untreated by a special diet, the behaviour is also like that in autism (Jervis, 1963).
It is curious that Kanner did not mention these neurological conditions that overlap in their behaviour pattern with autism. This may have been because he was convinced of the uniqueness of his syndrome and the high intellectual potential of the children.
Another thread in the story is the theory that autism is the earliest form of schizophrenia. Kanner at first wrote that autism -and schizophrenia were quite separate but., - later, he wavered under the influence of child psychiatrist colleagues (Kanner, 1949).
The tide began to turn in the 196Os. There were two main reasons for this. First, parents who were independent minded enough to reject the idea that they were to blame for their children's condition came together to form parents 1 associations. The first of these, by a small margin, was the British Society for Autistic Children, now known as the British National Autistic Society. Parents in other countries followed suit and now societies are to be found in very many counties throughout the world. Their influence has been of major importance in changing ideas on autism and the needs of the children and their families.
The second factor was the introduction of scientific method into the field. Prior to the 196Os, papers on autism were either clinical case descriptions or what can only be called armchair theorizing. In 1961, Mildred Creak, well known for her interest in autistic disorders, chaired a committee of professionals in the field who produced a set of criteria that defined what they called 'childhood schizophrenia' (Creak, 1964). Despite this terminology, t is clear that they were describing disorders we now refer to as autistic. The nine criteria, known as the 'Nine Points' were an unsatisfactory mixture of observation and interpretation that were hard to apply in practice. Nevertheless, the work represented the first serious attempt to define a range of disorders including Kennerīs autism. The confusion between autism and schizophrenia occurring in childhood continued to affect the field until, early in the 197Os, Kolvin (1971) and his colleagues carried out a study comparing the two groups of conditions and listed the many differences.
A major contribution to the scientific study of autistic disorders was made by Victor Lotter (1966). He carried out, in the former English county of Middlesex, the first ever epidemiological study of Kennerīs autism. He used as the crucial defining features, the two selected by Kanner and Eisenberg (1956) as the most important, that is, social aloofness and indifference to others and resistance to change in elaborate repetitive routines. He found that nearly 5 in 10,000 children had this syndrome.
Michael Rutter and his colleagues also began their series of studies in typical autism in the 196Os. They describes in detail the clinical features, they investigated the children's profiles on intelligence tests and they followed them . up into. adolescence and adult life (Rutter, 1970).
other workers have studied the parents and found no evidence that they caused their children to be autistic through abnormal child- rearing practices (DeMyer, 1975; 1979). Most of the studies that examined the parentīs occupations found that they came from all walks of life (Wing, 1993). Kennerīs theory that the parents were mostly of high social class was not upheld.
-Following Victor Lotterls work-, there have been a number of other studies of the prevalence of autism defined in various ways (Wing, 1993). My colleague, Judith Gould, and I carried out a study in one area of London of children with all kinds of disabilities (Wing and Gould, 1979). We looked for children who had any feature of autistic behaviour, not just those who had typical Kennerīs autism. As a result of this, we developed the hypothesis of a wide spectrum of autistic conditions of which Kennerīs autism was only one small part. We found a total of 20 per 10,000 children with autistic spectrum disorders combined with mental retardation (IQ below 70). It was during the course of this study that we first saw a few children with the pattern of behaviour describes by Hans Asperger. It was a great pleasure to me that I was able to meet Dr. Asperger when he visited London, even though we disagreed because he thought his syndrome was separate from Kennerīs autism and I thought t was part of the spectrum.
In the 198Os Christopher Gillberg and his colleagues developed and 'extended work on the autistic spectrum. Gillberg (1992) has hypothesized that there are a range of disorders of empathic understanding of which the autistic spectrum is a part but not the whole. Ehlers and Gillberg (1993) have also studied Asperger's syndrome among children in mainstream schools and found a prevalence of at least 36 in 10,000, that is nearly 4 per 1000. They found nearly twice that number (71 per 10,000) who would fit into the wider autistic spectrum.
The 199Os have brought advances in understanding the cause and underlying neuropathology of typical autism, although there is still a long way to go. Michael Rutter and his colleagues have shown the importance of genetic factors in autism and probably other autistic spectrum disorders as well (Bolton, 1994). There has also been a growth of interest in the various developmental syndromes in which aspects of autistic behaviour, or even the full picture of typical autism, can occur. From the point of view of the neuropathology, there is growing evidence of involvement of the limbic system, the cerebellum and part of the frontal cortex in autism. From the work of Margaret Bauman and Thomas Kemper (1994) t appears that the abnormalities occur at the cellular level and date from very early in development.
Another advance promises to aid early recognition. Simon Baron- Cohen and his colleagues (1996) have developed a brief screening instrument that appears to be able to identify children who are autistic at the age of 18 months. The basis of the examination is the ability to engage in joint referencing and pretend play.
Parallel with the increasing knowledge of the nature of autistic disorders there has been a steady development of methods of educating and caring for people with these conditions. This aspect will be well covered in the rest of this conference.
We have come a long way from the era of myths and legends, through the unhappy deviation into psycho-analysis, to the -practical realism of the present day. We now know.. that there is a wide spectrum of autistic conditions, with Kennerīs and Aspergerīs syndromes each forming only a part of these. The whole spectrum is united by the presence of three underlying impairments of social interaction, communication and imagination, known as the 'triad'. When these impairments are present, the individual pattern of activities is narrow and repetitive. Conditions in the spectrum can occur together with any level of ability from profound mental retardation up to superior levels of intelligence. The outcome in adult life is closely related to level of ability in childhood. only those with normal or high intelligence have any prospect of becoming independent in adult life. However, much can be done through education to improve quality of life for all those affected, regardless of ability.
Autistic spectrum conditions are developmental disorders caused by physical abnormalities in parts of the brain. Complex genetic factors are important in the causation but there are other physical causes that can lead to autistic conditions. Adding together the prevalence of all autistic disorders in people of all levels of ability, the prevalence is around 9 in every 1000. Despite claims that have been made for a variety of methods, no curative treatment has yet been found that stands up to proper investigation. However, we have a great deal of knowledge about methods of education and how to structure the environment and daily program to increase skills and diminish disabilities and disturbed behavior.
The hope for the future is that we will identify the precise causes and find effective methods of prevention and treatment.
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