Autistic Spectrum Disorders

An Introductory Handbook for Practitioners

Rita Jordan

• Publisher: David Fulton Publishers
• Year: 2013
• ISBN:
  9781136800733
• Edition: 1
• Topic: Education
• Subtopic: Education General

Written for practitioners working in the field of autism and related disorders, including Asperger's syndrome, this handbook offers an overview of understandings of these disorders from a behavioral, biological and psychological perspective. A coherent analysis of the different theoretical viewpoints is provided, especially at the psychological level which has the greatest bearing on practice. This makes the book relevant to those interested in developmental psychology as well as to those who seek a greater understanding of autism.

Chapter 1
The Nature and Definition of Autism

Identification of a new syndrome

He wandered about smiling, making stereotyped movements with his fingers, crossing them about in the air. He shook his head from side to side, whispering or humming the same three-note tune. He spun with great pleasure anything he could seize upon to spin... When taken into a room, he completely disregarded the people and instantly went for objects, preferably those that could be spun... He angrily shoved away the hand that was in his way or the foot that stepped on one of his blocks...' (Kanner 1943; reprinted in Kanner 1973 pp. 3-5)

This description, of a five-year-old boy called Donald, was written over 60 years ago. Kanner saw Donald and made these observations in 1938, and they appear in his landmark paper, published in 1943. That paper was based on a study of 11 cases that Kanner had encountered in his work as a child psychiatrist in the USA. He decided, as a result of this study, that these children had enough in common, and were sufficiently different from other children he saw, to warrant the identification of a separate condition.

Autism, then, has only been defined as a condition since the early 1940s although, as Frith (1989a) has shown, it is likely that people with autism have always been with us. Given its complex manifestations and the controversies over aetiology, it is not surprising that there have been, and continue to be, controversy and misunderstandings over diagnosis and treatment as well. Wing (1997) gives an overview of the history of ideas in autism. Kanner, while describing the features of the disorder with an accuracy and a perceptiveness that has largely stood the test of time, came to think the condition was an emotional illness with a psychogenic origin. Mothers of children with autism were described as 'refrigerator mothers who had only managed to defrost long enough to have a child'. Some workers in this area have defended this position (e.g. Bettleheim 1967) but research and clinical experience over the years has failed to provide any evidence that mothers (or indeed fathers) 'cause' autism. If parents of children with autism appear odd in any way, it is more likely to be an effect of having such a child (or a mark of a broader genetic phenotype) rather than a cause.

At almost the same time, Asperger was also identifying a group of four children as having autism (Asperger 1944, translated Frith 1991a). Kanner's work became well known and had great influence throughout the world, but it is only comparatively recently that Asperger's work has been taken up internationally. As we shall see, this has led to questions about the exclusivity of the two 'syndromes' or indeed whether there are two separate syndromes at all. The earliest confusions, however, were between autism and childhood psychoses. For many years the terms 'childhood psychosis' and 'childhood schizophrenia' were used as synonyms for 'early infantile autism', even though autism was not a deterioration in social functioning but an 'autistic' aloofness from the start.

Kanner's description

Kanner saw the 'defining' features of the syndrome as being:

• a profound autistic withdrawal;
• an obsessive desire for the preservation of sameness;
• a good rote memory;
• an intelligent and pensive expression;
• mutism, or language without real communicative intent;
• over-sensitivity to stimuli; and
• a skilful relationship to objects.

A profound autistic withdrawal

The children failed to relate to people normally, especially other children, and appeared to be happiest when left alone. This lack of social responsiveness appeared to Kanner to start very early in life, as shown by autistic infants' failure to put out their arms to the parent who was about to pick them up, or to mould themselves to the parent's body when held.

An obsessive desire for the preservation of sameness

The children were abnormally upset by changes of established routine, or in familiar surroundings. A different route to school or a rearrangement of furniture would cause a tantrum, and the child could not readily be calmed until the familiar order was restored.

A good rote memory

The children Kanner saw showed an ability to memorise large amounts of effectively meaningless material (e.g. an encyclopaedia index page), which was out of line with their apparent severe learning difficulties in other respects. This good memory is tantalising - leading one to feel that if only it could be turned to some practical use, the child might learn well. However, as later modules in the courses will show, even this is limited to certain aspects of memory.

An intelligent and pensive expression

Kanner believed that the outstanding memory and dexterity shown by some of his cases reflected a superior intelligence, despite the fact that many of the children had been considered to have severe learning difficulties. Certainly, an impression of intelligence is given by the lack of any physical stigmata in most cases of autism. Unlike individuals with many types of severe learning difficulties, individuals with autism usually look 'normal'. Kanner remarked on his cases' 'intelligent physiognomies', and other authors have described children with autism as unusually beautiful. The strong impression of intelligence (that an individual, with autism, could, if only they would) is often felt by parents and teachers. This may reflect the fact that intellectual development is patchy or it may be to do with the difficulty experienced in autism of initiating spontaneous behaviour without a clear (usually visual) prompt. It is this lack of spontanous behaviour, which nevertheless can be elicited by the correct prompt, which furthers the impression that the individual could do it if s/he wanted to. Professionals, parents and researchers have all debated whether it is a deficit or a problem in motivation. When we look at the nature of some of the difficulties in more depth later we will see how there are difficulties in functioning which are to do with the ability to intend actions and thus to perform actions spontaneously. In other words, as a parent once put it: 'I used to wonder whether it was that he can't do something or that he won't do something until I finally realised that he can't help won't.'

Mutism, or language without real communicative intent

This includes children without speech but also those that only used echolalia. Kanner was particularly struck by the phenomenon of 'delayed echolalia' whereby the children repeated language they had heard some time before (even years before), but failed to use words to communicate beyond their immediate needs. Kanner also remarked upon what he termed 'the reversal of pronouns' so that the children would use 'you', when referring to themselves and 'I' when referring to the other person. This usage would sometimes follow from a direct repetition of the other speaker's remark (immediate echolalia) and so appeared to be an echo. Later texts in the courses will show that this is not quite the case, but confusion with pronouns is certainly characteristic of autism (Jordan 1989). In the same way, the individual with autism commonly uses the whole of a question as a request for the item which usually follows (e.g. 'Do you want a sweet?' meaning, 'I want a sweet'). Again, this might not be a true request in the usual sense of the term, but it can come to function as a request if it is responded to as such.

Oversensitivity to stimuli

Kanner noticed that many of the children he saw reacted strongly to certain loud noises and to objects such as vacuum cleaners, lifts and even the wind. Some also showed feeding problems or extreme food fads. These phenomena pose a 'chicken and egg' problem. Is perceptual or even sensory oversensitivity one of the core features of autism, or does it result from a failure to analyse input and to perceive social meaning? This issue has not been resolved to date, and informs the debate about some of the psychological theories of autism.

A skilful relationship to objects

Kanner noted the contrast between the very good manipulation of objects that the children showed and the uses made of those objects. The actions they performed were often advanced in terms of manual dexterity, but they did not create new ways of using the objects or engage with others in social play activities with objects. On the contrary, their activities were characterised by repetition and the rigid performance of set routines.

Other characteristics

Kanner also remarked that all his cases had intellectual parents. However, this is probably due simply to a referral bias; Kanner's sample is unlikely to have been representative. Parents who persist in trying to obtain a diagnosis for their children are likely to be well educated and know the system. Kanner also described the parents as cold, although in this first paper his was very far from a psychogenic ('refrigerator mother') theory. Instead he states, 'These children have come into the world without the innate inability to form the usual, biologically provided affective contact with people' (p. 242).

Later Kanner views

A further study of 23 children in 1946 led Kanner to elaborate on these characteristics, particularly in relation to language. He noted then how apparently mute children might, under conditions of stress, utter complete and wellarticulated phrases. Many of the children with language showed both immediate and delayed 'echolalia' (the parroting of phrases - using the exact intonation of the speaker) far in excess of any found in normal language development, both in the amount echoed and in the developmental period over which it occurred. They were also characterised in the following ways:

• their language was also extremely literal;
• they used simple negation to avoid unpleasant events but not to deny;
• they did not affirm by saying 'yes' but by repetition;
• they showed metaphorical substitutions, transfer of meaning by substitute analogy of the whole for the part and the part for the whole; and
• their speech showed 'pronominal reversal' (referring to themselves as 'you' and the person being spoken to as 'I').

By the 1950s Kanner was being influenced by the current ideologies of attachment theory (Bowlby 1969) and had moved away from detailed descriptions of deviant behaviour to produce broader defining characteristics (Eisenberg and Kanner, 1956) which were:

• extreme isolation;
• obsessive insistence on the preservation of sameness;
• onset of the condition within the first two years of life.

The other symptoms he considered to be both secondary to, and caused by, these two elements (e.g. communicative impairments), or non-specific to autism (e.g. stereotypies).

This has moved from the previous emphasis on the language and communication characteristics, to omission of language features from the defining criteria. The rare 'odd' phrases occasionally seen in otherwise mute children led to the belief that there was an elective element in the muteness and the child's parroting of heard expressions was seen as cruel mimicry. Bettleheim (1967) even claimed that pronominal reversal could not be explained by linguistic or pragmatic confusion on the part of the child, or by the child's exact parroting of the phrases he heard addressed to him, but instead resulted from a refusal to use 'I' - a denying of self.

Diagnostic criteria

All this may seem very messy and vague compared with, say, the diagnosis of measles, but it is not uncommon in medicine, and very common in psychiatry, for conditions to be defined by, and diagnosis based on, sets of behavioural characteristics that cluster together often enough to form a 'syndrome'. Of course there has to be more to it than that or we might have 'syndromes' of all fair-haired blue eyed people, or chance associations of big noses and musical talent or whatever. The features defining a syndrome should be pathological or deviant from normal development, and there is the assumption that they reflect some underlying common cause, or at least a common pathway.

Thus, there began to appear lists of 'points' for the diagnosis of autism, although it was often called 'childhood schizophrenia' at this stage. Sometimes these 'points' (referring to aspects of abnormal behaviour or development) were merely seen as descriptive i.e. 'salient features'. Thus, there was no clear prescription of which features had to be present in order to make the diagnosis of autism and which were merely features that frequently accompanied autism but were not essential criteria. Creak's nine points (1964) were of this nature, whereas O'Gorman's six points (1967) were described as 'essential' and so presumably all six needed to be present before a diagnosis could be made. Rendle-Short (1971, cited Newson 1979) came up with 14 points, seven of which had to be present in order for a diagnosis to be made. There were misgivings about the nature of some of these points themselves, some of them in Rendle-Short's list, for example, seeming contraindicative of autism. This points system, also led to a confusing and unacceptable, situation. Under this system, two children might be diagnosed as having autism, and yet not have a single 'defining feature' in common!

Rutter et al. (1971) reformulated these lists to give the following four essential diagnostic criteria:

• delay in speech and language development;
• an 'autistic-like' failure to develop interpersonal relationships;
• ritualistic and compulsive phenomena; and
• onset before 30 months.

The four points were reformulated in 1978 (Rutter 1978) to include a description of these social abnormalities and to take account of greater understanding about the nature of the difficulties in communication and behaviour. The 'autistic-like' failure in interpersonal relationships was spelt out as:

• failure to come for comfort or a cuddle;
• lack of eye gaze giving the appearance of aloofness or distance;
• relative failure to become attached to parents;
• little or no separation anxiety;
• sometimes little variation in facial expression;
• apparent lack of interest in people;
• tendency when a toddler to treat all adults in the same way; and
• failure to make friends and join in group activities.

These amended criteria formed the basis of the diagnostic criteria accepted by the World Health Organisation and were very similar to American formulations under DSM. The four criteria were:

• delayed and deviant language development, which has certain defined features and is out of keeping with the child's intellectual level;
• impaired social development, which has a number of special characteristics and is out of keeping with the child's intellectual level;
• insistence on sameness, as shown by stereotyped play patterns, abnormal preoccupations, or resistance to change; and
• onset before the age of 30 months.

Newson (1979) modified Rutter's criteria to spell out some of the 'special characteristics' and to emphasise communication deficits. Her reformulation kept the same four points:

• impairment of language and all forms of communication, including gesture, facial expression and other 'body language', and the timing of these;
• impairment of social relationships, in particular a failure of soci...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Preface
• Dedication
• Introduction
• 1 The Nature and Definition of Autism
• 2 The Importance of Diagnosis in Education and Care
• 3 Autism and Behaviour
• 4 The Biological Bases of Autism
• 5 Psychological Theories on the Nature of Autism
• 6 The Individual with an Autistic Spectrum Disorder
• Appendices
• References
• Index