Autism

The Nature of Autism

Ever since Kanner (1943) first described the behaviour pattern he called 'early infantile autism', workers in the field have tried to define its essence. The problems of definition have been made more complicated by the comparatively recent interest in the syndrome described by Asperger, which has many similarities to Kanner's autism. At first, the theories tended to suggest an emotional abnormality but, over the years, evidence has been built up to show that autistic behaviour is due to physical dysfunction of the brain.

The Triad of Impairments

In recent years, studies of infants and children without handicaps, as well as work with children with autism and related disorders, have contributed to our understanding of the autistic conditions, which are now generally regarded as disorders of development. The central problem is a triad of impairments affecting social interaction, social communication and imagination. This triad is often accompanied by a limited, narrow, repetitive pattern of activities. Recent research has shown that the skills of social interaction, communication and imagination are, like other developmental skills, dependent upon aspects of the function of the brain although the precise areas involved have not yet been identified.

Essential Features of Autism

Impairment of Social Interaction

Examples

• The most severe form is apparent aloofness and indifference to other people, although some people with autism enjoy certain forms of active physical contact.
  
• In less severe form, the individual passively accepts social contact, even showing some pleasure in this, though s/he does not make spontaneous approaches.
  
• Some individuals with the triad approach other people spontaneously, but do so in an odd, inappropriate, repetitive way and pay little or no attention to the responses of the people they approach. (NB Even the aloof group may become more sociable with increasing age, though few, if any, become appropriate in social interaction or form real friendships with age peers.)
  

Impairment of Social Communication
Examples

• Lack of appreciation of the social uses and the pleasure of communication. This is also true even of those who have a lot of speech, which they use to talk 'at' others and not with them, appearing uninterested in comments of others.
  
• Lack of understanding that language is a tool for conveying information to others. They may be able to ask for their own needs but cannot talk about feelings or thoughts.
  
• Poor comprehension of the information conveyed by gesture, miming, facial expression, bodily posture, vocal intonation, etc.
  
• Lack of use of gesture, miming, facial expression, vocal intonation and bodily posture, etc. to convey information. Some more able people do use gestures but these tend to be inappropriate and do not convey information.
  
• Those with good vocabularies have a pedantic, concrete understanding and use of words, an idiosyncratic, sometimes pompous choice of words and phrases, and limited content of speech.
  

Impairment of Imagination
Examples

• As children, an inability to play imaginatively with objects or toys or with other children or adults.
  
• A tendency to select for attention minor or trivial aspects of things in the environment instead of an imaginative understanding of the meaning of the whole scene (e.g. attending to one earring instead of a whole person, a wheel instead of the whole toy train, a switch instead of the whole piece of electrical apparatus, reacting to the needle used for an injection while ignoring the person who is giving it).
  
• Some individuals with the triad have a limited range of imaginative activities that may be copied, for example from TV programmes, but they pursue these repetitively and cannot be influenced by suggestions from others.
  
• Lack of understanding of the purpose of any pursuits that involve an understanding of words and their complex associations, e.g. social conversation, literature, especially fiction, poetry, etc. There is a consequent lack of motivation to indulge in these activities, even if the necessary skills are available. Some verbal autistic people are fascinated with words but do not use them as tools of communication and social interaction.
  

The Triad of Impairments is accompanied by: -

Repetitive, stereotyped activities

These can take simple or complex forms. Individuals of higher levels of ability tend to show more complex routines.

Examples of simple, stereotyped activities:
Flicking fingers, objects, pieces of string, etc.; spinning objects or watching things that spin; tapping and scratching on surfaces; inspecting, walking along and tracing lines and angles; feeling special textures; rocking, especially standing up and jumping from back foot to front foot; tapping, scratching or otherwise manipulating parts of the body; repetitive head banging or self injury; teeth grinding; repetitive grunting, screaming or other noises.

Examples of complex, stereotyped activities involving objects:
Intense attachment to particular objects for no apparent purpose; a fascination with regular repeated patterns of objects, sounds, etc.; the collection, for no apparent purpose, of large numbers of particular objects such as plastic bottles, pebbles, or the tops from tubes of Smarties.

Examples of complex, stereotyped activities involving routines;
Insistence on following the identical route to certain places; insistence on a lengthy bedtime ritual; repetition of a sequence of odd bodily movements.

Examples of complex, verbal or abstract repetitive activities:
Fascination with certain topics, e.g. electricity, astronomy, birds; asking the same series of questions and demanding standard answers.

N.B. The above are examples of stereotyped activities. The possible variations on this theme are endless. It is thought that in many instances, routines, obsessions or stereotyped activity help to reduce anxiety by introducing internal controls or predictability. The level of disability will vary in accordance with the developmental and intellectual level of the individual and will be influenced by personality.

Underlying Causes and Associated Conditions

Autistic spectrum disorders can be caused by a variety of conditions that affect brain development and that occur before, during or after birth. They include, for example, maternal rubella, tuberose sclerosis, lack of oxygen at birth, encephalitis complicating a childhood illness such as measles or whooping cough. A genetic trait is important in some cases. As yet, for most individuals with an autistic spectrum condition, it is not possible to specify the exact cause. However, as research progresses, more causes come to light. It is hoped that, eventually, in every case both the original cause and the essential brain pathology will be identified.

As previously emphasised, autistic spectrum conditions can occur in association with any other physical or psychological disability. It is not possible to exclude autism just because an individual has, for example, cerebral palsy, a hearing or visual impairment, Down's syndrome, or other chromosomal abnormality. Similarly, autistic disorders can and often do co-exist with aphasia, dyslexia, semantic-pragmatic disorder, or any other type of specific or general learning disability. None of these conditions can 'explain away' autistic behaviour. If an autistic spectrum disorder is present in addition to some other disability, it should be recognised as it has important implications for treatment and prognosis. In addition, many individuals, thought to be up to one third, have an underlying seizure disorder which may require treatment with appropriate anti-convulsants.

Autism is a pattern of abnormal development that unfolds over time. It is easy to miss the important clues to the underlying impairments if one relies solely upon observation of the individual's behaviour in the unfamiliar surroundings of a clinic. Diagnosis depends upon obtaining a detailed developmental history from the parents and a careful assessment of the individual's skills and disabilities. Time taken to listen to the parents' story with attention and interest gives a real understanding of the individual and helps to establish the foundation for a good relationship with the family.

References

Frith, U. (Ed.) (1991), Autism and Asperger Syndrome, Cambridge: Cambridge University Press.

Gillberg, C., Persson, E., Grufman, M. and Themner, U. (1986), Psychiatric disorders in mildly and severely mentally retarded urban children and adolescents: epidemiological aspects. British Journal of Psychiatry, 149, 68-74.

Kanner, L. (1943), Autistic disturbances of affective contact, Nervous child, 2, 217-250.

Wing, L. and Gould, J. (1979), Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification, Journal of Autism and Childhood Schizophrenia, 9, 11-29.