Introduction
Examples of autism traits and behaviour can be identified as far back as 1747 as seen in the case of Uta Frith’s analysis of Hugh Blair and his mental capacity which demonstrated characteristics of autism (Wolff, 2004).
Much research and development has been undertaken over the past 80 years to arrive at where we are at today, with assessment tools such as the Diagnostic and Statistical Manual of Mental Disorders diagnostic approach (currently DSM-V) and models for autism explanation being developed.
This post will look at the historical development and consider the key factors within autism research. Further can still be done to understand autism, and one area in which continued work is needed is within the biological model presented by Fletcher-Watson and Happe (2019) and discussed further later on.
This post will firstly look at the historical origins of autism, reviewing the timeline of developments and research in this area. Key theorists such as Eugen Bleuler, Dr Hans Asperger, Dr Leo Kanner, and Lorna Wing will be drawn upon and an outline of their work and timeline will be included.
I will progress considering the development tools for diagnosis and assessment, and the impact on the understanding of how children on the spectrum learn and develop.
I will then conclude with examining the features of autism, and how their presentation is unique to each individual and the implications of this when diagnosing and supporting learners on the spectrum.
A critical analysis of the historical basis to the origins of autism and how it has evolved into the concept of an autism spectrum with reference to key figures and the impact of their work.
As indicated within the introduction, autism traits and behaviour can be seen as far back as 1747 as analysed by Uta Frith when she explored the witness testimonies of a case around mental capacity of Hugh Blair and his ability to contract a marriage, in which the brother gained the annulment and the inheritance. The behaviour that was recognised was the deficit within social communication and relationships, an abnormal gaze, echolalia and repetitive behaviour (Wolff, 2004). There are further individual cases throughout history which have been re-analysed and reflected upon by theorists such as Lorna Wing and Uta Frith. They support the theory that autism had existed within the classifications of mental retardation and schizophrenia and at the time autism had not been categorised.
The term ‘Autism’ was first used by Eugen Bleuler in 1908, when he described schizophrenia patients who demonstrated withdrawn and self-absorbed behaviours (Mandal, 2019, and Volkmar, Reichow and McPartland, 2012). However, it was the work of Asperger and Kanner that were two pioneers and built the foundations of an understanding of the key behaviours in autism. Both Asperger and Kanner started work on this in 1930s and it is believed that neither knew of the other’s work and they both followed different approaches.
Kanner first used the term ‘Autism’ in a study with 11 children and noted their similarities in behaviours such as being alone and repetitive and obsessive behaviours. He later named the term ‘infantile autism’, however, there was some confusion and overlaps with infantile schizophrenia (Volkmar et al, 2012). Kanner published his original paper in 1943 defining infantile autism, which led to professional interest rising in this area (Feinstein, 2010). Feinstein, discusses in detail the journey of Kanner, his development and interest in the area of autism, and his own confusion in which he was working with. He considered those with brain damage, that he may be incorrect with his theory and that they all had schizophrenia instead. Some of this confusion may have come from the wealth of influential psychiatrists at the time that Kanner respected and admired. Kanner continued to push through with his research though and to gain further clarity around the behaviours and a separate condition; autism.
Asperger first published a report in 1944 which looked at areas of autism, social disability and difference. He described a form of autism which later became known as Asperger Syndrome. Wolff (2004) discusses that within the paper all the cases were boys. His research identified that the patients had poor relationships, had special obsessive interests and that their language was idiosyncratic. He also noted that many of the parents had similar personality traits, and considered whether this was a variant of male intelligence which is an interesting concept to research further (Wolff, 2004). Asperger’s work was not recognised in the same way as Kanner’s at first, maybe because his work was a little more disorganised and incomplete (Wolff, 2004 and Feinstein, 2010) or maybe due to being written in German, and later once translated its value was recognised. It was the work of Lorna Wing in 1981 that highlighted the work of Asperger and autism as we now know it was identified.
An interesting concept in Kanner’s early writing was refined by Bruno Bettelheim and was proposed in the 1950s. He outlined the concept that autism in children was caused by cold and unloving parents and used the term ‘refrigerator mother’, and it became a popular misguided concept that stayed around for some time (Feinstein, 2010). Bettelheim stated that parents reacted abnormally to their normal infant’s behaviour, therefore the child withdrew from normal situations and a cycle of behaviour occurred in which the child became less responsive with an emotionless parenting style being the factor in which the child gained the condition (Rajendran and Mitchell, 2007). Bettelheim termed this as ‘chronic autistic disease’. His concept of autism was quite different to that of Kanner, who saw autism as a ‘behavioural syndrome’ in contrast to Bettelheim who saw autism as disease caused by pathological parenting (Feinstein, 2010). Thankfully, this concept has been challenged over the years and the work of Lorna Wing has supported moving this on. In 1971 Wing published a book, which was a guide for parents, this became an important point of reference around the globe to counteract the refrigerator mother approach. Wing (and her husband Dr John Wing) continued with their research into autism.
Wing has made a profound contribution to the understanding of autism and she first used the term a continuum and then a spectrum in 1979 (Happe and Frith, 2020). Wing’s understanding came from looking at research conducted on twin studies in which there was evidence that there was a biological basis to the condition (Rutter, 2020, Feinstein, 2012). It was discovered that there is a higher incidence of autism in family members. There is still much more research needed in this area as highlighted by Fletcher-Watson and Happe (2019) when they discuss autism at the biological level.
Much research and progress in the area of autism has been made over the decades with the key theorists and psychologists and psychiatrists discussing the disorder. One key moment was the development of triad of impairments in social communication, verbal and non-verbal communication and imagination by Wing and Gould in 1979. This led to clarity around the behaviours of impairment and supported the development of models and tools for assessment such as the Theory of Mind (ToM), Childhood Autism Spectrum Test (CAST), Autism Diagnostic Observation Schedule (ADOS) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). The next section will focus on how this development in history has had an impact on practice within the areas of diagnosis and assessment.
How the history has shaped practice in terms of diagnosis and assessment and enhanced an understanding of the ways in which individuals on the autism spectrum learn and develop.
The development of theories in autism was key in the development of tools for diagnosis and assessment. One of the main cognitive theories in the development of children with autism is that of the ‘Theory of Mind’ (ToM). Milton (2012, p3) outlines ToM as ‘the ability to empathise with others and imagine their thoughts and feelings’. It has been researched and argued that autism has a deficit or impairment with ToM. This hypothesis seeks out to frame some of the social impairments that those with autism experience. Happe (1994), also developed advanced tests creating stories around motivations of true life events to explore or test this theory further. McGuire and Michalko (2011) discuss the ToM in terms of a contrast of ‘Mindblindness’, stating it is a condition that some people with autism experience. They outline that it is an inability to empathise or predict the motivations and intentions of others. It is a simple view of understanding whether someone can take a normal course of action or not. An alternative view of ToM is that of executive function or dysfunction as outlined by Rajendran and Mitchell (2007) and Fletcher-Watson and Happe (2019). This is presented as a difficulty in switching attention, a lack of impulse control and the need for sameness.
Fletcher-Watson and Happe (2019) present fascinating psychological theory at three different levels; the behavioural level, the biological level and the cognitive level. The behavioural level, refers to the action we see and is what some diagnosis and assessment tools are based upon. The biological level relates to an individual’s family history and connections and further is much needed at this level to examine bio-markers or epigenetics (Rutter, 2011) for autism. Finally, at the cognitive level in which models are created and assessment tests are based upon. Profiling tools are based around some of these elements; gathering information around the behavioural level through the implementation of a ‘Childhood Autism Spectrum Test’ (CAST) type of questionnaire given to both a parent and teacher, and through asking questions around family to gather a wider picture relating to the biological level. This would show whether other family members showed similar traits and experiences, which could be useful within diagnosis or developing strategies for support. Some of the questions within the questionnaire also relate to the cognitive level, however, more developed tests would be advantageous such as in the testing that is carried out for an autism diagnosis such as the Autism Diagnostic Observation Schedule (ADOS). A range of diagnostic tools is usually used to give breadth of perspective across the different areas and to form a broader evidence base on which to draw from.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was first created in 1952 and is the assessment method and diagnostic tool most commonly used in the UK (Blashfield, Keeley, Flanagan and Miles, 2014). We are currently on the fifth presentation of this manual and autism has seen many reviews and changes within it. The introduction of subtypes such as Asperger’s have been included (Volkmar, State and Klin, 2009), and have disappeared again. It was the introduction of DSM-III in 1980 that first categorised autism as a separate diagnosis describing it as ‘pervasive developmental disorder’ which was separate from schizophrenia. Previously, autism was described as a psychiatric condition. In this version, it had three areas of criteria; a lack of interest in people, impairments in communication, and responses to the environment (Zeldovich, 2018). DSM-III was revised in 1987 and the criteria expanded; The new 16 criteria indicated that the condition was wider than a single entity and implied a spectrum. DSM-IV was released in 1994 and outlined autism as a spectrum condition. DSM-V followed in 2013 in which Asperger and Rett syndrome were removed from the autism category and there was some debate around this. Some people with Asperger’s were concerned they would lose their identity and support that they had previously received.
How the broader autism spectrum has increased our awareness of the varying manifestations and individual differences found.
Drawing together the history of autism and the progress towards the development in theories and assessment of autism, this next section will focus on our understanding of the individual differences between people who are categorised as being on the autistic spectrum, or having an autism spectrum condition.
As we have seen, there are many debates around theories, particularly the ToM and the extent to which individuals might demonstrate ToM (Rajendran and Mitchell, 2007). As research progresses, we can see that this is not a fixed and rigid condition that can be neatly categorised and specified, the DSM has developed and adapted over the years due the progress made in understanding the condition. From experience, it can be seen that each individual with an ASD diagnosis is different and unique, and therefore the needs of the individual should be carefully taken into account and planned for.
The presentation of the triad of impairments created by Wing and Gould in 1979 (Wing, 1993); social communication, social interaction and social imagination can vary greatly from one individual to another, therefore a profile must be considered for each individual. Which elements of each are causing the most difficulty and in what way? Only then can effective support and interventions be implemented.
Each area is broad within its presentation, for example, Social Interaction may include:
· inappropriate touching
· difficulty understanding / using non verbal body language
· personal space issues
· unaware of different social relationships / hierarchy
· struggle to initiate and maintain relationships
· not understanding / reading social cues / rules
This has been seen from my experience of working with pupils with autism, for example maintenance of relationships can be difficult due to the other factors in this area; they may have an over-reliance on rules which can cause arguments with peers when they are playing a more relaxed game of football.
With Social Imagination:
· doesn’t understand others views / feelings/ lack of empathy
· difficulties with Theory of Mind
· agitated by changes in routine
· unable to generalise information
· special interests / obsessive behaviour
· literality
· rigid thought patterns
I have observed this on many occasions when pupils have become distressed by changes of routine that they have not had time to prepare for, becoming agitated and needing to leave the building. Special interests are another area I have seen often, pupils become absorbed in their interest and want to share this with others, they may not pick up on the verbal or behavioural cues when the recipient is becoming bored.
and Social Communication
· not appreciate the social uses or pleasure of communication.
· talk at people rather than to them.
· expression of own emotions/feelings.
· understanding the emotions/beliefs of others.
· reading the meaning of gestures, facial expressions or tone of voice.
(ASD Helping Hands, 2021)
Finally, this area has been in my practice when pupils have difficulty both expressing and reading other people’s emotions; not understanding the subtleties in the differences between anger and sadness which can result in difficulties in acting inappropriately for the circumstances.
As we can see from the above, autistic pupils may have these difficulties in varying degrees, or even some elements but not others. This makes it more complex when supporting and working with those with ASC, and tools for diagnosis, assessment and support are needed to identify the difficulties for each individual.
As noted in the last section, there was some concern around the removal of sub-categories within the DSM (Zeldovich, 2018). Some would argue that this another step forward in the development of the assessment of autism, with greater reliability and consistency being applied under the umbrella of autism (Tobe, 2017). However, others would argue that categorisations within autism are useful to define areas of need further, and provide more appropriate support. There is a concern from the Asperger community that a lack of support or services will be available for those with higher functioning autism, or Asperger’s Syndrome (as previously categorised). An area that has been introduced to DSM-V is that of Social (Pragmatic) Communication Disorder (SCD) which is being considered as an alternative diagnosis to ASC or Asperger’s Syndrome. This element categorises the main elements of communication difficulties seen in those with ASC, but does not include the areas of repetitive and restrictive behaviours (OPI, 2021). As this is relatively new to DSM-V, there is much less written and researched about it, and something to explore further.
Conclusions
There are many strengths to autism, for example having a sharp and defined interest or focus, paying attention to fine detail, and to clearly follow rules. These should be embraced and supported when devising plans and considering outcomes. I am developing my own thinking around the debates in which some theorists believe autism can be cured (Boucher, 2017) and although many believe that this perspective is no longer acceptable (Happe and Frith, 2020) it is still around. I am taking a stance which aligns much more within the thinking around the more recent term of neurodiversity (Silberman, 2017, Singer, 2017). Milton (2014, 2020) outlines this as variations in neurological development which are part of natural diversity, rather than a medical model of disability. There are co-occurring conditions with autism that may need to be considered within a medical such as epilepsy or anxiety, which may benefit from a medical approach (Happe and Frith, 2020) However it is important to remember that we are all different, with different strengths and this should be embraced.
References
ASD Helping Hands, (2021). The Triad of Impairments. The Triad of Impairment — ASD Helping Hands [Date Accessed: 17/02/2021].
Blashfield, R. Keeley, J. Flanagan, E. and Miles, S. (2014). The Cycle of Classification DSM-I through DSM-V. The Annual Review of Clinical Psychology. 10:25-51.
Boucher, J. (2017). Autism Spectrum Disorder; Characteristics, Causes and Practical Issues. SAGE. London.
Feinstein, A. (2010). A History of Autism, Wiley-Blackwell. Oxford.
Fletcher-Watson, S and Happe, F (2019). Autism; A New Introduction to Psychological Theory and Current Debate. Routledge, London.
Happe, F. (1994). An Advanced Test of Theory of Mind, Understanding of Story Characters Thoughts and Feelings by Able Autistic, Mentally Handicapped and Normal Children and Adults. Journal of Autism and Developmental Disorders. 24:2, 129-154.
Happe, F. and Frith, U. (2020). Annual Research Review: Looking Back to Look Forward – Changes in the Concept of Autism and Implications for Future Research. Journal of Psychology and Psychiatry. 61:3, 218-232.
Levy, F. (2007). Theories in Autism. The Royal Australian and New Zealand College of Psychiatrists. 41:859-868.
Mandal, A. (2019). Autism History. Autism History (news-medical.net) [Date Accessed: 16/02/2021].
McGuire, A. and Michalko, R. (2011). Minds Between Us: Autism, Mindblindness and the Uncertainty of Communication. Educational Philosophy and Theory. 43:2, 1469-5812.
Milton, D. (2012). So What Exactly is Autism? Autism Education Trust. DfE.
Milton, D. (2014). So What Exactly are Autism Interventions Intervening With? GAP. 15.2.2014
Milton, D. (2019). Disagreeing over Neurodiversity. Psychologist, 32 . p. 8. ISSN 0952-8229.
Optimum Performance Institute. (2021). DSM-V and How it Affects the Diagnosis of Asperger’s Disorder. DSM-V and How it Affects the Diagnosis of Asperger’s Disorder - OPI Residential Treatment Center for Young Adults - Private Pay Mental Health Program (optimumperformanceinstitute.com) [Date Accessed: 17/02/2021].
Rajendran, G. and Mitchell, P. (2007). Cognitive Theories of Autism. Science Direct, Developmental Review 27. 224-260.
Rutter, M. (2011). Progress in Understanding Autism: 2007-2010, Journal of Autism Development Discord, 41:395-404.
Silberman, S. (2017). Neurotribes. Allen and Unwin. London.
Singer, J. (2017). Neurodiversity; the Birth of an Idea. Amazon. UK
Toby, H. (2017). DSM-5 Changes: Autism Spectrum Disorder. Therapist Development Center Blog. DSM 5 Changes: Autism Spectrum Disorder (therapistdevelopmentcenter.com) [Date Accessed: 17/02/2021].
Volkmar, F. State, M. and Klin, A. (2009). Autism and Autism Spectrum Disorders: Diagnostic Issues for the Coming Decade. The Journal of Child Psychology and Psychiatry. 50:1-2, 108-115.
Volkmar, F. Reichow, B. and McPartland, J. (2012). Classification of Autism and Related Conditions; Progress, Challenges and Opportunities. Dialogues in Clinical Neuroscience, 14.3
Wing, L. (1993). The Definition and Prevalence of Autism: A Review. European and Child Adolescent Psychiatry. 2:2 61-74.
Wolff, S. (2004). The History of Autism, European Child Adolescence Psychiatry, 13:201-208.
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Time line
1747
Hugh Blair case
(Uta Frith)
In 1947 Uta Frith analysed witness testimonies from 1747 in the case of Hugh Blair and his mental capacity which demonstrated mannerisms and characteristics of autism.
1809
John Haslam
‘Observations of madness and melancholy’ discusses case of children with similar characteristics.
1879
Henry Maudsley
‘The pathology of mind’ the case of a 13 year old with possible Asperger syndrome.
1908
Eugen Bleuler
The term Autism was first used by Bleuler which described schizophrenic patients that demonstrated withdrawn and self-absorbed behaviours. The term came from the Greek word meaning self.
1930s
Dr Hans Asperger
Dr Leo Kanner
Both started work in this area at the same time, but with different approaches. Further details discussed below.
1943
Dr Leo Kanner
First used the term autism in a study with 11 children and noted their similarities in behaviours such as ‘aloneness’ and obsessive behaviours. The term was later named as early infantile autism. At times there was confusion with terms such as infantile schizophrenia.
1944
Dr Hans Asperger
Published a report which looked at areas of autism, social disability and difference. He describes a form of autism later known as Asperger Syndrome. It is noted that the cases were all boys, and they had obsessive interests and impaired social interactions.
1950
Bruno Bettelheim
Developed the ‘refrigerator mother’ concept in which autism in children was caused by cold and unloving parents. It was therefore implied that it was something that could be preventable.
1952
Publication of DSM-I
Diagnostic and Statistical Manual of Mental Disorders.
Autism in children was linked with childhood and adult schizophrenia.
1956
Kanner and Eisenberg
Revised study and criteria – only two identifiable features of autism; isolation and obsessive need for sameness. They also noted if a parent had milder symptoms then the child may have a fuller emergence of autism.
1962
NAS
The National Autistic Society was formed.
1964
Bernard Rimland
Considered autism was based on biological factors, this included; immune systems, environmental pollutants, antibiotics and vaccines.
1967
Bruno Bettleheim
Considered the refrigerator mother concept and made it popular.
1968
DSM- II published
1977
Susan Folstein and Michael Rutter
Published a study of autism and twins, and concluded that genetics are an important cause of autism.
1979
Lorna Wing and Judith Gould
A large scale study led to the triad of impairments in social communication, verbal and non-verbal communication and imagination.
1980
DSM-III published
Autism is listed as its own category for the first time, making it distinct from childhood schizophrenia.
1981
Lorna Wing
Looked at Asperger’s original findings and the term Asperger Syndrome was developed.
1987
DSM-III
Diagnostic criteria for autism is included.
1994
DSM-IV
Asperger’s Syndrome is included as a separate disorder from Autism.
1998
Andrew Wakefield
Published a study suggesting a link between autism and the MMR vaccine, this was later discredited in 2001.
2009
Autism Act 2009
Law in England after a National Autism Society campaign.
2013
DSM-V
Overall term of Autism Spectrum Disorder introduced. Combining all sub-categories under one term of Autism. Asperger’s Syndrome is no longer a separate category.
2015
DfE
SEND Code of Practice introduced. Autism Spectrum Disorders are identified under Social, Emotional and Mental Health category.
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