from syndrome to spectrum

Eagle-eyed readers will have spotted a big difference between Kanner’s 20 ‘essential common characteristics’ and the three characteristics of autistic disorder (impairments in social interaction and communication, and restricted and repetitive behaviour) outlined in fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published in 1994. What happened to Kanner’s syndrome in those 50 intervening years?

To summarise the transformation of Kanner’s syndrome, I want to focus on two papers, one a review by Kanner and Leon Eisenberg in 1956 (I used a reprint of this paper from a book chapter), and the other by Lorna Wing and Judith Gould published in 1979 – the account of their famous Camberwell study. Comments from the authors in Adam Feinstein’s excellent resource A History of Autism shed further light on the changes that took place.

Reviewing Kanner’s syndrome

Kanner’s proposal that he’d found a new syndrome generated considerable interest, debate – and confusion. Similar syndromes with different names were puzzled over. There was much discussion about whether Kanner had found a new syndrome and whether (or in what way) it was related to schizophrenia. By 1956, Kanner’s syndrome had been diagnosed in over 120 children “with reasonable certainty”. Kanner and his new colleague at Johns Hopkins, Leon Eisenberg, reviewed the syndrome in their paper ‘Early infantile autism 1943-1955’ and tried to clarify the situation.

They first collapsed Kanner’s 20 essential common characteristics into five;

the five characteristics of early infantile autism

Several of the original 20 characteristics were omitted;

ability to speak
• physically normal
• food
• masturbatory orgiastic gratification
• from highly intelligent families.

The authors then identify two features as ‘pathognomonic’ (distinguishing characteristics); ‘extreme self-isolation’ and ‘obsessive insistence on the preservation of sameness’. An impairment in communication was no longer seen as a critical feature; “The vicissitudes of language development, often the most striking and challenging of the presenting phenomena, may be seen as derivatives of the basic disturbance in human relatedness.” (p.5). Adam Feinstein asked Leon Eisenberg why he and Kanner had left out the language impairment. Eisenberg said: “I was following Kanner’s lead. It wasn’t that we had extensive discussions.” (Feinstein, 2010; p.47)

Despite this attempt at clarification, the confusion over syndromes and symptoms continued. In 1958 the child psychotherapist E.J. Anthony observed wryly: “The cult of names added chaos to an already confused situation, since there did not seem to be a sufficiency of symptoms to share out among the various prospectors, without a good deal of overlap.” (Wing & Gould, 1979)

Kanner complained in 1965 about a “pseudo-diagnostic wastebasket into which an assortment of heterogeneous conditions were thrown indiscriminately. Infantile autism was stuffed into the basket along with everything else…Such looseness threw all curiosity about diagnostic criteria to the winds as irrelevant impediments on the road to therapy, which was applied to all-comers as if their problems were identical. The therapeutic cart was put before the diagnostic horse and, more often than not, the horse was left out altogether.” (Feinstein, 2010; p.41)

Carl Fenichel, who founded a treatment centre in New York thought differently. At the Leo Kanner Colloquium on Child Development, Deviations and Treatment in 1973 he said; “We scrapped these labels 18 years ago at our place….We found that all these labels are just meaningless… We learn more about these kids from working with them on a day-to-day basis. Too many people feel that sticking a label on them means that they now know what this kid needs. I think this is a dangerous, misleading and destructive process.” (Feinstein, 2010; p.53)

The Camberwell study

The situation was in desperate need of clarification. In 1977 Lorna Wing and Judith Gould, based at the Maudsley Hospital in London, began a study designed to sort out the classification of disorders of social interaction. In 1979 they published their findings. Their paper opens with list of syndromes similar to Kanner’s, which illustrates how confusing the picture was at the time;

dementia precoccissima
dementia precoccissima catatonia
primitive catatonic psychosis of idiocy
dementia
symbiotic psychosis
autistic psychopathy and
early infantile autism.

The symptoms of the syndromes tended to overlap, so rather than starting with the syndromes, Wing and Gould began with the children’s characteristics. They screened 914 children in the London Borough of Camberwell who were known to health, education or social services as having a physical or mental handicap or behaviour disturbance. They identified 132 who showed either the key features associated with impairments of social interaction in the literature (social interaction and verbal or nonverbal language and repetitive, stereotyped activities) or signs of severe retardation.

They found the children could be divided into two groups; the ‘sociable severely retarded’ group who showed social behaviour appropriate to their mental age, and the ‘socially impaired’ group, who didn’t. The only named syndrome that matched the characteristics of any of the children was Kanner’s early childhood autism, so the socially impaired group were sub-divided into autistic (according to Kanner’s criteria) and non-autistic children. (There were further sub-divisions that I’ll look at another time.) Two of Wing and Gould’s findings are especially relevant to a discussion about Kanner’s syndrome.

First, they found a cluster of abnormalities “consisting of impairment of social interaction, repetitive activities in place of imaginative symbolic interests, and impairment of language development”. This cluster became known as the Triad of Impairments. (Incidentally, if anyone knows when this term was first used, I’d be interested to know. My inquiries so far have drawn a blank.)

Secondly, although some children met the criteria for Kanner’s syndrome, the pattern of abnormalities Wing and Gould found within their socially impaired group wasn’t clear-cut; “Unlike the other named syndromes, the behavior pattern described by Kanner could be identified reliably, but the findings of the present study bring into question the usefulness of regarding childhood autism as a specific condition.” (p.27)

Wing and Gould concluded: “The distribution of the variables among the subgroups suggested that they formed a continuum of severity rather than discrete entities”. (p.26)

Later, the continuum became a spectrum. In an interview with Adam Feinstein, Judith Gould said; “we first called it the ‘autistic continuum’ and then we realized that the word continuum had an implication of discrete descriptions along a line, whereas that was not really what it was. It was not a question of moving in severity from very severe to mild… The concept is more like a spectrum of light, with blurring.” (Feinstein, 2010: p. 153.)

Wing and Gould were surprised by their findings. Lorna Wing commented:

“…Leo Kanner would have found it very difficult to accept the idea of an autistic spectrum, because he was so wedded to his idea of a unique syndrome. I myself started off quite convinced that Kanner was right. … meeting the children … showed me that the idea of a neat barrier between Kanner’s autism and the others was rubbish. And slowly, my view was changed. I had to accept the experience in front of my very eyes.” (Feinstein, 2010; p.151)

Wing and Gould’s findings showed that although some children did have the essential common characteristics described by Kanner (presumably Kanner and Eisenberg’s two pathognomonic features), they appeared to have those features by chance, rather than because they had a specific disorder with symptoms as described by Kanner.

What was also clear was that some children’s social skills were not commensurate with their mental age, that impaired social skills were associated with repetitive behaviours and impaired language, but that these impairments varied considerably between individuals. Wing and Gould’s findings have been supported by subsequent research and are reflected in the DSM-IV criteria for autistic disorder.

It’s interesting to note that as the number of children found to have impairments in social interaction went up, so the number of essential characteristics they had in common went down. Those common characteristics also became less specific. There’s a reason for that, which I’ll move on to in a later post.

What can we conclude about Kanner’s syndrome? I’ve suggested there’s little evidence to support what he thought was the cause of his syndrome (essentially a disruption of the social instinct), and Wing and Gould found little evidence to support the idea that childhood autism was a specific condition. Although we can probably reject Kanner’s hypothesis that he had found a unique syndrome, the children he described were clearly showing atypical development, so we’re still left with the question of why autistic disorder, as it’s now called, shows such a wide variation in symptoms and, of course, what causes them.

Before moving on to more recent theories about autism and its causes, at the risk of labouring the point, I next want to revisit the idea of the syndrome, a concept that still underpins the classification of mental disorders.

References

Feinstein, A (2010). A History of Autism. Wiley Blackwell.

Kanner. L.. & Eisenberg, L. (1956). Early infantile autism 1943-1955, American Journal of Orthopsychiatry, 26, 55-65.

Reprinted as:

Eisenberg, L. & Kanner, L. (1958). Early infantile autism 1943-1955. In C. F. Reed, I. E. Alexander and S. S. Tomkins (eds.) Psychopathology: A Source Book, Harvard University Press.

Wing, L. & 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.

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