Autism in Childhood - Eight

Autistic Psychopathy in Childhood, ex Die ‘Autistischen Psychopathen’ im Kindersalter. Asperger, H. (1944) Archiv für Psychiatrie und Nervenkrankheiten, 117, 76-136.Translated and annotated by Uta Frith. From “Autism and Asperger syndrome” Edited by Uta Frith. ISBN-10: 052138608X

©1991 Cambridge University Press.

Part Eight

Drive and Affect in the Autist

It will be clear by now that the personality of the children presented here lacks, above all, harmony between affect and intellect, While intellect may often be above average, drives and instincts are often severely disturbed. This is shown in the failure of instinctive situational adaptation and when faced with the practical demands of ordinary life. It is also shown in the expressive aspects of behaviour.

We will now go on to look at these disturbances of drive and feeling one by one.

We start with sexuality. The picture is by no means uniform. Some individuals, throughout their childhood, and also beyond puberty, are sexually uninterested. They have a weak drive and never achieve healthy sexuality even in later life. However, in the majority of cases, there are early signs of strong sexual activity.

In many cases, this is shown in masturbation which appears early, is practised intensively and obstinately, and is not amenable to change. Since any feelings of shame or guilt are largely absent, the children may masturbate in public, exhibitionistically, and they cannot be made to desist. One also hears of homosexual acts in relatively young children, as in case 2. Sadistic traits are frequently reported. As an example, we mention some remarks of a seven-year-old boy with strongly autistic features; ‘Mummy, I shall take a knife one day and push it in your heart, then blood will spurt out and this will cause a great stir.’ ‘It would be nice if I were a wolf, Then I could rip apart sheep and people, and then blood would flow.’ Once, when the mother cut her finger, ‘Why isn’t there more blood? The blood should run!’

When he injured himself on one occasion, he was said to have been utterly thrilled, so that the doctor who tended the wound remarked on the child’s state as extremely odd. At the same time, the boy was particularly anxious, He was afraid to fall over in his chair and extremely afraid of fast-moving vehicles on the road.

There is also not infrequently a tendency to use obscene words which may stand in strange contrast to the otherwise often stilted language of these children.

Thus, with the sexual aspect of affective life there is often a definite disharmony, either a weakness or precocity and perversion, but no harmonious integration of sexuality into the developing personality. The same is also true for other areas of affective life. Over-sensitivity and blatant insensitivity clash with each other, Here are some examples.

In the sense of taste we find almost invariably very pronounced likes and dislikes. The frequency of this phenomenon provides yet more proof of the unity of the type. There is often a preference for very sour or strongly spiced food, such as gherkins or roast meat. Often there is an insurmountable dislike of vegetables or dairy produce. [68]

It is no different with the sense of touch. Many children have an abnormally strong dislike of particular tactile sensations, for example, velvet, silk, cotton wool or chalk, They cannot tolerate the roughness of new shirts, or of mended socks. Cutting fingernails is often the cause of tantrums. Washing water too can often be a source of unpleasant sensations and, hence, of unpleasant scenes.

In the hospital we have observed hypersensitivity of the throat which was so strong that the daily routine inspection with the spatula became an increasingly difficult procedure.

There is hypersensitivity too against noise. Yet the same children who are often distinctly hypersensitive to noise in particular situations, in other situations may appear to be hyposensitive. They may appear to be switched off even to loud noises. [69]

The impression of disharmony and contradiction only increases when we consider the higher feelings as they are manifested in relationships to objects, to animals and to other people, As soon as one starts to work with these children, one is struck by a distinctive emotional defect which one may well consider an ultimate cause of their social disturbance. This defect is apparent in their isolation while they are in the midst of other people and in their contrariness with their environment and especially their closest family.

They lack the displays of affection which normally make life with a small child so richly rewarding, One never hears that they try to flatter or try to be nice. Indeed, they often turn nasty when one tries to be nice to them. Their malice and cruelty too clearly arise from this impoverished emotionality.

Autistic children are egocentric in the extreme. They follow only their own wishes, interests and spontaneous impulses, without considering restrictions or prescriptions imposed from outside. They lack completely any respect for the other person, They treat everyone as an equal as a matter of course and speak with a natural self-confidence. In their disobedience too their lack of respect is apparent. They do not show deliberate acts of cheek, but have a genuine defect in their understanding of the other person.

For personal distance too they have no sense or feeling, just as they unconcernedly lean on others, even complete strangers, and may run their fingers over them as if they were a piece of furniture, so they impose themselves without shyness on anybody. They may demand a service or simply start a conversation on a theme of their own choosing, All this goes, of course, without any regard for differences in age, social rank or common courtesies. [70]

Autistic children's relations to objects, too, are abnormal. With the normal child, particularly the infant, things become alive because he fills them with life through his vivid relationship with the world around him, He gains experience and maturity through lavishing his attention and love on objects. This does not happen with autistic children. Either they take no notice of the objects in their environment, for instance, they take little interest in toys, or they have abnormal fixations. Perhaps they fixate on a whip or a wooden brick or a doll that they never let out of their sight, and cannot eat or sleep when the ‘fetish’ is not there. There can be the most severe tantrums at any attempt to take away the object of such passionate attachment. [71]

Very often, the relationship of autistic children to things is limited to collecting, and here again, instead of the harmonious order and richness of a normally balanced affective life, we find deficiencies and empty spaces, in which singular areas develop to an excessive extent.

The collections that are favoured by autistic children appear like soulless possessions. The children accumulate things merely in order to possess them, not to make something of them, to play with them or to modify them, Thus, a six-year-old-boy had the ambition to collect 1,000 matchboxes, a goal which he pursued with fanatical energy. The mother, however, never saw him play trains with them as other children do.

Another boy collected cotton threads; a third ‘everything` that he found on the street, but not like the street urchin, who has everything in his trouser pocket that he might need for his pranks. The autistic individual just stacks boxes full of useless junk. He constantly orders things and watches over them like a miser, Thus, there arc serious rows when the mother dares to throw anything away.

In adulthood the passion for collections often becomes more interesting and selective, in short more ‘rational’, and their mental attitude to collecting improves. The real collector-type is often an eccentric with pronounced autistic traits. [72]

Autistic children also do not have a proper attitude towards their own bodies. It is often well nigh impossible to teach them the numerous requirements of cleanliness and physical care. Even as adults they may be seen to walk about unkempt and unwashed, including those who have taken up an academic career.

Up to the end of their childhood autistic children tend to he extremely messy eaters. They may smear or ‘paint’ with their food while being preoccupied with some strange problem of their own.

Another characteristic of autistic children is the absence of a sense of humour. [73] They do not ‘understand jokes’, especially if the joke is on them. This is another reason for their often being the butt of teasing: If one can laugh at oneself, one can take the edge off ridicule.

However, autistic children are rarely relaxed and carefree and never achieve that particular wisdom and deep intuitive human understanding that underlie genuine humour. When they are in a merry mood, as sometimes happens, then this often strikes one as unpleasant. The mood is exaggerated and immoderate, They jump and rampage around the room, infringe other people‘s space, are aggressive and annoying.

When making puns, however, autistic people sometimes shine, and may even be highly creative, This can range from simple word-play and sound associations to precisely formulated, truly witty remarks.

Nevertheless, if one focused only on the features just described, one would gain a false impression of the emotional side of autistic individuals. There are also observations that do not show such a decidedly negative picture.

Again and again, we have been surprised by the severe bouts of homesickness of autistic children when newly admitted to the ward. At first, this phenomenon did not seem to us to fit at all with the otherwise blatant signs of emotional poverty. Ordinary children, even those who have a very strong and genuine emotional bond to their family, adapt to their new environment after a short period of grief. This is because they can soon feel the love and care offered to them, and because they increasingly become interested in the new environment and the various activities that fill their days.

Autistic children suffer from homesickness much more severely, For days they may cry desperately, especially in the evenings, when the pain always breaks out anew. They talk about their poor tormented parents and about their home with the tenderest words - with the mature language that we have already mentioned - and also with an exceptionally differentiated emotion, which children of that age cannot usually express.

In a peculiar mixture of naivety and sophistication they give reason upon reason why they cannot stay, why they definitely have to go home today. They write imploring and quite shattering letters home. This all lasts very much longer than the homesickness of normal children, until at last they too get used to us and start to feel happy under the inescapable structure and guidance that we impose.

It is possible that an exceptional degree of bonding to the objects and habits of the home, bordering on the obsessional, causes these children to suffer so much at separation, Therefore, it may be their general limitation in the normal freedom of action which lies at the root of this reaction, Nevertheless, the phenomenon of severe homesickness shows that autistic children are capable of strong feelings.

There are other examples. One boy, whose highly creative verbal expressions have already been quoted, had two white mice for which he cared tenderly, and which he preferred to all human beings, as he frequently pointed out. This boy deeply upset his parents by his spitefulness and cruelly tormented his little brother. There are similar examples of undoubted emotional attachments to animals and also to particular people which can regularly be observed in autistic children.

In view of these facts, the problem often emotionality of autistic children is made extremely complicated for us, In any case, the children cannot be understood simply in terms of the concept ‘poverty of emotion’, used in a quantitative sense. Rather, what characterises these children is a qualitative difference, a disharmony in emotion and disposition. They are full of surprising contradictions which makes social adaptation extremely hard to achieve.

Genetic and Biological Factors

Given that the autistic personality type is both circumscribed and persistent, the questions of heredity must arise.The idea that psychopathic states are constitutional and, hence, inheritable has long been confirmed. However, it is a vain hope to think there may be a clear and simple mode of inheritance. These states are undoubtedly polygenetic, but it is as yet impossible to know whether such a trait is dominant or recessive.

The task of tracing the pedigrees of our children will have to remain for a later investigation. We want only to state briefly that over the course of ten years we have observed more than 200 children who all showed autism to a greater or lesser degree.

We have been able to discern related incipient traits in parents or relatives, in every single case where it was possible for us to make a closer acquaintance. [74]

Usually certain autistic peculiarities were present, but often we also found the fully fledged autistic picture starting with abnormalities of expressive functions and gaucheness up to the higher level of 'integration difficulties'. If it is the father who has transmitted the autistic traits, then he will in most cases have an intellectual profession. If one happens to find a manual worker among them, then it is probably someone who has missed his vocation (see case 2.).

In many cases the ancestors of these children have been intellectuals for several generations and have been driven into the professions by their nature. Occasionally, we found among these children descendants of important artistic and scholarly families. Sometimes it seems as if of the former grandeur only the eccentricity remains - which often also characterises great scientists. Many of the fathers of our autistic children occupy high positions, despite their noticeable peculiarities. This testifies to the social value of this personality type.

The familial findings we have sketched here certainly suggest a dominant mode of inheritance. They also suggest specificity since there is astonishing similarity between autistic individuals.

It is fascinating to note that the autistic children we have seen are almost exclusively boys. Sometimes girls had contact disturbances which were reminiscent of autism, and there were also girls in whom a preceding encephalitis had caused the state (as in case 4, Hellmuth L.). However, we never found the fully formed picture as shown in cases 1 to 3. How can this be explained? There is certainly a strong hint at a sex-linked or at least sex-limited mode of inheritance.

The autistic personality is an extreme variant of male intelligence. [75] Even within the normal variation, we find typical sex differences in intelligence. In general, girls are the better learners, They are more gifted for the concrete and the practical, and for tidy, methodical work.

Boys, on the other hand, tend to have a gift for logical ability, abstraction, precise thinking and formulating, and for independent scientific investigation. This is the reason, too, why in general boys at older age levels do better than girls in the Binet test. The narrowly logical and abstract items which start at the ten-year level are simply more congenial to boys!

In the autistic individual the male pattern is exaggerated to the extreme. In general, abstraction is congenial to male thought processes, while female thought processes draw more strongly on feelings and instincts. In the autistic person abstraction is so highly developed that the relationship to the concrete, to objects and to people has largely been lost, and as a result the instinctual aspects of adaptation are heavily reduced. [76]

While we have never met a girl with the fully fledged picture of autism, we have, however, seen several mothers of autistic children whose behaviour had decidedly autistic features. It is difficult to explain this observation. It may be only chance that there are no autistic girls among our cases, or it could be that autistic traits in the female become evident only after puberty. We just do not know. [77]

When surveying out case material, we found that more often than not autistic children were only children. [78] This is noticeable even after allowing for urban population trends. Precise numbers have to await further investigation. An observer coming from a background of ‘individual psychology’ (‘Individual-psychologie’) would naturally explain the whole clinical picture out of the situation of the only child, and see in this proof for an exogenous cause of autism.

He would explain the disturbed social relations, as well as the precocious speaking and thinking, simply from the fact that only children grow up among adults and never learn to adjust to siblings, Parents and teachers too often tend to explain the typical difficulties by referring to the notion of the only child. However, here as so often, this particular psychological approach confuses cause and effect. If one sees how autistic children grow up autistic from babyhood, and if one sees that those who grow up among siblings develop in exactly the same way as those who are only children, then an explanation in terms of exogenous causes must seem absurd.

Autism does not arise because there are unfavourable developmental influences for a siblingless child, but because there is an inherited disposition. It may be an expression of autism in the parents that they have brought into the world only one child. Undoubtedly, there are many reasons for the wish to have children, and this is subject to change by outside forces. An excellent example of such change can be seen most recently in Germany. [79]

The variations of the human character suggest, however, that the wish for children, or its converse, has a deep biological basis. A lack of or reduction of this wish is a characteristic trait in most autistic personalities and can be considered another symptom of their hyposexual, instinctually disturbed nature.

Many autistic people lead solitary lives and do not marry and have children. Many of those who do marry show tensions and problems in their marriage, In such a marriage the proper harmony between mind and body cannot be found and there is little space for raising large numbers of children.

One is reminded here of Ludwig Klages who said ‘the intellect is the enemy of life’. We need to emphasise, then, that being an only child is a symptom rather than a cause of the autistic condition.

In our description of the cases, especially the first, we saw that there were a number of similarities between autistic psychopathy and schizophrenic states. Indeed, the question arises whether a child as deviant as Fritz V. suffers from childhood schizophrenia. We considered this question and rejected the diagnosis of a schizophrenic psychosis in this case. The same applies to the others, who were less deviant in any case.

We now need to turn to another question. Could it be that at least some of the cases described are precursors of schizophrenia? The answer is again no. Our cases here do not show the progressive deterioration that would be expected for psychosis. In essence, they remain the same throughout their life, though there is often improved adaptation, and many can achieve a reasonable degree of social integration.

I know of only one case, first considered to be severely autistic, in which, two years later, a progressive destruction of the personality occurred, and hebephrenia was diagnosed, In all other cases, some of which I have observed for twenty years or longer, I have not seen a transition of autistic personality disorder into genuine schizophrenia. [80]

Concerned with this, we now need to ask whether autistic psychopathy derives, perhaps partially, from a genetic disposition to schizophrenia. If we presuppose polygenetic inheritance for schizophrenia, are autistic individuals carriers of single genes which, in combination, would cause schizophrenia, or is autism a sign of disposition towards schizophrenia which has failed to manifest itself?

These questions can be clarified only by means of exact family studies. It would be necessary to find an excess of schizophrenics in the blood relations of autistic children. We can give no conclusive answers at present but have to refer again to future studies. Meanwhile, it should be pointed out that we do not believe that there is an excess of schizophrenics in the families of autistic children, and thus the autistic personality is neither biologically nor genetically related to schizophrenia. [81] This would be consistent with Schroder’s view of personality disorder or psychopathy; he maintained that psychopaths are not mad, nor half nor quarter mad.

Continue reading the final part: Autism in Childhood - Part Nine

68 It is possible that food allergies, if investigated, might have had links with some of the aversions mentioned.

69 In contrast to Kanner (1943) Asperger remarks on the paradoxical phenomenon of hyper and hyposensitivity to sound, light and touch. This phenomenon has since been observed in autistic children of all ability levels. No consensus has been reached, however, on the diagnostic value or meaning of this feature.

70 All the autistic features which Asperger considers in the three preceding paragraphs can he explained by the theory that autistic individuals lack a proper conception of mental states:

first, they do not display affection or try to be nice, because they do not try to manipulate other peoples feelings towards them;

secondly, they are totally egocentric because they do not distinguish their own from other people’s mental states and do not recognise that they may differ;

thirdly, they appear to be rude because they are unaware of the social nicenes that allow smooth mutual understanding.

Likewise, the disobedience and bad behaviour that seemed to be the mayor reasons for referral of Asperger's cases may arise from a defect in understanding the effect of their behaviour on another persons mental state.

71 The potential link between disturbance of active attention, attachment to objects and narrow preoccupations is referred to by Asperger as a poor relationship to the world of objects. While Kanner makes a distinction between poor relations to people and good relations to objects, Asperger points out examples of poor relations in both spheres.

72 Later examples or collections mentioned by Asperger include collecting toys and collecting sewing thread. Collecting as a peculiarly autistic feature is not mentioned in Kanner`s original paper. This has since been frequently documented in autistic individuals of all levels of ability.

73 This original observation of Asperger's has been amply confirmed by later case descriptions. A sense of humour depends crucially our an intact ability to understand the use of language in communication, that is, pragmatics.

74 Unfortunately, a pedigree study was never completed, and the summary statement that autistic traits were always present in a relative of the child was never backed by data. Gillberg (chapter 4 “Autism and Asperger syndrome”. Edited by Uta Frith. ISBN-10: 052138608X), however, provides detailed evidence for the heritability of Asperger syndrome in six family studies.

75 This provocative idea deserves to be re-examined in the light of neurobiological theories on sex differences in brain maturation (for example, Geschwind and Galaburda, 1985).

76 Asperger’s comparison of the sexes in terms of underlying thought processes and interests is very much in accord with cultural stereotypes. As yet we have little scientific basis for these widely held beliefs. So far there is no empirical evidence to suggest that autistic boys differ from autistic girls in terms of abstract thinking.

77 In his textbook (1951) Asperger still maintains that the only young girls he has seen with the full clinical picture of autism are those who have acquired autism after presumed encephalitis. That young girls too can show the typical Asperger variant of autism has been well established, several eases are described elsewhere in “Autism and Asperger syndrome”. Edited by Uta Frith. ISBN-10: 052138608X

It remains true, however, that girls are vastly outnumbered by boys. A sex-linked mode of inheritance is compatible with this pattern.

78 Epidemiological studies have not confirmed that autistic children are predominantly only children.

79 This refers to the pressure which the fascist regime then put on families to produce more children. This single remark is the only one in the whole paper to refer to a point of fascist ideology at a time when it would have been opportune to make many more such references. Apparently, acceptance of Asperger’s thesis was delayed because he was not a party activist.

81 Asperger’s view is identical to that of Kanner and has been confirmed by epidemiological studies; schizophrenia is not seen in increased numbers in the families of autistic children.