Autism in Childhood - Five

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 Five

Ernst K.

This seven-and-a-half-year-old boy was also referred to us by his school because of severe conduct and learning problems.

The following points from the family history deserve to be mentioned. Birth and physical development were normal. Ernst was an only child. His speech was somewhat delayed (first words at the age of one-and-a-half). For a long time, the boy was reported to have had speech difficulties (stammering). Now, however, his speech was exceptionally good, he spoke ‘like an adult’.

He was reported to have been a very difficult toddler, paying heed to neither his indulgent mother not his strict father. He was said to he unable to cope with the ordinary demands of everyday life. The mother believed that it was because of his clumsiness and impracticality that he had more difficulties than other children. For instance, it was still necessary to dress him, since, by himself, he would dawdle endlessly and also make a lot of mistakes. He had learnt to eat by himself only recently and was still a messy eater. The mother also reported that occasionally he could be very naughty and would not do what he was told.

He was never able to get on with other children. It was impossible to go to a park with him, as he would instantly get embroiled in lighting. Apparently, he hit or verbally abused other children indiscriminately. This had become more of a problem since he started school, He acted like a red rag to his class and was teased mercilessly. However, rather than keeping away from the other children, he acted as a trouble-maker. For instance, he would pinch or tickle other children or stab them with his pen.He liked to tell fantastic stories, in which he always appeared as the hero. He would tell his mother how he was praised by the teacher in front of the class, and other similar tales. [31]

The report said that it was difficult to know how bright he was. Before he entered school, everyone was convinced that lie would learn particularly well, since he was always making clever remarks and original observations. Moreover, he had by himself learnt to count to twenty, as well as picking up the names of various letters. At school, however, he failed miserably. He just managed to move up from the first form (wrongly, as we had cause to observe later), but now, in the second form, according to the teacher, he was not performing adequately.

Instead of listening and answering when appropriate, he constantly argued with the teacher as to how to hold his pen, According to the report, he had a strong tendency to argue with everybody and to reprimand them. He was ‘very precise': certain things always had to he in the same place, and certain events always had to happen in the same manner, or he would make a big scene. [32]

There was an interesting contradiction here: in certain matters he was particularly messy and could not get used to things being done in an orderly fashion, but in others he was pedantic to the point of obsession.

Family history

The father was said to be very highly strung and irritable. By profession he was a tailor's assistant. Although we had known the boy for many years, we had seen the father only once. He was clearly eccentric and a loner. The mother did not like to talk about her domestic circumstances. However, it was plain that her life could trot have been very happy due to the husband's difficult character.

Then mother was a very bright and extremely nice woman whose life was not easy. She complained of nervousness and headaches. She was also very sensitive. She found it hard to cope with the fact that her son, who was obviously her one and only interest in life, was such an odd child and did so badly at school. She constantly tried to take his side against the school and fought desperately against a transfer into a special school for retarded children.

The rest of the family was said to be without any special peculiarities, the information being given with some reticence.

Appearance and behaviour

Ernst was tall (a 2cm above average), very thin and delicate. His posture was slack, and his shoulders drooped. The face was handsome with finely chiselled features, marred only by large, sticking-out and somewhat misshapen ears.He was particularly vaso-labile, that is, when embarrassed or excited, there were bright red blotches on his face, sharply outlined, and big sweat drops on the ridge of his nose.

Again, the eye gaze was highly characteristic, far away and unfocused. The eye did not seem to grasp anything and was vaguely aimed into the distance. Mainly for this reason the boy looked as if he had just ‘fallen from the sky`. His voice too fitted in with this. It was high, slightly nasal and drawn out, roughly like a caricature of a degenerate aristocrat (for example, the immortal Graf Bobby). [33]

It was not only his voice but his speech too which conveyed the impression bordering on caricature. Ernst talked incessantly, regardless of the questions he was being asked. Everything he did was accompanied by elaborate explanations. He constantly justified why he did something in a particular way. He had to tell others at once whatever it was that captured his attention, whether or not the remark was relevant to the situation. Some of these ‘asides’ were quite remarkable, not only in the sense that they were very adult in diction, but also because they showed good observation.

His practical skills, in sharp contrast, were highly inadequate. Even the simplest demands foiled him. He could recite in minute detail all the things he was doing when getting up and getting dressed in the morning, but in fact he was always forgetting or confusing things. While he could recite the theory, on a practical level his inadequacy was only too obvious.

In a group, which is meant to follow a common command, he behaved impossibly badly, especially in PE lessons. Ernst always stuck out from the group. This was not only because he was clumsy from a motor point of view but, above all, because he had no notion of discipline or appeal. He was a nuisance when he complained or was hurt, lust as much as when he started to talk unconcernedly: ‘Oh yes, I’ve got it, l know it already’.

To the very end of his stay on the ward he remained a stranger, walking between the other children without ever properly taking part in their games. At most, he would tell off one or other of them, or suddenly start a furious fight, either for no apparent reason or because somebody had teased him. Of course he was the perfect target for teasing, indeed, his whole demeanour was designed to provoke teasing. He was quite a spiteful boy, who pinched and pushed children secretly and spoiled their games. When the smaller children or the teacher were upset about this, he was only spurred on to further mischief.

He made life hard for himself by his awkwardness and endless hesitations. If something was only slightly different from the way that he had imagined it or from what he was used to, he was upset and confused and would go into long tirades.It was very difficult for the teacher to put a stop to this. He also tortured himself with his obsessive pedantries. For example, he had wanted a pullover for Christmas, but because this wish could not be granted, he was given a particularly nice shirt and some toys as well. He was inconsolable over this ‘incorrectness’. He never even looked at the other presents, and was unhappy over the whole Christmas period. [34]

Intelligence and attainment testing

Apt as his remarks might have been occasionally, Ernst’s whole behaviour spoke of such disturbed adaptation that we did not expect him to perform well on an IQ test. This was indeed the case.

Ernst lacked concentration to a high degree. This was not because he was distractible from outside (passive attention), but because his active attention was disturbed. It was typical that during testing he seemed either to be somewhere else or as if he had just fallen from the sky. He was clearly not tuned in for proper responding and was clueless on most of the test questions. Thus he only managed a very poor performance even when one held him down long enough by look or by word.

Very characteristic again was the performance on the similarities subtest. Here are some examples:

FLY/BUTTERFLY ‘The fly has wings like glass. From the wings of the butterfly you can make silk [this apparently referred to the silky shine]. They are colourful. The butterfly, when it gets colder goes down, and in the spring he turns into a caterpillar and then again a butterfly, first he is a cocoon and this is all silvery.’ Then he talked about some events that had happened to him involving moths in his room and worms in the soup, which had nothing to do with the question.’

RIVER/LAKE ‘In the river the water flows, and in the lake it stands still, and on the top is green slime.

WOOD/GLASS 'Glass breaks more easily and wood doesn't. Glass is a mass, wood is sappy and damp. It has marrow in the middle. Wood burns to ash, glass stretches apart then melts.’

STAIRS/LADDER ‘The ladder is leaning like this, and die stairs go like that, and up there like this [be draws steps by gesture]. The stairs have a kind of surface for treading on, the ladder has rungs.’

CHILD/DWARF ‘The dwarf is small, the child big. The dwarf looks completely different. It has a pointed hat, but this is red. The child has a bonnet.’

Again, we found the peculiar signs of ‘autistic intelligence’. Performance was best when he gave a spontaneous response, worst when he had to reproduce learnt material or do something in a prescribed manner. His knowledge of the world arose mainly out of his own experience and did not come from learning from others. This is, of course, precisely what makes the achievements of autistic people so often particularly original and delightful.

With the less able children, who are much more disturbed, however, the answers are not so much valuable as deviant. The bits of knowledge that they gain accidentally from their own experience often miss the point. This is the same with their language. In the favourable ease, we can often obtain especially apt and original verbal expressions. In the unfavourable case, however, the expressions tend towards neologisms and are often more abstruse than delightful.

With Ernst K. the negative aspects outweighed the positive ones, especially if we consider that he was a good half-a-year older than Harro L. His performance on similarities was by far the best he managed on the test, demonstrating as it did his independent powers of observation and experience.

On the other tests, especially the school attainment tests, we could see the reverse side of ‘autistic intelligence’. If somebody can only experience in an original way, and if he can only be ‘his own self’ rather than feel himself to be an integral part of the world - in other words, if he is nor engaged in constant interaction - then he is unable to learn. He cannot assimilate the ready-made knowledge and skill that others present to him. He is also unable to build up ‘automatic programmes’ through practice and habit.

All autistic individuals, therefore, have their characteristic difficulties of automatisation. The cleverest among them can overcome their difficulties in the end by dint of sheer intellect. The more disturbed ones fail at school to a far worse extent than one would expect on the basis of their formally tested intelligence.

Ernst belongs among these unfavourable cases. In all school subjects his performance was miserably poor. He could do arithmetic only with continuous concrete presentation. He did, however, count on his Fingers quite skilfully and quite fast, so that occasionally he was able to simulate a competence that he did not have.

His reading was very slow. He often confused letters and had the greatest difficulty in blending letters together. His comprehension of written text was, perhaps, slightly better. His most blatant failure was in writing. Like almost all autistic individuals, this motorically clumsy boy had atrocious handwriting. The pen did not obey him, it stuck and it spluttered; he corrected without concern for appearance and would simply write new letters on top of the old ones; he crossed out, and his letters varied in size.However, this was not the worst aspect of his writing. Even when copying - where he drew letter by letter with painful effort — he would make many spelling mistakes. In dictation, one could hardly recognise what the words were meant to be; letters were omitted, inserted, or put in the wrong order, and some could not be recognised at all.

On the basis of his performance, it was hard to understand how the boy could have advanced after the First school year to a higher form. The reason probably lies in his habit of constantly asking questions and talking about things that occasionally sounded quite clever. Thus, on the surface, his difficulties were disguised.

One could readily imagine that a teacher might have considered the boy to be essentially quite bright from the way he talked and would try to explain away his poor performance. The teacher might have blamed lack of attention and also considered that he did not yet know his pupil well enough after only a year at school, and, of course, he would have hoped for improvement.

It had become clear during testing that the boy’s spelling deficiency was caused mainly by his inability to segment words into letters. He was unable to understand the structure of a word in terms of its individual elements. [35] Therefore we used the whole word method, leaving aside phonics, as an experiment when teaching him. However, when he had to read and write words in this fashion, this too proved extremely slow and tedious.

Besides his specific learning difficulties, there were, of course, his general learning difficulties which resulted from his contact disturbance. Nevertheless, it was possible to demonstrate that the boy made some progress. The personal effort put in by the teacher was immense. Of course Ernst had to he taught individually, since it would have been impossible to get him to concentrate on his work in a bigger group.

It was clear that the boy could not progress satisfactorily in a normal school, and that transfer to a special school was inevitable, However, since the mother considered such a transfer terribly degrading for her child, we tried the normal primary school again.

Now, two years later, he attends the third class of the special school, and he certainly does not count among their best pupils. Indeed, he finds me school much harder than the typical special school pupil, who has difficulties with abstract thinking but can readily acquire the practical skills of everyday life.

It was quite difficult to decide whether Ernst was particularly able or mentally retarded, but there are numerous unequivocally retarded people who show the typical and unmistakable characteristics of autistic psychopathy: the disturbance of contact, with the typical expressive phenomena in terms of glance, voice, mimics, gesture and movement, the disciplinary difficulties, the malice, the pedantries and stereotypies, the automaton-like nature of the whole personality, the lack of ability to learn (to acquire automatic programmes), juxtaposed with relatively superior spontaneous performance.

Indeed, in the mentally retarded autistic individual the impairments just mentioned are usually even more striking, since there is no counterweight of otherwise normal functions. [36]

In a reasonably sized out-patient population such cases are not particularly rare, and they are instantly recognisable to the experienced clinician. Anybody who knows such cases will immediately think of the remarkable similarity to personality disorders with an organic cause. These are disorders which are unequivocally caused by brain damage, possibly due to birth injury or to encephalitis in early childhood.

Both of these clinical phenomena result in the same disturbances · whether in terms of pathological anatomy or in terms of function. Characteristic stereotypies in particular are common to both the autistic and the brain-injured retarded child; for example, hopping, fidgeting, whirling, spinning of objects (often with surprising skill) or rhythmic rocking (for instance, of the upper body).

In both groups we find a primitive spitefulness which, even with the severely retarded individual, often has the appearance of real cunning, since these children seem to sense whatever it is that might he the worst thing at any particular moment. In fact, parents often consider this ability to be proof of their child’s intelligence. Water supplies in the house are particularly popular targets for mischief (and one can indeed do a lot of it there!), but equally popular is throwing things out of windows, even when these are opened only for an instant.

Then there is the instinctive aggression which is characteristic of both clinical groups, shown frequently in pinching, biting and scratching. Brain-injured patients often distinguish themselves by masterful spitting, especially if they have plenty of material due to hyper-salivation!

In short, the disturbance of contact which we have already described in autistic children with this characteristic features can be found in a very similar form in many post-encephalitis cases.

It is often not easy to differentiate diagnostically whether, in such cases, the disturbance is constitutional (that is, autistic psychopathy), or a sequel to acquired brain damage. Important factors to consider are family history, birth history, presence of high fever with dizziness, sleepiness, vomiting, fits at any time, and other neurological symptoms.

Among these are signs or hints of spastic paresis such as dysarthtic speech, stuttering, oculomuscular symptoms, strabismus, vegetative signs such as increased salivation (in out experience, hardly ever absent in the brain-injured), increased eye brilliance (which, together with some other elusive features, forms the basis of the ‘encephalitic glance’) and profuse sweating.

Lastly, there are endocrine disturbances, in particular, obesity. It is increasingly believed that endocrine disturbances are caused by primary cerebral disturbances, in particular, disturbances of the hypophysis. With endocrine disturbances go certain trophic disturbances such as double-jointedness, especially of the fingers, or a particular prominence of the middle of the face. The alveolar appendices can become enlarged and coarse, and the gums become hypertrophic. These signs are particularly striking when they are seen in children who earlier were of an elfin beauty. Three, four or five years after encephalitis, they have a badly misshapen face. As an example, another case will be described briefly.

Continue reading: Autism in Childhood - Part Six

31. As in the case of Harro L., the information given does not tell us if Ernst himself believed his fantastic stones to be true or ii he was aware that they were not and told them deliberately to mislead his mother.

32 This observation clearly relates to the phenomenon which Kanner calls insistence on sameness, and which he believes to be a cardinal symptom of autism. Asperger observes but does not particularly focus on this symptom.

33 Graf Bobby, the butt of popular jokes in German-speaking countries and particularly in Austria, is a refined aristocrat who constantly finds ordinary events incomprehensible. This image of the gentle innocent may well have been inspired by the existence of able autistic people.

34 By the examples he gives Asperger implies deeper links between insistence on sameness, obsessive pedantry, narrow preoccupations and tenaciously held ideas.

35 Asperger here describes a problem that is strongly suggestive of classic dyslexia, a disorder marked by severe problems in phonome segmentation (see Snowling (1987) for a detailed discussion). It is not known as yet whether dyslexia co-occurs with autism more than one would expect by chance.

36 Asperger’s claim that autistic features are even more striking in retarded individuals than in those of normal intelligence is important to note. His clinical picture of autism is not limited to able children alone.