Autism in Childhood - Four

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 Four

Harro L.

Our second case is a boy who also shows the main characteristics of autism in highly typical form, except that the relationships to the outside world are not as severely disturbed as in our first case. Instead, the positive aspects of autism become more obvious: the independence in thought, experience and speech.

This eight-and-a-half-year-old boy was referred to us by his school as unmanageable [20] He was in his third year at school, but was repeating the second year because he had failed in all subjects. [21] The teacher believed that he “could if he only wanted to”. Occasionally, he made surprisingly clever remarks of a maturity way beyond his age.

On the other hand, he often refused to cooperate, sometimes using bad language, for example, “this is far too stupid for me”, which threatened to undermine the discipline of the whole class. He hardly ever did his homework.

Worse still were his conduct problems. He rarely did what he was told but answered back and with such cheek that the teacher had given up asking him so as not to lose face in front of the class. On the one hand, Harro did not do what he was supposed to do, on the other, he did exactly what he wanted to do himself and without considering the consequences. He left his desk during lessons and crawled on the floor on all fours.

One of the principal reasons for his being referred by the school was his savage tendency to fight. Little things drove him to senseless fury, whereupon he attacked other children, gnashing his teeth and hitting out blindly. This was dangerous because he  was not a skilled fighter. Children who are skilled fighters know exactly how far they can go and can control their movements so that they hardly ever cause real trouble. Harro was anything but a skilled fighter, and since he was very clumsy, could not control his movements and had no idea where to aim, he often allegedly caused injury to others. He was said to be extremely sensitive to teasing, and yet in many ways, with his strange and comical behaviour he directly provoked teasing.

He was said to be an inveterate “liar”. He did not lie in order to get out of something that he had done - this was certainly not the problem, as he always told the truth very brazenly - but he told long, fantastic stories, his confabulations becoming ever more strange and incoherent. [22]

His early independence in certain things was outstanding. Since his second school year, that is, since he was only seven years old, he had travelled alone by train to school in Vienna. His parents lived in a village approximately 25 km from Vienna. The father, who wanted his son to have better opportunities, disdained the village school and therefore sent him to school in Vienna.

On a more unpleasant note, Harro also showed his social unconcern in sexual play with other boys, allegedly going as far as homosexual acts and coitus attempts.

From the family history, we note that Harro was an only child. He was a forceps delivery, but no disturbances were observed that might relate to any birth injury. His mental and physical development was unremarkable. As a small child, he was supposed to have been perfectly ordinary, except that his stubbornness and independence were evident very early.

The father, who brought the child to us, was a strange man, and very similar to his son. He appeared to be something of an adventurer. He originally came from Siebenburgen (Transylvania) and during the First World War, under great danger from the Romanian army, fled to Austria via Russia. By profession he was a painter and sculptor, but out of financial necessity he was making brooms and brushes.While there was severe unemployment at the time we saw the boy, the contrast of the two jobs was certainly striking. The father, who himself comes from peasant stock, is a typical intellectual. He professed to be completely and painfully self-taught. One could make out from what he said that he had nothing to do with anyone in the village where he lived and where he must have been considered highly eccentric. He said himself that he was nervous and highly strung but that he controlled himself to such an extent that he appeared to be indifferent.

The mother, whom we never saw (we felt that the father did not want us to see her) was also supposed to be highly strung. In both the father’s and mother’s families there were said to be many highly strung people. No more details were obtained.

Appearance and expressive characteristics

Harro was a rather small boy, 4 cm below average in height, and of stocky and muscular build. His arms and legs looked as if they were too short for his body. In some ways, he looked like a miniature adult, especially since his facial features were very mature.

His typically lost gaze was often far away. Sometimes he appeared to be in deep thought, then he would draw together his brows and assume a strange, slightly funny dignity. His posture too was odd. He stood broadly, arms held away from the body, as a portly gentleman or a boxer might do. He had few facial expressions and gestures. His dignified seriousness was only rarely interrupted, for instance, when he secretly laughed to himself. It was usually impossible to make our what had struck him as funny at that moment.

His voice fitted this picture well. It was very deep and appeared to come from very far down, in the abdomen. He talked slowly and in a deadpan way without much modulation. He never looked at his interlocutor while talking. His gaze was far away. With a tense, even cramped, facial expression, he tried to formulate his thoughts. In this, he succeeded remarkably well.

He had an unusually mature and adult manner of expressing himself, not, as one occasionally sees in children, by using ready-made copied phrases, but drawn from his own quite unchildlike experience. It was as if he coined each word to fit the moment. Often he did not respond to questions but let his talk run single-mindedly along his own tracks.

He could describe his own experiences or feelings with an unusual degree of introspection. He could look at himself as a detached critical observer (‘I am dreadfully left-handed’). [23] Although he was aloof from things and people or perhaps because of this - he had rich experiences and his own independent interests. [24]

It was possible to talk to him as to an adult, and one could really learn from him. This phenomenon is well demonstrated by his behaviour during intelligence testing, as described below.

Intelligence testing

First, some general remarks about the testing methods that we use in our department. The main difference from traditional testing (for example, the Binet test, from which we have taken some subtests) is that we use a clinical approach where we are not interested merely in the passing and failing of single tests but, instead, in the qualitative aspects of performance.

First we score the performance according to the level reached, and represent this graphically to obtain a test profile. In this way, one can see the discrepancies between the performances in various tests, which would otherwise have been submerged in the overall IQ score. [25] More importantly, we observe how the child solves various problems, his method of working, his individual tempo, his concentration and, above all, his ability to relate and communicate.

We adapt the way we test according to the personality of the child, and we try to build up good rapport. Of course, every good tester would do this anyway. Thus, it is important to help the anxious, inhibited child who lacks self-confidence, for example, by starting off the task for him or by helping hint along. The chatty and hyperactive child, or the child who does not keep a distance, on the other hand, has to he restrained and somehow made to do the required work. Obviously, any help given needs to be taken into account later when scoring, which is not easy.

We also try to find out what special interests each child may have. We always let the children produce something spontaneously, and we let them expand on their responses by asking more questions. If there is a particular failure or if there are specific problems on some subtest, then we ask questions that are not part of standard procedure until we have clarified the reason for the difficulty.

This method of testing demands much greater experience than schematically laid down methods with rigid scoring. However, if carried out well, it can tell us not only about the intellectual ability of the child, but also about important personality functions.

It was almost as difficult to carry out the testing with Harro as it was with Fritz. Very often, he shut off completely when a question did not interest him. Sometimes he did not seem to hear the question. A lot of energy went into simply making him do the tasks. Again and again he went off on a tangent and had to be brought back. However, once his attention was engaged, his performance could he remarkably good.

Any tests that did not yield anything of special interest will be omitted, hurl will describe in detail the results of the similarities subtest. Here, where Harro was able to produce answers spontaneously, he became lively and interested, and one even had to cut him off, since he threatened to go on for ever.

TREE/BUSH ‘The bush, that is where the branches grow straight off the ground, completely tumbled up, so that it can happen that three or four cross over each other, so that one has a knot in one’s hand. The tree, that is where there is first a stem and only then the branches, and not so jumbled up, and rather thick branches. This happened to me once, that is where I cut into a bush, I wanted to make myself a sling, I cut off four branches and then  I have an eight part knot in my hand. This comes when two branches rub against each other, then there is a wound there, then they grow together.’

STAIRS/LADDER ‘Stairs are made out of stone. One doesn’t call them rungs, they are called steps, because they are much bigger, and on the ladder they are thinner and smaller and round. It is much more comfortable on the stairs than on the ladder.’STOVE/OVEN ‘The stove is what one has in the room as a firebringer (!) and the oven is where you cook something.’

LAKE/RIVER ‘Well, the lake, it doesn’t move from its spot, and it can never he as long and never have that many branches, and it always has an end somewhere. One can‘t compare at all the Danube with the Ossiach Lake in Corinthia- not in the least little bit.’

GLASS/WOOD ‘Glass is transparent. Wood, if you wanted to look through it, you would have to make a hole in it. If one wants to beat on a piece of wood then one has to beat a long time until it breaks, unless it‘s a dry twig. Then that would break easily. With the glass you need to hit only twice and then it’s broken.’

FLY/BUTTERFLY ‘The butterfly is colourful, the fly is black. The butterfly has big wings so that two flies could go underneath one wing. But the fly is much more skilful and can walk up the slippery glass and can walk up the wall. And it has a completely different development! [Now he becomes over-enthusiastic, talks with exaggerated emphasis.] The fly mother lays many, many eggs in a gap in the floorboards and then a few days later the maggots crawl out. I have read this once in a book, where the floor talks - I could die laughing [!] when I think of it - what is looking out of this little tub? A giant head with a tiny body and a trunk like an elephant? And then a few days later they cocoon themselves in and then suddenly there are some dear little flies crawling out.

And then the microscope explains how the fly can walk up the wall: rust yesterday I saw it has teeny weeny claws on the feet and at the ends tiny little hooks; when it feels that it slips, then it hooks itself up with the hooks. And the butterfly does not grow up in the room as the fly does. I have not read anything about that and I know nothing about it (!), but I believe (!) that the butterfly will take much longer with his development’.

ENVY/MEANNESS ‘The mean one has something and doesn’t want to give it away, and the envious one wants to have what the other one has’. [26]

School attainment tests

Since most children who come to us for observation also have learning difficulties, we frequently use scholastic attainment tests. Naturally, we are aware of environmental influences here, for example, neglect of educational needs, Incidentally, when do environmental influences not play .1 role where test performances are concerned? It is a grave error to think that the responses to Binet tests come entirely from within the child and show no environmental effects!

READING He read a story shoddily and with errors. However, one could notice clearly that he read for meaning and that the content of the stony interested him. He wanted to read faster than he was able to and for this reason was not very accurate. As this observation suggests his reading comprehension was excellent. He could reproduce what he had read in his own words, and he could say what the moral of a story was even though the moral was not explicitly presented in the text (the fable of the fox who was punished for his vanity).

WRITING TO DICTATION His handwriting, as to be expected from his general clumsiness, was very poor. He carried on writing carelessly and messily, crossing out words, lines going up and down, the slant changing. His spelling was reasonably accurate. As long as his attention was focused on a word, he knew how to spell it. It was very significant, then, that he made more spelling errors when copying than at dictation, Really, one would expect that copying should not present any problems at all, since, after all, the word was there in front of him; but this very simple and straightforward task simply did not interest him.

MATHEMATICS Here his ‘autistic originality’ was particularly evident. A few examples:

27 and 12 equals 39. He spontaneously explained how he had worked this out: ‘2 times 12 equals 24, 3 times 12 equals 36, I remember the 3 [he means 27 is 3 more than 2 times 12], and carry on.’

58 plus 34 equals 92. ‘Better: 60 plus 32, I always go for the tens.’

34 minus 12 equals 22. ‘34 plus 2 equals 36, minus 12 equals 24, minus 2 equals 22, this way I worked it out more quickly than any other.’

47 minus 15 equals 32. 'Either add 3 and also add 3 to that which should be taken away, or first take away 7 and then 8.

'52 minus 25 equals 27. ‘2 times 25 equals 50, plus 2 equals 52, 25 plus 2 equals 27.’

A word problem (consider that the boy was only eight-and-a-half years old, and was only in the second year of the primary school!)

A bottle with a cork costs 1.10 schillings, the bottle costs just one more schilling than the cork, how much does each cost? After five seconds he gave the correct solution and explained when asked; ‘When a bottle costs 11 schilling more, then you have to leave one schilling aside, and something of the 10 groschen still needs to be left, so I have to divide by 2, so the cork costs 5 groschen and the bottle costs 1 schilling and 5 groschen.'

Fascinating as his mastery of numbers may be, we can nevertheless see the disadvantages of his original methods. They were often so complicated - however ingenious - that they resulted in errors. To use the conventional methods that are taught at school, for example, starting with tens and then units when subtracting, did not occur to Harro.

Here we come to an important insight: in autism there is a particular difficulty in mechanical learning, indeed there is an inability to learn from adults in conventional ways. Instead, the autistic individual needs to create everything out of his own thought and experience. More often than not this results in defective performance, even in the more able autistic individuals.

In this way we can explain why such a bright boy as Harro was unable to attain the end of his form year and had to repeat it. Of course, in school he was more difficult than during individual testing, where we made allowances for his problems and provided an opportunity for him to give spontaneous and original answers. On the ward too, we were able to observe how much worse his performance was when he was taught in a group. Being taught in a group, of course means that everybody has to pay attention and do what the teacher asks.

Harro could do neither of these. His mind wandered off on his own problems and he would not know what the lesson was about. He took away from the lesson only those things for which he had a particular affinity and could think about in his own way. According to the school report he hardly ever knew what homework he had to do, and could not therefore do the appropriate work at home despite the father’s efforts. It is not surprising, then, that in the previous year he had not been able to advance to the next form despite his undoubted ability which was recognised by the school. [27]

Behaviour on the ward and educational treatment

The peculiarities of Harro’s behaviour can all be explained in terms of his contact disturbance, that is, his extremely limited relationship to his environment. Through the length of his stay on the ward he remained a stranger. One would never see him join in a game with others. Most of the time, he sat in a corner buried in a book, oblivious to the noise or movement around him. Usually, of course, such fanatical reading is rare before the age of ten.

The other children found him odd and he became an object of ridicule because of the way he looked and the ‘dignity’ that went with it (children are particularly sensitive to this!). Nevertheless, they treated him with a certain shyness and respect, and with good reason. Any teasing by other children was trier with brutal and ruthless aggression. He did not see the funny side of things and lacked any sense of humour, especially if the joke was on him.

He could he shamelessly recalcitrant when disciplinary requests were made. He always answered back, for example, ‘l wouldn’t even dream of doing this’. Even if he happened to be temporarily impressed by the teacher‘s authority, he would at least grumble to himself.

Harro did not form any close relationships, either with another child in the ward or with an adult, His interest could be engaged, and then it could be very stimulating to talk to him. Nevertheless, he never became warm, trusting or cheerful, just as the staff could never quite warm towards him, and he never became free and relaxed.

All his movements eloquently expressed his problem. His facial expressions were sparse and rigid. With this went a general stiffness and clumsiness. Nevertheless, there were no neuropathological symptoms indicating spasticity. The clumsiness was particularly well demonstrated during PE lessons. Even when he was following the group leader’s instructions and trying for once to do a particular physical exercise, his movements would be ugly and angular.

He was never able to swing with the rhythm of the group. His movements never unfolded naturally and spontaneously - and therefore pleasingly - from the proper co-ordination of the motor system as a whole. Instead, it seemed as if he could only manage to move those muscular parts to which he directed a conscious effort of will. What was true of many of his responses in general was also true here: nothing was spontaneous or natural, everything was ‘intellectual’ [28]

Nevertheless, through patience and practice improvement was achieved in a number of practical skills. Like all autistic children, Harro was especially clumsy if not downright obstinate when it came to daily chores such as getting washed. One had to fight hard to teach him the important social habits of everyday life. The many practical skills needed in daily life present little problem to normal children. They can copy and learn them from adults with ease. This is, of course, what teachers expect.

The teacher who does not understand that it is necessary to teach autistic children seemingly obvious things will feel impatient and irritated. Autistic children cannot cope with precisely such simple matters, It is impossible to say whether this is because of motor clumsiness or because of a failure to understand. Both seem to go together. Furthermore, they are particularly sensitive about personal demands, and it is far easier to engage their interest intellectually. It is not surprising, therefore, that autistic children show negativism and malice to seemingly petty and routine demands, and that it is there that serious conflicts often arise.

How, then, should one treat these difficulties? We have already noted in the first ease that more can be achieved by ‘switching off‘ one’s affect and by using an impersonal, objective style of instruction. Here, with the more able and less disturbed Harro, we found a way which we believe to be successful with more autistic children. The boy was more amenable when a request appeared not to be directed towards him in particular, but was verbally phrased in a very general, impersonal way, as an objective law, standing above the child and the teacher, for instance, ‘One always does such and such. . .’, ‘Now everyone has to . . .’, ‘A bright boy always does...’.

Another important point is this: normal children acquire the necessary social habits without being consciously aware of them, they learn instinctively. It is these instinctive relations that are disturbed in autistic children. To put it bluntly, these individuals are intelligent automata. Social adaptation has to proceed via the intellect. In fact, they have to learn everything via the intellect. [29] One has to explain and enumerate everything, where, with normal children, this would be an error of educational judgement.

Autistic children have to learn the simple daily chores just like proper homework, systematically. With some children who admittedly were somewhat older than Harro, it was possible to achieve a relatively smooth integration by establishing an exact timetable in which, from the moment of rising at a particular time, every single occupation and duty was outlined in detail.

When such children left the hospital they were given a timetable. It was, of course, made up in consultation with the parents and adapted to the individual needs of each family. The children had to give an account of how well they followed the timetable, sometimes by keeping a diary.

They felt that they were firmly tied to this ‘objective law’. In any case, many of them have pedantic tendencies veering towards the obsessional, and it was possible to use such tendencies for this regulatory purpose.

In this way Harro too achieved better adaptation, though not without difficulty. He certainly began to respond better to the demands of group teaching. Several months after he left, we heard that he was much happier at school. Unfortunately, we have not heard from him since, as his parents, we believe, have moved.

The difficulties these children have with instinctive adaptations are, then, amenable to partial compensation through an intellectualising approach. The better the intellectual ability the more successful this approach. Now, the autistic personality is certainly not only found in the intellectually able. It also occurs in the less able, even in children with severe mental retardation. [30] It is obvious that in the latter case adaptation is much more difficult to achieve. A further case will be given as an example.

Continue reading: Autism in Childhood - Part Five

20 As in the case of Fritz V., conduct problems seem to have been the main reason for referral.

21 Failure to reach the required standard at the end of the school year resulted in

repetition. The child was placed with a younger age group going through the same syllabus again. This would have carried a stigma for the family and the child.

22 Sadly, examples of fantastic stories told by Harro are not given. In their absence iris difficult to know whether these stories were imaginative in the ordinary sense of the word, that is whether Harro was fully aware of their fictitious nature. Donald (Kanner’s first case) was also said by his mother to dramatise stories, again without examples to illustrate what was meant by this.

23 ‘Ich bin ein ganz furthterlichter’

24 Narrow social impairment included being aloof as well as odd. He showed, for instance, aggressive disrespect for teachers, and kept himself apart from his peers.

25 The examples Asperger gives of IQ test questions are chosen to illustrate the quality of the autistic child‘s way of thinking, hut they do not go beyond a clinical impression. His colleague Elisabeth Worst, in 1976, published profiles of IQ test performance which show a characteristically uneven pattern such as is generally found in autism. The nature of this pattern is discussed in Frith (1989).

26 Asperger believes that his examples of answers of the similarity questions demonstrates depth and originality of thinking. However, a striking feature of the answers is their seamless mixture of general knowledge and personal memory. Perhaps this indicates that the children had little idea of the purpose of the questions. The normal listener would realise that general questions require

general answers, and refrain from recounting specific autobiographical incidents.

27 Underachievement at school is commonly found in autistic children of both normal and high intellectual ability and this has been confirmed by recent research. For recent reviews see Gillberg (1989).

28 Almost certainly, the ideas Asperger has in mind here are those discussed in a classic work of German literature, Heinrich von Kleist's (1810) essay about the puppet theatre. Kleist contrasted the natural grace of the unconsciously moving child with the artifice of mechanical puppetry. Similarly, Asperger contrasts ‘intellectualised’ behaviour, which is formal and stilted, with spontaneous behaviour, which is naturally graceful and appealing.

29 Asperger frequently recommends learning through conscious intellectualising as the appropriate method to the education of autistic children. In the method of Heilpädagogik this form of compensatory learning would be taught only when it was clear that normal intuitive learning had failed.

30. The important insight that autism can occur at all levels of intellectual ability, including the subnormal range of intelligence, has often been overlooked, even by Asperger himself in his later papers.