Autism in Childhood - Six

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 Six
Hellmuth L.

This boy is the fourth child of his parents, who are themselves without any peculiarities. He was born seven years after the third child, when the mother was forty-one years old. He had severe asphyxia at birth and was resuscitated at length. Soon after his birth he had convulsions, which recurred twice within the next few days, but have not since.

His development was delayed and he started walking and talking towards the end of his second year. However, he then learnt to speak relatively quickly, and even as a toddler he talked ‘like a grown up’ He was always grotesquely fat, despite a strict, medically supervised diet. He gained weight without having a big appetite.

When we met him six years ago, at the age of eleven, he had distinctly formed 'breasts and hips‘ He has remained thus up to now (we have recently seen him again). He had bilateral cryptorchidism (for about a year he had been masturbating a good deal).

The boy had been treated with hormone preparations, especially thymus and hypophysis preparations, since his early childhood but without any effect on his condition. He was double-jointed to a high degree.

When one shook his hand, it seemed as if it had no bones and were made of rubber. He had knock knees and flat feet. He had noticeably increased salivation, and when he talked one could hear the saliva bubbling in his mouth.

His appearance was grotesque. On top of the massive body, over the big face with flabby cheeks, was a tiny skull. One could almost consider him microcephalitic. His little eyes were closely set together. His glance was lost and absent but occasionally lit up with malice. As is to be expected from his whole appearance, he was clumsy to an extraordinary degree.He stood there in the midst of a group of playing children like a frozen giant. He could not possibly catch a ball, however easy one tried to make it for him. His movements when catching and throwing gave him an extremely comical appearance. The immobile dignity of the face which accompanied this spectacle made the whole even more ridiculous.

He was said to have been clumsy in all practical matters from infancy, and has remained so ever Listening to the boy talking, one was surprised how clever he sounded. He kept his immobile dignity while speaking and talked slowly, almost as if in verse, seemingly full of insight and superiority. He often used unusual words, sometimes poetical and sometimes unusual combinations. This was consistent with an interest in poetry as reported by the mother.

He clearly did not have any feeling for the fact that he did not really fit into this world. Otherwise he would not have shown off in his peculiar way, especially not in front of other children. It was not surprising, then, that he was continuously taunted by other children who ran after him in the street. Of course, he could never do anything to his fleet-footed tormentors, becoming only more ridiculous in his helpless rage. This was the reason the mother had arranged for him to be taught privately over the last school years. He managed, surprisingly, to attain the fifth grade of primary school.

His school knowledge was very uneven. He was an excellent speller and never made mistakes. He also had quite a good style. On the other hand, his arithmetic was very poor, not only in terms of the mechanical aspects, but also when problems were presented in verbal form.

One noticed the degree of his disability and his ignorance of worldly things when questioning him about ordinary matters of everyday life. This was where he failed abysmally, giving empty, pompous sounding answers. The mother was quite right when she said that he was always ‘in another world'. However, this did nor prevent him from doing a lot of malicious things to the people he lived with and to other children. He enjoyed hiding or destroying objects, especially when he was little.

He was reported to have been pedantic from earliest childhood, for instance, he created scenes when something was occasionally placed in a slightly different position from usual. In everything he did, it was said he had his particular rituals. He was especially concerned with his clothes , did not tolerate a grain of dirt on them, washed his hands very frequently and observed his body and its functions very closely. His pedantries tyrannised the household and he was in general very difficult to cope with. [37]

Much of his description is reminiscent of the earlier cases. This boy was ‘an autistic automaton’, impractical and instinctually disturbed. His relationships with the outside world were extremely limited.He did not have any genuine human relationships, was full of pedantries and also showed spiteful behaviour.

In Hellmuth’s case there were clear indications that his autism was due to brain injury at birth. His medical history - asphyxia, fits, endocrine disorder, hyper-salivation, neurologically based apraxia — clearly pointed to an organic cause.

We can therefore draw the preliminary conclusion that there are cases where an organic disorder can result in a picture that, in numerous critical points, is closely similar to the picture presented by ‘autistic personality disorder’ of constitutional origin. [38]

The Clinical Picture of Autistic Psychopathy

Instead of describing further cases in detail, let us work out the typical characteristics that autistic children have in common. The information we draw on comes from all our cases, but, as expected with any typological approach, not every case has every feature. Nevertheless, those who know such children never cease to be surprised at the striking coincidences of detail.

The autistic personality is highly distinctive despite wide individual differences. Our method would have failed if it ignored the differences and if it let each child’s unique personality vanish behind the type.

Autistic individuals are distinguished from each other not only by the degree of contact disturbance and the degree of intellectual ability, but also by their personality and their special interests, which are often outstandingly varied and original.

A crucial point which makes clear that the autistic personality type is a natural entity is its persistence over time. From the second year of life we find already the characteristic features which remain unmistakable and constant throughout the whole life-span. [39]

Naturally, intelligence and personality develop and, in the course of development, certain features predominate or recede, so that the problems presented change considerably.

Nevertheless, the essential aspects of the problem remain unchanged. In early childhood there are the difficulties in learning simple practical skills and in social adaptation. These difficulties arise out of the same disturbance which at school age cause learning and conduct problems, in adolescence job and performance problems, and in adulthood social and marital conflicts. Thus, apart from its distinctiveness, it is its constancy which makes autism a highly recognisable entity.

Once one has properly recognised an autistic individual one can spot such children instantly.They are recognisable from small details, for instance, the way they enter the consulting room at their first visit, their behaviour in the First few moments and the first words they utter. [40]

Physical Appearance and Expressive Characteristics

Autistic children lose their baby features very quickly. Instead of a chubby, soft and undifferentiated baby face, they have highly differentiated, finely boned features. They can be of almost aristocratic appearance, possibly somewhat degenerate, Their early thoughtfulness has formed their faces. The furrowed brow betrays the introspective worrier. [41]

The characteristic peculiarities of eye gaze are never absent. It is not only poets who know that the soul lies in the eyes. From the first moment when an infant can properly ‘look’, that is, from the third month of life, and well before there is any verbal expression, the majority of his social relations are based on eye gaze. [42]

How the small child drinks in the world with his eyes! With his eyes he grasps things and expresses his feelings in a much less inhibited way than the adult, who has learnt to distance himself and to hide his feelings.

With our children here, there is at fundamental difference. Hardly ever does their glance fix brightly on a particular object or person as a sign of lively attention and contact. [43]

One can never be sure whether their glance goes into the far distance or is turned inwards, just as one never knows what the children are preoccupied with at a particular moment or what is going on in their minds.

The disturbance is particularly clear when they are in conversation with others. Glance does not meet glance as it does when unity of conversational contact is established. When we talk to someone we do not only ‘answer’ with words, but we ‘answer’ with our look, our tone of voice and the whole expressive play of face and hands. A large part of social relationships is conducted through eye gaze, but such relationships are of no interest to the autistic child. Therefore, the child does not generally bother to look at the person who is speaking.

The gaze goes past the other person or, at most, touches them incidentally in passing. However, autistic children do not look with a firmly fixed glance at anything, but rather, seem to perceive mainly with their peripheral field of vision. Thus, it is occasionally revealed that they have perceived and processed a surprisingly large amount of the world around them.

There is one situation, however, in which the eye gaze of these children becomes extremely expressive; their eyes light up when they are intent upon some malicious act, which is then perpetrated in an instant.

It will have become obvious that autistic children have a paucity of facial and gestural expression. In ordinary two-way interaction they are unable to act as a proper counterpart to their opposite number, and hence they have no use for facial expression as a contact-creating device.

Sometimes they have a tense, worried look. While talking, however, their face is mostly slack and empty, in line with the lost, faraway glance. There is also a paucity of other expressive movements, that is, gestures. Nevertheless, the children themselves may move constantly, but their movements are mostly stereotypic and have no expressive value. [44]

Next in importance to eye gaze as a channel for expression is language. [45] As we saw with our first case, Fritz V., language expresses interpersonal relationships as much as it provides objective information.

Affect, for instance, can be directly expressed in language. We can hear from the tone of voice what relationship people have to each other, for instance superior and subordinate, and whether they are in sympathy or antipathy. This is regardless of the often deceptive content of the words themselves. It is this aspect of language which tells us what someone really thinks. In this way the perceptive listener can get behind the mask. He can tell from an individual’s expressions what is lie and truth, what are empty words and what is genuinely meant.

It is impossible to list all that can be revealed in volume, tone and flow of speech since these aspects are as varied as the human character. In any case, we do not intellectually understand many of these qualities and can only feel them intuitively. [46]

Again, it will come as no surprise that contact-creating expressive functions are deficient in people with disturbed contact, If one listens carefully, one can invariably pick up these kinds of abnormalities in the language of autistic individuals, and their recognition is, therefore, of particular diagnostic importance.

The abnormalities differ, of course, from case to case. Sometimes the voice is soft and far away, sometimes it sounds refined and nasal, but sometimes it is too shrill and ear-splitting. In yet other cases, the voice drones on in a sing-song and does not even go down at the end of a sentence. Sometimes speech is over-modulated and sounds like exaggerated verse-speaking.

However many possibilities there are, they all have one thing in common; the language feels unnatural, often like a caricature, which provokes ridicule in the naive listener.One other thing; autistic language is not directed to the addressee but is often spoken as if into empty space. This is exactly the same as with autistic eye gaze which, instead of homing in on the gaze of the partner, glides by him.

In a wider sense, the choice of words too must be considered among the expressive functions of language. This will become clear in the following section.

Continue reading: Autism in Childhood - Part Seven

37 These examples are again reminiscent of Kanner‘s insistence on sameness.

39 This important statement, that symptoms are present from the second year of life, is so well buried in the text that it has often been overlooked. Instead the belief has persisted that Asperger‘s cases show normal development, especially in language, up to three years or later.

40 A good example of give-away behaviour in the First few moments of an encounter with an autistic child is given by Kanner (1943) in his notes on Donald: ‘An invitation to enter the office was disregarded but he had himself led willingly. Once inside, he did not even glance at the three physicians present . . . but immediately made for the desk and handled papers and books.’

41 In his later textbook (1952) Asperger stresses that the appearance of autistic individuals varies greatly. The aristocratic appearance he emphasises here is not a general feature of autistic people. While many writers have commented on the beauty of young autistic children, few also mention that even captivating beauty can be lost in adolescence and adulthood.

In early and middle childhood, an unchildlike, self-absorbed and socially disinterested demeanour, combined with childlike symmetrical features, may result in Asperger’s attractive image of the little prince.

42 In normally developing children socially motivated gaze can be observed in the first year of life ie, at it is as yet not clear whether it is absent in autistic babies. Since autism cannot be reliably diagnosed before the age of two or three, direct observations are hard to come by .

43 Asperger's conclusion that the peculiar pattern of gaze in autistic individuals is due to the short and fleeting nature of the glance, noting equally briefly on people as on things, is remarkable since, for decades, many professionals have held the belief that autistic children deliberately avoid looking at people. The idea of gaze avoidance may be partly responsible for the misunderstanding of autism as a state of withdrawal from social contact. Earlier awareness of Asperger`s work might have prevented this misconception.

44 While Kanner rarely mentions poverty of expression in autistic children, Asperger goes into great detail to convey the nature of this to him essential symptom of autism. It may he that the disturbance of expressive functioning that Asperger highlights is more striking in cases with fluent language and paradoxically poor communication.

45 Asperger addresses and anticipates here that aspect of language we now know as pragmatics. It is well established that autistic individuals have a specific failure in pragmatics, that is, in the use of language. This is true even it their speech is otherwise linguistically sophisticated.

46 In Asperger’s remarks about expressive functions the influence of Ludwig Klages (for example, 1936) is strongly evident. Klages was a widely read author of the time who attempted to find a scientific basis for character-reading from phenomena observed in each person’s style of behaviour. Target behaviour included voice, movement, facial expression and also handwriting.

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