Autism in Childhood - Three

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 Three

CONSTRUCTION TEST (a figure made out of sticks, and consisting of two squares and four triangles, is exposed for a few seconds and has to be copied from memory). Even though he had only half-glanced at this figure, he correctly constructed it within a few seconds, or rather, he threw the little sticks so that it was perfectly possible to recognise the correct figure, but he could not be persuaded to arrange them properly.

RHYTHM IMITATION (various rhythms are beaten out to be copied). In spite of many attempts he could not be persuaded to do this task.

MEMORY FOR DIGITS He very readily repeated six digits. One was left with a strong impression that he could go further, except that he just did not feel like it. According to the Binet test, the repetition of six digits is expected at the age of ten, while the boy was only six years old.

MEMORY FOR SENTENCES This test too could not be properly evaluated. He deliberately repeated wrongly many of the sentences. However, it was clear that he could achieve at least age-appropriate performance.

SIMILARITIES Some questions were not answered at all, others got a nonsensical answer. For instance, for the item tree and bush, he just said, ‘There is a difference’. For fly and butterfly, he said, ‘Because he has a different name’, ‘Because the butterfly is snowed, snowed with snow’; asked about the colour, he said, ‘Because he is red and blue, and the fly is brown and black’. For the item wood and glass, he answered, ‘Because the glass is more glassy and the wood is more woody.’ For cow and calf, he replied, ‘lammerlammerlammer’ To the question ‘Which is the bigger one?’ he said, ‘The cow I would like to have the pen now’.

Enough examples from the intelligence test. We did not obtain an accurate picture of the boy’s intellectual abilities. This, of course, was hardly to be expected. First, he rarely reacted to stimuli appropriately but followed his own internally generated impulses. Secondly, he could not engage in the lively reciprocity of normal social interaction, In order to judge his abilities it was therefore necessary to look at his spontaneous productions.

As the parents had already pointed out, he often surprised us with remarks that betrayed an excellent apprehension of a situation and an accurate judgement of people. This was the more amazing as he apparently never took any notice of his environment.

Above all, from very early on he had shown an interest in numbers and calculations. He had learnt to count to over 100 and was able to calculate within that number space with great fluency.

This was without anybody ever having tried to teach him - apart from answering occasional questions he asked. His extraordinary calculating ability had been reported by the parents and was verified by us.

Incidentally, we found, in general, that the parents had an excellent understanding of their child’s intellectual abilities. Such knowledge as the boy possessed was not accessible by questioning at will. Rather, it showed itself accidentally, especially during his time on the ward, where he was given individual tuition. Even before any systematic teaching had begun, he had mastered calculations with numbers over ten. Of course, quite a number of bright children are able to do this before starting school at six.

However, his ability to use fractions was unusual, and was revealed quite incidentally during his first year of instruction. The mother reported that at the very beginning of schooling he set himself the problem - what is bigger 1/16 or 1/18 and then solved it with ease. What somebody asked for fun, just to test the limits of his ability, “What is 2/3 of 120”, he instantly gave the right answer, ‘80’.

Similarly, he surprised everybody with his grasp of the concept of negative numbers, which he had apparently gained wholly by himself; it came out with his remark that 3 minus 5 equals ‘two under zero’. At the end of the first school year, he was also fluent in solving problems of the type, ‘If 2 workers do a job in a certain amount of time, how much time do 6 workers need?’

We see here something that we have come across in almost all autistic individuals, a special interest which enables them to achieve quite extraordinary levels of performance in a certain area. This, then, throws some light on the question of their intelligence. However, even now the answer remains problematic since the findings can be contradictory and different testers can come to different intelligence estimates. Clearly, it is possible to consider such individuals both as child prodigies and as imbeciles with ample justification. [17]

Now, a word about the boy’s relations to people. At first glance, it seemed as if these did not exist or existed only in a negative sense, in mischief and aggression. This, however, was not quite true. Again, accidentally, on rare occasions, he showed that he knew intuitively, and indeed unfailingly, which person really meant well by him, and would even reciprocate at times. For instance, he would declare that he loved his teacher on the ward, and now and then he hugged a nurse in a rare wave of affection.

Implications of remedial education

It is obvious that in the present case there were particularly difficult educational problems.

Let us consider first the essential prerequisites which make a normal child learn and integrate into school life, in terms not just of the subject matter taught, but also of the appropriate social behaviour. Learning the appropriate behaviour does not depend primarily on intellectual understanding. Well before the child can understand the spoken words of his teacher, even in early infancy, he learns to comply. He complies with and responds to the glance of the mother, the tone of her voice, the look of her face, and to her gestures rather than the words themselves. In short, he learns to respond to the infinitely rich display of human expressive phenomena.

While the young child cannot understand this consciously, he none the less behaves accordingly. The child stands in uninterrupted reciprocity with his care-giver, constantly building up his own responses and modifying them according to the positive or negative outcome of his encounters. Clearly, an undisturbed relationship with his environment is an essential requirement, In Fritz’s case, however, it is precisely this wonderful regulating mechanism which is severely disturbed.

It is a sign of this disturbance that Fritz’s expressions themselves are abnormal, How odd is his use of eye contact! Normally, a great deal of the outside world is received by the eye and communicated by the eye to others, How odd is his voice, how odd his manner of speaking and his way of moving! It is no surprise, therefore, that this boy also lacks understanding of other people’s expressions and cannot react to them appropriately. [18]

Let us consider this issue again from a different point of view. It is not the content of words that makes a child comply with requests, by processing them intellectually. It is, above all, the affect of the care-giver which speaks through die words. Therefore, when making request, it does not really matter what the care-giver says or how well-founded the request is.

The point is not to demonstrate the necessity of compliance and consequence of non-compliance - only had teachers do this. What matters is the way in which the request is made, that is, how powerful the affects are which underlie the words. These affects can be understood even by the infant, the foreigner or the animal, none of whom is able to comprehend the literal meaning.

In our particular case, as indeed, in all such cases, the affective side was disturbed to a large extent, as should have become apparent from the description so far.The boy’s emotions were indeed hard to comprehend. It was almost impossible to know what would make him laugh or jump up and down with happiness, and what would make him angry and aggressive. It was impossible to know what feeling were the basis of his stereotypic activities or what it was that could suddenly make him affectionate.So much of what he did was abrupt and seemed to have no basis in the situation itself. Since the affectivity of the boy was so deviant and it was hard to understand his feelings, it is not surprising that his reactions to the feeling of his caregivers were also inappropriate. [19]

In fact, it is typical of children such as Fritz V. that they do not comply with requests or orders that are affectively charged with anger, kindness, persuasion or flattery. Instead, they respond with negativistic, naughty and aggressive behaviour.

While demonstrations of love, affection and flattery are pleasing to normal children and often induce in them the desired behaviour, such approaches only succeeded in irritating Fritz, as well as all other similar children. While anger and threats usually succeed in bending obstinacy in normal children and often make them compliant after all, the opposite is true of autistic children. For them, the affect of the care-giver may provide a sensation which they relish and thus seek to provoke. “I am so horrible because you are cross so nicely”, said one such boy to his teacher.

It is difficult to know what the appropriate pedagogic approach should be. As with all genuine teaching, it should not be based primarily on logical deduction but rather on pedagogic intuition. Nevertheless, it is possible to state a few principles which are based on our experience with such children.The first is that all educational transactions have to be done with the affect ‘turned off’. The teacher must never become angry nor should he aim to become loved. It will never do to appear quiet and calm on the outside while one is boiling inside. Yet this is only too likely, given the negativism and seemingly calculated naughtiness of autistic children!

The teacher must at all costs be calm and collected and must remain in control. He should give his instructions in a cool and objective manner, without being intrusive. A lesson with such a child may look easy and appear to run along in a calm, self-evident manner. It may even seem that the child is simply allowed to get away with everything, any teaching being merely incidental. Nothing could be further from the truth. In reality, the guidance of these children requires a high degree of effort and concentration. The teacher needs a particular inner strength and confidence which is not at all easy to maintain!

There is a great danger of getting involved in endless arguments with these children, be it in order to prove that they are wrong or to bring them towards some insight. This is especially true for the parents, who frequently find themselves trapped in endless discussions.

On the other hand, it often works simply to cut short negativistic talk: for example, Fritz is tired of doing sums and sings, ‘don't want to do sums any more, I don’t want to do sums any more’. The teacher replies, ‘No, you don’t need to do sums’, and continuing in the same calm tone of voice, ‘How much is . . .?’ Primitive as they are, such methods are, in our experience, often successful.

There is an important point to be made here. Paradoxical as it may seem, the children are negativistic and highly suggestible at the same time. Indeed, there is a kind of automatic or reflex obedience. This behaviour is known to occur in schizophrenics. It could well be that these two disorders of the will are closely related!

With our children we have repeatedly found that if one makes requests in an automaton-like and stereotyped way, for instance, speaking softly in the same sing-song that they use themselves, one senses that they have to obey, seemingly unable to resist the command.

Another pedagogic trick is to announce any educational measures not as personal requests, but as objective impersonal law. But more of this later.

I have already mentioned that behind the cool and objective interaction with Fritz and all similar children there needs to be genuine care and kindness if one wants to achieve anything at all. These children often show a surprising sensitivity to the personality of the teacher.

However difficult they are even under optimal conditions, they can be guided and taught, but only by those who give them understanding and genuine affection, people who show kindness towards them and, yes, humour.

The teacher’s underlying emotional attitude influences, involuntarily and unconsciously, the mood and behaviour of the child. Of course, the management and guidance of such children essentially requires a proper knowledge of their peculiarities as well as genuine pedagogic talent and experience. Mere teaching efficiency is not enough.

It was dear from the start that Fritz, with his considerable problems, could not be taught in a class. For one thing, any degree of restlessness around him would have irritated him and made concentration impossible. For another, he himself would have disrupted the class and destroyed work done by the others Consider only his negativism and his uninhibited, impulsive behaviour. This is why we gave him a personal tutor on the ward, with the consent of the educational authority. Even then, teaching was not easy, as should be clear from the above remarks.

Even mathematics lessons were problematic when, given his special talent in this area, one might have expected an easier time. Of course, if a problem turned up which happened to interest him at that moment (see previous examples), then he ‘tuned-in’ and surprised us all by his quick and excellent grasp. However, ordinary mathematics - sums - made for much tedious effort.As we will see with the other cases even with the brightest children of this type, the automatisation of learning, that is, the setting up of routine thought processes, proceeds only with the utmost difficulty.

Writing was an especially difficult subject, as we expected, because his motor clumsiness, in addition to his general problems, hampered him a good deal. In his tense fist the pencil could not run smoothly. A whole page would suddenly become covered with big swirls, the exercise book would be drilled full of holes, if not torn up. In the end it was possible to teach him to write only by making him trace letters and words which were written in red pencil. This was to guide him co make the tight movements.

However, his handwriting has so far been atrocious, Orthography too was difficult to automatise. He used to write the whole sentence in one go, without separating the words. He was able to spell correctly when forced to be careful. However, he made the silliest mistakes when left to his own devices.

Learning to read, in particular sounding out words, proceeded with moderate difficulties. It was almost impossible to teach him the simple skills needed in everyday life. While observing such a lesson, one could not help feeling that be was not listening at all, only making mischief.

It was, therefore, the more surprising, as became apparent occasionally, for example through reports from the mother, that he had managed to learn quite a lot. It was typical of Fritz, as of all similar children, that he seemed to see a lot using only ‘peripheral vision’, or to take in things ‘from the edge of attention’.Yet these children are able to analyse and retain what they catch in such glimpses, Their active and passive attention is very disturbed; they have difficulty in retrieving their knowledge, which is revealed often only by chance. Nevertheless, their thoughts can be unusually rich.

They are good at logical thinking, and the ability to abstract is particularly good. It does often seem that even in perfectly normal people an increased distance to the outside world is a prerequisite for excellence in abstract thinking.

Despite the difficulties we had in teaching this boy we managed to get him to pass successfully a state school examination at the end of the school year. The exceptional examination situation was powerful enough to make him more or less behave himself, and he showed good concentration. Naturally, he astounded the examiners in mathematics.

Now Fritz attends the third form of a primary school as an external pupil, without having lost a school year so far. Whether and when he will be able to visit a secondary school we do not know.

Differential diagnosis

Considering the highly abnormal behaviour of Fritz, one has to ask  whether there is in fact some more severe disturbance and not merely a personality disorder. There are two possibilities; childhood  schizophrenia and a post-encephalitic state.

There is much that is reminiscent of schizophrenia in Fritz: the  extremely limited contact, the automaton-like behaviour, the  stereotypies. Against this diagnosis, however, speaks the fact that there is no sign of progressive deterioration, no characteristic acute onset of alarming florid symptoms (severe anxiety and hallucinations), nor are there any delusions.

Although Fritz shows a very deviant personality, his personality  remains the same and can largely be seen as deriving from father and mother, and their families. In fact, his personality shows steady  development, and on the whole this is resulting in improved  adaptation to the environment.

Lastly, the complex overall clinical impression, which cannot he pinned down further, is completely different from that of a  schizophrenic. There, one has the uncanny feeling of a destruction of personality which remains incomprehensible and incalculable, even if it is perhaps possible to some extent to stave off disintegration through pedagogic means. Here, however, there are numerous genuine  relationships, a degree of reciprocal understanding and a genuine chance for remedial education.

One has also to consider the possibility of a post-encephalitic  personality disorder. As we shall see below, there are a number of  similarities between autistic children and brain-damaged children who either had a birth injury or encephalitis. Suffice it to say here that there was no reason for thinking this applied in the case of Fritz.

There were certainly none of the symptoms that are always present in post-encephalitic cases (though these are sometimes easily overlooked). There was not the slightest evidence of neurological or vegetative symptoms such as strabismus, facial rigidity, subtle spastic paresis,  increased salivation or other endocrine signs.

Continue reading: Autism in Childhood - Part Four

17 Asperger and Kanner were both impressed by the isolated special abilities found in almost all their cases, Fritz shows superior rote memory and calculating ability; Donald likewise has excellent rote memory and could count to 100 at the age of five.

18 Recent findings of an impairment in the understanding of emotion in voice and face confirm Asperger’s impression. See Hobson (1989) for a review of research and theoretical interpretation.

Asperger believed autistic children to have a disturbed relation to the environment in general, and not merely to the social environment. It follows that their lack of emotional understanding is a consequence of the same underlying problem (that is, contact disturbance) which also results in their helplessness in practical matters of everyday life.

Kanner (1943), instead, contrasts the “excellent relation to objects with the non-existent relation to people”, a highly influential view which has become the basis of many theories of Autism.

19 From Asperger’s descriptions throughout it is clear that he believed autistic children to be capable of having strong feeling, and to be disturbed only in their ability to manifest such feelings appropriately.