In the DSM-IV autism is classiﬁed as a pervasive developmental disorder (PDD), meaning the affected child has a severe impairment in several areas of development: reciprocal social interaction skills, communication skills, or the presence of stereotyped behavior, interests, and activities. Autism appears in the ﬁrst three years of life, although it may be diagnosed much later, usually after school attendance has made the symptoms more obvious. There is no single pattern of symptoms common to all autistic children, since the disorder encompasses a wide spectrum of behavior patterns and a wide range of levels of functioning. There are some fairly standard features, however, including impaired social interactions, impaired verbal and nonverbal communication, and restricted and repetitive patterns of behavior (or stereotyped behaviors). The symptoms may vary from quite mild to quite severe. Some autistic children never develop spoken language and are classiﬁed as severely or profoundly mentally retarded (see Mental Retardation), while others have normal or above-average intelligence and can achieve high levels of education. All have in common a deﬁciency in social interaction accompanied by social withdrawal, often ﬁrst evident in a failure to make normal eye contact or to respond positively to social contact, especially physical contact, like hugs, which is ordinarily highly reinforcing to children. This is usually accompanied by stereotyped behavior (or repetitive movements without an immediately apparent purpose, such as rocking back and forth, spinning, tapping hands or feet, waving hands, etc). as well as varying degrees of language delay.
Leo Kanner (1894–1981) ﬁrst identiﬁed the syndrome as Early Infantile Autism in a 1943 paper, asserting that he had worked with such children since 1938. He argued that children with autism had of course existed prior to that time, but they had been misdiagnosed as mentally retarded or emotionally disturbed up to that point. Hans Asperger made similar discoveries at the same time, but the patients he worked with had all developed speech, so the term Asperger’s Syndrome or Asperger’s disorder is frequently used to refer to higher-functioning autistic people who are able to speak. Prior to Kanner, the word “autism” had already been used by Bleuler to mean “escape from reality.” Indeed, the bizarre behavior patterns associated with autism once led to the use of terms like “psychosis” and “childhood schizophrenia” to refer to individuals with this condition, but more recent research has shown clearly that autism and other PDDs are distinct from schizophrenia.
After Kanner provided a label for the syndrome, clinicians attempting to treat it began to notice a common pattern among parents of children with autism. They seemed not to show the warmth and affection characteristic of the normal positive parent-child relationship. As Freudian theory (see Freud) was then very much in vogue, this information pointed to a clear causal relationship: autism in a child is the result of being raised by cold, rejecting parents. Furthermore, in keeping with the sexism inherent in many psychoanalytic ideas, it was the mothers who bore the lion’s share of the blame. In the 1950s and through the 1960s, the theory that autism was caused by “refrigerator mothers” was immensely popular in the United States, largely due to the efforts of Bruno Bettelheim, an Austrian emigré who presented himself as a student of Freud and a survivor of the Dachau and Buchenwald concentration camps. Bettelheim established the Orthogenic School at the University of Chicago, where he treated (and frequently “cured”) hundreds of autistic children with a regimen that began with separating the children from their parents and forbidding their families from further contact with them. In his inﬂuential 1967 book, The Empty Fortress, Bettelheim asserts that “the precipitating factor in infantile autism is the parent’s wish that his child should not exist.” He goes on, in that book as well as in later work, to compare the mothers of autistic children to concentration camp guards.
The major source of this line of reasoning is a simple observation that was wildly and irresponsibly misinterpreted: parents of autistic children often do show them less warmth and affection than parents of non-autistic children. Consider, however, the fact that most autistic children do not enjoy social contact, especially physical contact, in the way that ordinary children do. Temple Grandin, an autistic adult who obtained a PhD and is renowned as an expert on animal behavior, recalls experiencing hugs from adults as painful, along with other sensory stimuli such as ordinary speech. Although direct ﬁrst-person descriptions such as Grandin’s are still rare in the literature, because her level of educational attainment is also rare, they tend to concur on this point. The sensitive parent will, of course, learn quickly that the child does not enjoy this sort of contact and will thus refrain from it. Ironically, the behavior of such sensitive and devoted parents became the source of a theory blaming them for their children’s problems.
By the time Bettelheim published The Empty Fortress, most of the psychological and psychiatric communities had already begun to accept that autism is a biologically based disorder with possible genetic factors, and that blaming the disorder on parents was ludicrous. No less ludicrous was Bettelheim’s claim to have cured the vast majority of the children left in his care. This claim was partly made possible by the fact that it was Bettelheim who diagnosed the children and determined when a cure had occurred. No outside observers were involved, nor were any clear objective criteria. Subsequent evidence has emerged to suggest that most of the children Bettelheim worked with were never autistic at all. This is not surprising, given that evidence has also emerged suggesting that Bettelheim grossly misrepresented his past and his credentials. Among many other things, he had no formal training in psychoanalysis.
Current thinking on the causes of autism continue to blame the parents, but only in an indirect, impersonal way: the disorder may have a genetic basis. As with schizophrenia, if one identical twin has autism, the other is much more likely to have it than a person without an identical twin. Because of this, researchers have spent the last twenty-ﬁve years hunting for genes that cause autism. As with most human characteristics, autism is unlikely to be caused by a single genetic defect. Some researchers suggest that the person with autism might have mutations in several genes; thus two people with the disorder might have completely different sets of mutations. The discovery of such genes has been hampered by the complex nature of autism. Because the symptoms of people with autism vary dramatically in degree and form, researchers believe the condition might involve two or more of a large number of genes. In fact, a person with autism may have mutations in several of perhaps twenty suspect genes. Although no clear genetic pattern has emerged yet, there are several promising hypotheses, and the research continues.
The clear presence of a genetic inﬂuence has, of course, not stopped people from continuing to look in unlikely places for a clear-cut cause of the disorder. In 1998 for example, a study of autistic children raised the question of a connection between the MMR (measles, mumps, rubella) vaccine and autism. This quickly resulted in panic among parents in the United Kingdom, thousands of whom chose not to get their children vaccinated. The original study was based on only twelve children, who allegedly were diagnosed with autism within a very short time of receiving the vaccine. In the United States, additional data have fueled the concern initiated by that study: there has been a substantial increase in the number of cases of autism diagnosed since the vaccine became widely used. This has created concern substantial enough that the Centers for Disease Control and Prevention (CDC) has created a special Web page (www. cdc.gov/nip/vacsafe/concerns/autism/autism-mmr.htm#5) to address MMR worries.
In fact, much larger studies have found no relationship between MMR vaccine and autism. For example, the CDC reports that researchers in the UK studied 498 children with autism born between 1979 and 1998 and found that the percentage of children with autism who had received the MMR vaccine was the same as the percentage of unaffected children in the region who had received the MMR vaccine, and that there was no difference in the age of diagnosis of autism in vaccinated and unvaccinated children. Furthermore, the onset of symptoms of autism did not occur within six months of receiving the vaccine. As for the increase in diagnoses, experts are in agreement that it has nothing to do with the use of the MMR vaccine.
The diagnostic criteria for autism are much better known among those who work directly with small children than they used to be, thanks in part to federal laws mandating that all children with disabilities must be provided with an education. Also, psychologists are learning to recognize early signs of autism in infants and toddlers, whereas in the past the diagnosis usually didn’t occur until at least the age of three. Improved diagnostic techniques have inevitably led to an increase in the number of cases identiﬁed, which has coincided with increased use of the MMR vaccine. The two developments have occurred simultaneously but appear to be unrelated.
Just as research on causes has ceased blaming the parents’ behavior, treatment has also progressed. There is no cure for autism, but the most effective approach to treatment of symptoms has been behavior modiﬁcation techniques (also known as behavior therapy or applied behavior analysis), perhaps because they focus in on particular problem behaviors rather than attempting to treat underlying causes. Behavioral techniques have been successful in increasing language use, eye contact, instruction following, self-care skills, letter, number, and word recognition, and many other desired behaviors; as well as helping to decrease stereotyped behavior, self-injury, social withdrawal, tantrums, and many others.
A disorder as mysterious and misunderstood as autism, however, has unfortunately also attracted a number of therapies with little or no scientiﬁc basis. Practitioners of facilitated communication, for example, claim to help autistic persons who have never learned the alphabet to type complex messages to their parents. Others have suggested that autism is actually caused by diet, and that autistic children’s behavior is much improved by removal of all gluten (grain protein) and casein (milk protein). Evidence suggesting improvement as a result of diet is inconsistent, almost entirely anecdotal, and ignores the clear role of genetics. Music therapy and play therapy have also been widely advocated for autistic children, despite a lack of controlled experiments indicating that they confer any beneﬁt (see also Pervasive Developmental Disorders).
- Azar, B. “The Development of Tools for Earlier Diagnosis of Autism Is Moving Quickly.” APA Monitor, 29(11) (1998);
- Bettelheim, B. The Empty Fortress: Infantile Autism and the Birth of the Self. Chicago: The Free Press, 1967;
- Finn, M. “In the Case of Bruno Bettelheim.” First Things, 74 (1997): 44–48;
- Grandin, T. Thinking in Pictures: And Other Reports from My Life with Autism. New York: Vintage Books, 1996;
- Kanner, L. “Autistic Disturbances of Affective Contact.” Nervous Child, 2 (1943): 217–250;
- McIntosh, H. “Autism Is Likely to Be Linked to Several Genes.” APA Monitor, 29(11) (1998);
- Pollak, R. The Creation of Dr. B: A Biography of Bruno Bettelheim. New York: Simon & Schuster, 1996.
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