Infantile Autism

The Syndrome and Its Implications for a Neural Theory of Behavior by Bernard Rimland, Ph.D.

Stephen M. Edelson

• Publisher: Jessica Kingsley Publishers
• Year: 2014
• ISBN:
  9781784500573
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

In 1964, the release of Dr. Bernard Rimland's book, Infantile Autism, revolutionized the autism field by providing the autism community with much-needed guidance on how to understand and treat individuals on the spectrum. He single-handedly realigned the field from a psychodynamic, parent-blaming perspective to a scientific, physiological course of action. This 50th anniversary edition presents the original book with contributions from leaders in the autism field, including Drs. Martha Herbert and Simon Baron-Cohen, who celebrate Dr. Rimland's exceptional work, and place his findings within the context of autism as we understand it today.

Bringing Dr. Rimland's findings up to date for a new generation of readers, this book will be fascinating reading for parents and those on the autism spectrum as well as professionals working with autism and anyone with an interest in autism and/or psychological theory.

Part I

THE CONTROVERSIES AND THEIR RESOLUTION

A Critical Analysis of the Literature

Introduction to Part I

The four chapters which constitute Part I will each treat one of the four major controversies which attend the problem of early infantile autism.

Chapter 1 is addressed to the root problem: Is infantile autism a clearly defined clinical and diagnostic entity? Because much of the controversy on all other aspects of infantile autism can be traced to a misunderstanding of this point, Chapter 1 will be largely devoted to a detailed description of the disease. There can be no substitute for reading Kanner’s lucid case histories (1943), but the descriptive data presented in Chapter 1 should prove useful in reducing the frequent overuse of the diagnosis. Several factors which have contributed to the confusion surrounding infantile autism are pointed out in the concluding section of Chapter 1.

Chapter 2 is concerned with a problem of far more significance than has heretofore been recognized: How accurate are the assertions of Kanner and others that autistic children are almost invariably the offspring of highly educated and intelligent parents?

Chapter 3 is concerned with the question of etiology: Is autism an organic defect or is the family environment wholly or partly responsible?

Chapter 4 discusses the question: Is infantile autism merely a variation of childhood schizophrenia?

It is the writer’s belief that the evidence now at hand is sufficient to render unnecessary any continuation of controversy on these points.

These chapters are based primarily on what is believed to be a substantially comprehensive review of the American and European literature. The several known papers not available at the time of this writing are so noted in the bibliography.

INTRODUCTION TO CHAPTER 1

Stephen M. Edelson

The symptoms of autism that Rimland described 50 years ago are still considered core symptoms of the syndrome today. They include feeding difficulties, repetitive behaviors, insistence on sameness, suspected deafness, splinter skills, and unique expressive speech.

In Infantile Autism as well as the film documentary The Invisible Wall, Rimland mentions that there are different types of individuals with autism. In other words, not everyone with autism exhibits the same symptoms and behaviors, and the severity of these symptoms and behaviors varies considerably among those given the same diagnosis of autism. For this reason, we now use the term autism spectrum disorder—a term Rimland felt was appropriate.

Over the years, we have learned much more about the symptoms and behaviors associated with autism, including seizures and sleep disturbances. Although Kanner’s initial paper published in 1943, titled “Autistic disturbances of affective contact,” mentioned several medically related issues, such as eating and gastrointestinal problems, there was little discussion of such problems until the mid-1990s. At that time, Rimland, along with colleagues Sidney Baker and Jon Pangborn, spearheaded an effort to bring needed attention to gastrointestinal problems such as chronic diarrhea and constipation, and immune problems such as inflammation. More recently, researchers have also documented impairments in metabolism (e.g., problems in methylation, detoxification, and mitochondrial function).

Although autism is accepted as a spectrum disorder, Rimland often considered two related traits, difficulties in social interaction and impairments in communication, to be defining features of every case of autism. In other words, if someone had excellent social and communication skills, he or she was unlikely to be diagnosed with autism. Rimland always felt strongly that more objective measures were needed to diagnose autism, such as biomarkers.

Citing Kanner on page 40, Rimland wrote, “The prognosis of early infantile autism has not been influenced by any form of therapy.” However, Rimland did comment on “…advice frequently given to the parents that the child be provided more stimulation” (page 41). Interestingly, within a short time after the publication of Infantile Autism, Rimland visited Ivar Lovaas at his autism clinic at UCLA. Witnessing the results that Lovaas was achieving, Rimland quickly realized that autism was treatable. He soon founded the National Society for Autistic Children (currently the Autism Society of America) to inform parents throughout the country about the benefits of behavioral therapy. Much research published after Infantile Autism has clearly demonstrated the importance of early educational intervention in relation to prognosis. In many of his writing and lectures, Rimland also argued that other physiologically based forms of early intervention, such as biomedical and sensory interventions, were important with respect to a child’s prognosis.

REFERENCE

Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217–250.

CHAPTER 1

The Syndrome of Early Infantile Autism

Background, Course, Diagnosis, and Prognosis

In 1943 Leo Kanner, then director of the Child Psychiatry Clinic at Johns Hopkins Hospital and author of the definitive textbook in child psychiatry, published his first description of a rare and remarkable behavior disorder in children. His paper, titled Autistic Disturbances of Affective Contact, was based on the striking similarities he had perceived in the case histories and behavior of 11 children brought to the clinic over a period of years. A year later he followed his initial detailed report with a brief paper in which he named the new syndrome “early infantile autism.” Kanner applied this title because the children had been unusual “from the beginning of life,” and because their aloof, withdrawn, “autistic” personalities caused them always to appear to be living in a private, inaccessible dream-world; isolated, seemingly by choice, from contact with others. (See Bruch [1959] for an interesting glimpse into Kanner’s clinic at the time the diagnosis was formulated.)

A. BACKGROUND

Kanner’s contribution in delineating the syndrome of infantile autism has made it possible to identify, in retrospect, a number of cases reported in the literature by earlier writers. Recently Vaillant (1962) has called attention to a very early textbook by John Haslam, written in 1809, which describes a five-year-old boy, identifiable as autistic, who had been admitted to Bethlehem asylum in 1799.

Witmer (1920) described a severely afflicted three-year-old boy who appeared in many ways to resemble the autistic cases of Kanner. At age seven, Witmer’s case seemed destined to recover.

In 1921 Meyer and Richards (reported by Darr & Worden, 1951) described a young girl who is now clearly recognizable as a case of infantile autism. Darr and Warden’s paper, written 28 years after the original case description, represents one of the few follow-up reports available.

Despert (1938) has presented several brief descriptions of children who had psychoses of “insidious onset.” Certain of these cases, in contrast with her cases of “acute onset,” are generally regarded as autistic.

Another early case of a girl afflicted with autism was reported in considerable detail by C. Bradley, in 1943, the same year in which Kanner’s now classic report was published.

B. COURSE AND SYMPTOMS OF THE DISEASE

Because of its rarity, little is known about the conditions under which infantile autism occurs. By far the largest group of cases has been that reported by Kanner and his colleagues at the Johns Hopkins Hospital clinic. Much of the available information comes from the reports of Kanner’s first 100 cases (Kanner, 1954a; Kanner & Lesser, 1958). The present writer’s survey of the available literature supports the data provided on the first 100 cases.

Infantile autism occurs primarily in first-born males. The sex ratio is about three or four boys to one girl (Kanner, 1954a; Keeler, 1957; Anthony, 1958). Eighty of the first 100 cases were boys, 20 were girls. Fifteen of the 100 had no siblings, 43 were first-born, 23 second-, 13 third-, and six were fourth- or fifth-born.

Pregnancy and birth. Complications of pregnancy are reported to be no more common than usual in births producing autistic children (Kanner, 1954a; Kanner & Lesser, 1958). Keeler (1957), however, reports that many of the mothers of his cases (number not specified) had experienced bleeding in the first trimester of pregnancy; and that others had a history of miscarriage and stillbirths. One of the ten cases seen by van Krevelen (1963) had a history of maternal bleeding in the first trimester, and another was afflicted with rubella in the fifth month.

Twelve of Kanner’s first 100 cases had been born prematurely. (The base rate for prematurity among whites in the United States is about 7%.) Keeler also notes an elevated incidence of prematurity in autistic children, and observes that for most a lack of movement was reported before birth.

The first two years. The child is usually exceptionally healthy and attractive, quite often precocious and alert in appearance. Very little that is unusual is noticed in the first months, except perhaps that feeding may be a problem. Some autistic infants are reported to have been apathetic and unresponsive in the first few months, while others have been given to implacable crying. Typically, it is not until about the fourth month that even a person experienced with babies may first notice anything unusual. The first awareness of any problem is often the observation that the child fails to make the usual anticipatory movements prior to being picked up. He also fails to make the usual adjustments of his body to adapt to the person carrying or holding him. Head-banging is common, both in the crib and while being held; the latter behavior causing considerable discomfort and chagrin to the adult holding him. Case histories of very young autistic infants have been supplied by Plenter (1955), Lazure (1959), Eveloff (1960), and Lewis and Van Ferney (1960).

Between the fourth and eighteenth months several disturbing symptoms will have begun to appear. These include prolonged rocking and head-banging in the crib, apathy and disinterest in the surroundings, unusual fear of strangers, obsessive interest in certain toys or mechanical appliances, highly repetitive and ritualistic play, insistence on being left alone and that the physical environment remain unchanged, and very unusual language behavior. Speech, of a very unusual sort, may have started early. Because speech is of special importance in early infantile autism, it will be discussed separately below, in conjunction with separate discussions of other behaviors of special interest.

By the time the child is 18 months to two years old the parents will have become quite concerned, especially if another child has been born which acquaints them with the much different normal pattern of development. One of the most disturbing of the symptoms is what has been called “autistic aloneness.” The child may sit for hours staring into space, motionless, as if deep in thought. The autistic child looks highly intelligent and always appears to be mentally occupied during these periods of self-imposed isolation. Sometimes a fleeting, pensive smile will cross his face. The child’s attention cannot be attracted by calling his name or speaking. No sign of attention is given.

Even more disturbing is the child’s utter lack of interest in people. Most autistic children act is if other people did not exist (e.g., Chapman, 1957; G. Arnold, 1960; Loomis, 1960), but a few appear to have an active aversion to others (e.g., Plenter, 1955). Coupled with the disinterest in persons is frequently an active interest in inanimate objects.

Specific problems and behaviors. Professional help is often sought after the child has reached the second birthday. Not only has the child’s development become of concern, he has become exceedingly difficult to live with.

Toilet training is ordinarily difficult to establish, though sometimes it can take place early. It is not uncommon for toilet training to start early, then be completely absent for several more years.

Feeding problems are almost the rule. Some children have ravenous appetites; others eat very little. Almost all have odd eating habits and preferences, however. Some children will take only milk. An autistic girl reported by Rattner and Chapman (1959) subsisted entirely on milk for her first six years. Others will never touch milk. One child went for several days without taking liquid until it was discovered he would drink only from a transparent container. Witmer’s case would not drink from a transparent container, nor would he drink water. Other children have been reported utterly to refuse to drink liquids which were not at a certain precise temperature. Absolute refusal to use the hands is also sometimes reported, which means spoon feeding. Creak (1952) reports an autistic child who loved chocolate, but would eat it only if cut into squares; round chocolate was not acceptable. Certain autistic children are exceedingly neat and clean in their habits, becoming upset at untidiness. One such child began eating with a spoon with perfect precision at nine months. One girl would eat only sandwiches she made herself, starting at three years of age.

Repetitive behavior and fetishlike preoccupation with mechanical objects such as vacuum cleaners, stoves, light switches, and faucets is a common symptom. Any attempt to divert the child from this type o...