Defining Autism from a Clinical Standpoint.

Autism is a disorder of perplexing nature that enivitably has impairments that last into adulthood for the afflicted and lifelong implications for their families. (`Asgeirsd`ottir et al, 2006, p.1361) Autism is not only difficult to understand

clinically and behaviorally in relation to the person with the disability but also diagnostically, in terms of inconsistency of classification. This paper intends to investigate the history of autism, explain the currently accepted clinical definition and description of the disorder and the recognized related condition along the autism spectrum disorder or ASD, Asperger’s disorder, and finally to attempt to explore the changeability of terms associated with autism. (Volkmar et al, 2005, p.2)

Autism has an interesting and varied history, reaching farther back, as some researchers have theorized than the pioneers who first published accounts of the disorder; Leo Kanner and Hans Asperger. (Frith, 2003, p.5) The inquiry into the history of autism leads one to believe that the disorder has been around undiagnosed for centuries before. Uta Frith (2003) reflects on cases of people with the probability of having some degree of the disorder, throughout history. She discusses, among others a Franciscan monk, Brother Juniper whom in his various encounters with fellow brethren and community, proved to be a person that lacked the ability to be aware that others had their own thoughts about things and occurances. This is indicative of the essence of autism as claimed by Baron-Cohen et al (2006). They assert that children with autism “have delays in the development of theory of mind”, (p.716) which is what Frith is drawing attention to above. Namely, the inability to comprehend the idea that people have their own thoughts and emotions outside of oneself.

Further exploration into the historical roots of autism is cited by Happe (1999). She reviews folktales of young men who are of an innocent nature and misinterpret advice given to them by literally comprehending it. One example given is from a traditional Malta story about a boy named Gahan. As the story goes, Gahan was late getting up on a Sunday morning and was not able to accompany his mother to church. Before she left she reminded Gahan to “pull the door behind [him]”. Gahan understood this statement literally, not figuratively. Poor Gahan subsequently then pulled the entire door by the door handle all the distance to church to meet his mother and the congregation, aghast at his action. (p.8)

Though there are possible historical accounts, autism was not thoroughly conceptualized until Leo Kanner and then a year later, Hans Asperger published their initial papers. In 1943, Leo Kanner offered clinical insight in his published work of 11 children who shared common threads of behavior. These attributes support the development of his concept of “early infantile autism”. (Fitzgerald and Lyons, 2007, p.2022) Included here are the features of his findings through his research:
extreme autisitc aloneness, anxiously obsessive desire for the preservation of sameness, excellant rote memory, delayed echolalia, oversensitivity to stimuli, limitation on the variety of spontaneous activity, good cognitive potentialities, and highly intelligent families. (Happe, 1999, pp.9-10)

A year later, Hans Asperger unaware of Kanner’s work published a dissertation concerning autism. Amazingly, the two clinicians individually, came up with the term “autistic”. (Happe, 1999, p.10) Originally, the word came from Eugen Bleuler who coined the term to describe the social extraction in adults with schizophrenia. Both Kanner and Asperger also believed that the nature of this affliction was inborn. They both noted finding the children not flexible with changes, socially detached, having strange idiosyncratic interests, and generally highly enjoyed routines. (Happe, 1999, p.11)

In 1979, Wing and Gould (Dodd, 2005) suggest there was a way to explain autism in a more broad and social fashion. They named this framework the “triad of impairments”. (p.2) They claim there are three areas of deficits as documented by their research; the impairment of social interaction, of social communication, and of social imagination. Later, they introduced a broader term of “autistic spectrum” (p.2) which is meant to represent a linking or continuum of autism that serves to describe mild to severe cases including Asperger’s disorder. This shift signifies a progressive move in the direction of the currently accepted definition of autism, also known as ASD. The spectrum construct includes cases today that would not have met Leo Kanner’s criteria.

Autism now, has the basis to form the clinical diagnostic criteria used by the American Psychiatric Association in the DSM-IV (1994) and the World Health Organization in the ICD-10 (1992) to aid medical practioners in the diagnosis process with much gratitude for Kanner and Asperger as well as for Wing and Gould. The diagnostic term “pervasive developmental disorder” or PDD was introduced into the DSM-III in 1980 along with a specifically designed example of autism, autistic disorder. In 1992 the ICD-10 was published and included a broader range of categories of autism. Finally, in 1994, the DSM-IV redefined criteria for autism and added three new classes of PDD, including Asperger’s disorder. (Volkmar et al, 2005, p.2) Asperger’s disorder, as defined in the DSM-IV is juxtaposed with autistic disorder and the areas of lesser deficits in Asperger’s disorder are in “language aquisition” and “cognitive development”. (1994, p.80)

Though the DSM-IV and the ICD-10 are the universally recognized manuals for diagnosing autism being partially based off the “triad of impairments”, they individually contain different classifications under the umbrella of PDD. The ICD-10 classifies what is known traditionally as classical autism, as “childhood autism” and the DSM-IV with the same criteria, names it “autistic disorder”. This trend of inconsistency is continued throughout both manuals. (Volkmar et al, 2005, p. 6) There is a growing body of evidence that suggests the current trend of classification for both autistic disorder and Asperger’s disorder is more likely to be considered ASD versus PDD. The works include Berckelaer-Onnes and Noens (2005), Shattock (2005), and Bolt et al (2006). To add to the confusion, there are also terms used by professionals and lay people alike within the spectrum to designate varying levels of cognitive and adaptive ability of persons with ASD, chiefly high-functioning and low-funtioning autism. (University of Cambridge, 2007) In addition, there is evidence of controversy of clarity of the definition of high-functioning autism. Dissanayake and Macintosh (2004) state there is “insufficient evidence to establish the validity of Asperger’s disorder as a syndrome distinct from high-functioning autism”. (p.421)

These issues of variability of terms associated with autism allows for possibly a too flexible framework of labels. The evidence seems to point in the direction that due to the varying display of classifications within autism after the “triad of impairments” was accepted, the trend affected the varying display of classification within both the DSM-IV and the ICD-10.

Using the evidence of the irregularity of presentation, a point can be made of the continual enigmatic nature of autism in this respect. If the two authoratative authors of the DSM-IV and the ICD-10 are not in agreeance of the classification of autism, one may speculate equal puzzlement among professionals in the field diagnosing the disorder. Extrapilating further, recounting the history of the definition of autism, one may say fairly the confusion surrounding autism may be the impetus for yet another more singular and universal set of classifications and descriptions. What is known is further research and collaboration in this area will be needed.
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