History of Autism

Posted on April 10, 2011



Autism is a neurodevelopmental disorder that has a short but dense history. Eugen Bleuler first coined the term in 1910 when he used it to describe a form of schizophrenic thought. The word was used later when two pioneers of Child Psychiatry recognised a group of children who behaved very differently from the rest. Leo Kanner and Hans Asperger both published their papers independently describing an autistic disorder within a year of one another 1943-44. The disorder received great interest from other psychiatrists at the time and as Freud’s psychoanalysis approach was at a height of popularity, the aetiology assumed to be due to a faulty relationship with the child’s mother. Kanner first termed the word refrigerator mother to describe the coolness of the parents he met during his research. Bruno Bettelheim believed the pathology laid in the mother not the child; he used Kanner’s term to berate mothers and went on to become well respected until after his death when controversy was found over his lack of credentials, poor research and misuse of power. Another controversy of a physician misusing his power was Dr Wakefield who created the MMR scare from poorly conducted research paper in which he exaggerated the results of finding a link with the MMR vaccine and autism. Treatment for autism has gone from experimental LSD, Electroconvulsive therapy, through to cognitive behavioural therapy. The cause remains unknown.



The Autistic Spectrum Disorder is defined today as a group of neurodevelopment syndromes characterized by defective social interactions, communication and stereotyped behaviours and interests. (DSM-IV 1994). Autism is one category of the spectrum itself. It is usually diagnosed when the child is not reaching their milestones for speech and social behaviour, alternatively from Asperger’s where a child has a normal development of speech but does display autistic behaviour in struggling with communication. In Asperger’s, it is often seen that a child wants to socialise but does not have the necessary tools to do so.

The aetiology of autism remains unknown but it is thought to be a multifactoral and polygenic disorder. Treatment options include intensive behavioural modification techniques and some drug therapies to treat the symptoms (e.g. SSRIs are used to reduce ritualistic behaviours) (Merck 2009).

Autism is a relatively recent concept and yet it has a rich history with plenty of controversy surrounding it. Even the great pioneers Leo Kanner and Hans Asperger had accusations against them. Kanner had been accused of plagiarising Asperger’s work and Asperger himself had links with the Nazis (Feinstein 2010). There also has been great stigma towards autistic children and their parents. Refrigerator Mother was a term coined by Kanner describing the coldness of the parents, especially mothers of those who are autistic. Bruno Bettelheim, accused mothers of causing the condition by not showing enough affection and stimulus to their child. There was also the MMR scare in which Dr Andrew Wakefield’s Lancet paper gave false evidence that the MMR vaccine increased the likelihood of a child contracting autism.

Defined only in 1910, there have been clues in historical papers that autism has been around for quite some time and there are some great historical characters that some believe had the conditions.

Child Psychiatry is the speciality that encompassed autism. The speciality itself only came about in the 1930s with Leo Kanner being the first named Child Psychiatrist at Johns Hopkins Hospital. It was here where he became renowned as a pioneer in autism.


Ancient Autism:


Recent definition and recognition of autism meant that the disorder passed through history relatively unnoticed despite its striking clinical features. Perhaps, Kanner’s autism had not existed until recently and there is a causal link between an environment change in the 20th century and the recognition of autism. More likely however, is that parents of autistic children were unlikely to expose their children to the public such was the stigma against anyone who did not fit the norm. It is a challenge therefore to find autism in history and requires an interpretation of subjective historical papers to consider the likelihood that autism is being described.

One of these examples was Utah Frith’s analysis of 29 witnesses in the legal case of Hugo Blair of Borgue in 1740s. Blair was a man who went to court for the decision of his mental capacity in allowing his marriage. According to Frith’s account, he showed convincing clinical features such as abnormality of language such as echolalia and he would always reply with the question and then the answer. He had stereotyped behaviour such as collecting feathers and sticks and always sat in the same seat in church. (Wolff S, 2003) (Houston R, Frith U 2000).

Professor Michael Fitzgerald is a Child Psychiatrist at Trinity University, Belfast and has named great figures that showed exceptional talents in arts and literature as being possible Asperger suffers. In his book, Asperger syndrome: a gift or curse? he explains that some historical talents such as Darwin, displayed eccentric behaviours making them likely to have the syndrome.


Age of Autism


Autism was first appointed as medical nomenclature by Dr Eugen Bleuler in 1911, when he used the Greek autos, meaning self to describe one mode of thinking. It was noticeable in pretend play, dreams and ‘schizophrenic’ fantasies. Bleuler described autism as a condition within Schizophrenia, which was the still the case until DSM III was launched in 1960s putting Autism under Pervasive Developmental disorders. The link between autism and schizophrenia has been debated thoroughly throughout its evolution. However, the word now is completely different from Bleuler’s original concept. Interesting, Eugen Bleuler was also responsible for replacing the term Dementia Praecox with Schizophrenia. Schizophrenia similarly evolved from Bleuler’s original description which was originally used to portray the mind the splitting. Bleuler perhaps prematurely named conditions before there was a much understanding and therefore misled future physicians. Utah Frith, in a Cambridge University press said, “autistic thinking in Bleuler’s sense has nothing to do with autism as we know it” (Frith U 1991)

Despite Bleuler forming the word, Hans Asperger and Leo Kanner are seen as the true founders of autism as we know it today. Both Austrian, Asperger and Kanner started to record their findings of their child patients who seemed different from the rest. They both within one year used the term autism and described the same condition completely independently. In 1943 Kanner published a paper “Autistic Disorders of Affective Contact” where he first recognised a unique syndrome in eleven case studies. This syndrome would later be called early infantile autism disorder.  (Kanner 1943)


Kanner was born in the Austrian town Klekotow in 1894 where he spent his first 12 years until him moved to Berlin in 1906. After graduating from school he decided to study medicine at Friedrich-Willhelms University, Berlin. His study of medicine was interrupted twice due to the First World War where he was conscripted into the Imperial and Royal Army of Austria and Hungary at the age of 20. He worked as an intern at military hospitals with the medical service of the 10th Infantry Regiment. When he finished his degree he worked as a cardiologist assistant and completed his thesis entitled ‘Investigations of the influence of rest, sleep and work on the electrocardiogram and cardiophonogram with special attention to conduction and depolarization time’ on 17 May 1920. (Neumärker 2005) i In December 1923, at a dinner party with his colleague Louis Holzt from Charite Hospital, Kanner abruptly suggested that they should move to America and avoid the economic difficulties of the time as Berlin was experiencing the Great Depression. With his wife and daughter, Kanner moved just six weeks later across the Atlantic and began working at The State Hospital in Yankton South Dakota and then on to Henry Phipps Psychiatric Clinic at Johns Hopkins Hospital, Baltimore where in 1930 he founded the Children’s Psychiatric Service and was it was here that he became the first ever doctor named a Child Psychiatrist. Adolf Meyer, appointed Kanner and despite their relationship was not an easy one from the start, Meyer’s input into Kanner’s work allowed the publishing of the first Child Psychiatry Textbook. A famous example of their coarse relationship was when Kanner attended a lecture organised by Meyer a few months in to his post. The lecture was introduced by Meyer and given by a neurologist, Paul Schilder, who discussed the sex centre of the hypothalamus and glucose metabolism. After it had finished Meyer asked the audience “Is there any discussion?” Kanner felt a great burden to answer, so he congratulated the neurologist for a particularly elegant lecture and finished with what he thought to be a humorous comment saying he now knew why we referred to our love objects as “honey” or “sugar” because of the proximity of the sex centre to the sugar centre of the hypothalamus. However, when he was greeted with a deathly silence from his colleagues and Adolf Meyer aggressively repeated the question, ignoring Kanner, “Is there any discussion!” Kanner realised he had made a grave mistake. (Einsenberg 1981)

In 1943 Kanner published ‘“Autistic Disorders of Affective Contact” where he described 11 patients who all had similar unique behaviours. He described the main symptoms of this distinctive condition as being the desire to preserve sameness, to remain isolated from others, communication deficits and lack of eye contact. Later he would use the term ‘Early Infantile Autism’.

Kanner wanted to discriminate his patients’ disorder from a subtype of Childhood Schizophrenia. They were compared due to the symptoms of aloneness both patients show. However, he argued that there was difference between the two conditions as aloneness in Childhood Schizophrenia only developed later on after two years of relatively average development whereas his patients showed the onset from the very beginning of life. This was shown by autistic children not taking up the anticipatory posture before being picked up and the failure to adjust their body towards the person holding them. He also believed that his group of patients were different from childhood schizophrenia as they showed intelligent and purposeful relations with real objects and therefore were not delusional. (Kanner 1943)


After Kanner’s article, 120 children were with ‘reasonable certainty’ diagnosed with early infantile autism at Johns Hopkins Paediatric Psychiatry unit. (Einseberg, Kanner 1953).


Hans Asperger was born in 1906 in Vienna and from the beginning of his medical career he wanted to work in paediatrics. He studied at University Children’s Hospital and was particularly interested in remedial pedagogy a form of treatment in which the use of medical and educational support is given to children with disabilities. (Frith 1991) When completing his medical degree in 1931 he took control of the play-pedagogic station at the university. As mentioned, he was accused of having affiliations with the Nazis during the war. However, in a 1938 paper, despite seeming to be in line with the Nazis in terms of eugenics he described how much we could do to help abnormal children and that there is a role for these children in society. He was protecting the children he cared for and perhaps he had to show that he was an ally to the Nazis for them to hear his arguments.


Asperger, like Kanner, felt that autism was a condition separate from Childhood schizophrenia. In his paper ‘Autistic Psychopathy’ he describes his patients not showing a disintegration of personality and are therefore were not psychotic. Although publishing his Die ‘aunstisehen Psychopathen’ im Kindesalter’ in which he looked at six case studies in 1944, one year after Kanner it was not until 1989 that his paper was translated into English. Lorna Wing was the first person to use the term ‘Asperger’s Syndrome’ in 1981. (Frith 1991) As there was little communication between Germany and the west, he remained large only in Germany and had to wait until 1994 for his syndrome to be entered into the DSM-IV post-humorously.


Despite Asperger and Kanner describing very similar symptoms in their child patients there were key differences between the two. In Asperger’s patients their manifestation age were three years or later, whereas Kanner’s patients were from first month of life. There were also differences in language development, Asperger described the child wanting to communicate but remains ‘one way traffic’ whereas Kanner described language as not being of the function of communication. (Van Krevelen 1971) Mostly however, Kanner described autism, as being a course whereas Asperger’s autistic psychopathy represented traits, so therefore is static. (Van Krevelen & Kuipers 1962) Asperger felt that his ‘autistic psychopathy’ was different from early infantile autism and Wolff and Barlow argued that it should be labelled as a Schizoid personality disorder as Asperger’s symptoms of lack of empathy, poor communication, isolation from others as this is similar to a Schizoid personality. (Wolff & Barlow 1979) Lorna Wing argued that there is no question that the Asperger’s is a form of Schizoid personality but she was uncertain whether its grouping was of any benefit. (Wing 1981).


At the end of his paper, Kanner discussed some wider issues surrounding autism, one that he noted the parents of each child were rarely warm and affectionate. He would later coin the name Refrigerator Mother to describe the coldness of the mother’s of autistic child he met. Later in 1960 in Time Magazine, Kanner is quoted saying ‘[mothers of autistic children] have defrosted only enough to have a child’. (Times Magazine website incl. image) This was taken in by Bruno Bettelheim, a Holocaust survivor who believed that children with autism behaved just like prisoners in concentration camps he had seen. His assumption therefore was that parents of autistic children, in particular the mothers, behaved like Nazi prison guards.

Bettelheim was an Austrian. He grew up in a wealthy Jewish family in fin-de-siecle. When the Nazi Anschluss (annexation) of Austria occurred in 1938, Bettelheim was sent to Dashau Concentration camp. One year later, Hitler marked his fiftieth birthday by freeing a number of inmates to show that he was ‘merciful’. Bettelheim was fortunate to be one of those inmates to be selected and shortly after being released he fled to New York. He taught art history in 1940s and later published “Individual and mass behaviour in extreme situations”.  This paper described how prisoners were led to behave like children due to the horrific environment. This paper became very large in the USA as it was the first paper describing the concentration camps. He was later asked to run the Orthogenic School for the emotionally disturbed children in Chicago. (Feinstein 2010)


Psychoanalytical psychology was the in the height of fashion for psychotherapy in 1940s-60s. Therefore, autism was mainly approached from a psychoanalytical prospective instead of a biological or genetic approach. Discussing genetics at that time post-Nazi Germany was a taboo subject as firstly it was believed to be a slippery slope towards eugenics and secondly some parents and physicians did not want to accept genetics being the cause as it implied autism being an incurable disease. Ironically, it was this period when the double-helix structure of DNA was discovered by James Watson, Francis Crick, Maurice Wilkins and Rosalind Franklin in 1953.


Bettelheim was firmly a psychoanalytical therapist. As mentioned, his blame for autism did not lie with the functioning of faulty wiring of the brain but rather the mother-child relation. His idea was that the pathology lay within the mothers and this was indicated by the behaviour of their children. His treatment for children with autism was his neologism, parentectomy and made the parents seek psychotherapy themselves. He would keep the children at the Orthogenic School and try to teach the children appropriate behaviour. (Feinstein 2010) In 1967 Bettelheim wrote the book The empty fortress in which he published these ideas and described success stories from The Orthogenic School.

Despite inspiring Bettelheim’s theories, Kanner condemned the blaming of parents for the “defects” of their children. He wrote In defense of mothers “How to bring up children in spite of the more zealous psychologists’. He also criticised Bettelheim’s book naming it ‘the empty book’.


After Bettelheim committed suicide in 1990 an investigation by students and researchers uncovered controversy surrounding Bettelheim’s career. One of these researchers was Richard Pollak who had met Bettelheim to find out about his brother who had been a student at the school who had died after falling on a family holiday. After being greeted aggressively by Bettelheim who accused his brother of committing suicide due to his father being named a ‘schiemel’ and mother being a typical Jewish mother, Pollak saw a darker side to the man who had been so admired. This sparked his desire to find out more.  What was uncovered was the lack of credentials Bettelheim had for the job, there were accusations of plagiarism, he was also know to spank the children if they behaved poorly. A former student told of physical and sexual abuse in the school and the staff had ‘instruction through terror’. Students said they feared the sounds of his footsteps from outside the dormitory. The Orthogenic School actually had very few autistic children in it despite Bettelheim basing all of his research on autism from the findings at the school. He also hired staffs that were untrained; some believed it was to make sure no one would disagree with Bettelheim. (Pollak 1997)


Of course, Bettelheim overlooked the detail that many of the siblings of autistic children were socially and developmentally normal, thus reflecting healthy parenting. Clearly, once disproved and fought against, Bettelheim became an enemy to autism by the autistic community and perhaps set autism back instead of forwards. Hans Eysenck, in his book Decline and Fall of the Freudian Empire, blamed Freud himself for ‘setting Psychiatry back 100 years.’ (Eysenck 1986)


Another explanation for the coldness of the parents is that autism has a genetic basis. In 1977 Michael Rutter and Susan Folstein conducted a twin study of 21 pairs (11 MZ 10DZ) with one of the pair being already diagnosed with autism. It was found that there was a 36% concordance between MZ twins compared to a 0% concordance with DZ twins. The concordance for cognitive abnormality was 82% in MZ twins and 10% in DZ. It was concluded that there is a genetic influence towards cognitive abnormality, which incorporated autism. This research questioned the mindset at the time that autism was psychogenetic and not an organic condition. (Rutter and Folstein 1977)


However, this was not the first description of autism as biologically borne condition. Dr. Bernard Rimland in 1967 published his book Infantile Autism: The Syndrome and its Implications for neural theory of behaviour. Despite Kanner giving the foreword and full support (Bernard 1967), it fell on deaf ears of the psychoanalysists who were largely in control at the time.


Hidden Agendas of the Rule Benders


Dr Andrew Wakefield was a researcher at the Royal Free Hospital in London who in February 1998 published a Lancet paper that showed a possible link between the MMR vaccine with autism and gastrointestinal deformities. In this paper he looked at 12 children with pervasive developmental disorders referred to the Royal Free Hospital all having intestinal abnormalities. Onset of behavioural symptoms, according to parents, where associated with mumps, measles and rubella vaccine in eight of the 12 parents. One child had a measles infection and another had otitis media. (Wakefield 1998) Wakefield in a later press conference argued for singular vaccines rather than the combined MMR vaccine. This paper and later papers published by Wakefield caused a massive media scare, despite two months after the study the Lancet produced a Finnish 14 year prospective study showing there being no link between the MMR and Bowel disease or autism (Peltola 1998). Even the Prime Minister at the time, Tony Blair refused to comment whether he had his son immunized with the vaccine.


However, the Lancet was not aware of a number of factors about the study. When the Sunday Times reporter, Brian Deer in 2004 released an article on his investigation on Wakefield they found that he had distorted the true findings of the research. There was not one child of the 12 that did not have some inaccuracy over their information in the data submitted in the study. Deer found that Wakefield took £50,000 from the Legal Aid Board (LAB) who represented clients who wanted to sue the MMR before the study. This money was said to pay for the care of five children the LAB represented. However, as the NHS is there to cover these costs, it was thought that Dr. Wakefield took this money for himself. He had a clear conflict of interest. The Sunday Times also found that his referrals of the patients were not sent through the normal routes. Many patients were brought over from far distances especially for the study. In a later paper done by Wakefield the participants he obtained were from his son’s birthday party in which he took blood samples. In a lecture afterwards, he spoke humorously about the unhappiness and pain he inflicted on the children. (Deer 2011)



The GMC stated that this was a clear misconduct professional duty of care as a medical practitioner. He also did not consult the ethical committee prior to the study and therefore went ahead without ethical approval.  All these factors led to the retraction of his Lancet papers and in 2010 after 136 days of investigation the GMC terminated Wakefield’s licence to practise. (GMC 2010)

Despite his investigation outcome, Wakefield continues to have many supporters; he still states that he has done nothing unethical.  (Godlee et al 2011) The implications of his paper and its effect on the incidence of Mumps, measles or rubella are not yet determined yet it is clear that the ongoing distrust towards vaccines will continue thanks to a small case study with a weak link a best that has been shown to be fraudulent. Certainly it gave autistic parents perhaps a glimmer of hope to find the aetiology of autism but once again took responsibility for causing their child’s developmental disorder.




As the cause of autism remains unknown there still has not been any drugs or therapy that can cure it. Most treatments aim to control the symptoms. The development of therapeutics in psychiatry has come a long way in 20th century. However, there have been many ethically questionable occurrences especially in the 1950-60s, in particular the experimental nature of treatment used by the clinicians on their patients. Bettelheim’s treatment for children was, as mentioned, parentectomy where children would be separated from their parents and Bettelheim would try to start a new attachment with others at the Orthogenic School. He used milieu therapy as a way of giving the children a realistic environment for later life. His main treatment to cure autism was to treat the parents with psychotherapy and they were the ones with the pathology.

The psychedelic drug LSD has been used experimentally during the 1960s at a time when infantile autism and childhood schizophrenia were being thought to be mutual disorders. Despite some researchers claiming marked results there was a lack of experimental controls.  (Sigafoos 2007)

In a recent study, Lee Watchell proposed the use of electoconvulsive therapy (ECT) as a technique to stop an autistic boy from self-harming. The child was known to punch himself an average of 109 times/hour. None of the cognitive behavioural therapy they used was being effective. ECT is still used today and the primary use is to treat depression. According to the study, the therapy was a success and the boy had marked improvements in his behaviour. (Watchell 2009)

In 1966 Dr Eric Schoppler founded the TEACCH approach (Treatment and Education of Autistic and Communication handicapped Children) at the University of North Carolina School of Medicine, where the child and their parents learn strategies and skills to enable the child to function as independently and meaningfully as possible. (TEACCH)

The NHS uses a multitude of therapy and drugs today. Applied Behavioural Analysis where communication, social, cognitive and academic skills are broken down to small tasks and the child has their behaviour reinforced with rewards. Speech and Language therapy is used to improve listening, attention, the ability to understand the tone and context of language and nonverbal communication skills. The medication used today remains to treat the undesirable symptoms of a pervasive developmental disorder such as aggressive behaviour. SSRIs such as fluoxine and proxitine are used. (NHS website)


Where the future lies

The DSM V (Diagnostic and Statistical Manual of Mental Disorder) is likely to be published in May 2013 and there have been large changes to the content from the previous manual. All the neurodevelopmental conditions have been removed except autistic spectrum disorder. Perhaps this is statement of the times that as our understanding of psychological conditions improve we are finding that there is some kind of neurological basis even if extremely subtle. Therefore, the barriers between neurology and psychiatry will perhaps dissolve and the two specialities will combine to become either a speciality of its own, (e.g neuropsychiatry) or they both may go on to fall under just neurology.

Recent studies looking at the imaging of the brain of autistic patients show scrambled connections in the Limbic system between the amygdala and the hippocampus. Whether this explains the aetiology or some of the clinical features of the condition are unclear. As our understanding of neurology improves, especially our understanding of the neurology of conscious thought and personality perhaps there will be a much better understanding of Autistic Spectrum disorder.

Genetically, we may find the specific loci for the genes that predispose autism. However, this carries with it the ethical dilemma about prenatal testing for autism and termination.


Autism has an extremely short history in medicine. It is amazing to think how the condition has transformed from just a word used by Bleuler to describe schizophrenia into a household name. April marks National Autistic Awareness month in America. There have been plenty references to the condition in books and films; despite sometimes lacking accuracy of the condition, it improves the awareness of the condition. Hopefully awareness helps increase education about the disease and therefore decreases the stigmatisation of autistic child and family.



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