Wednesday, 23 March 2011

Kanner's original autism descriptions

You will find some recurrent themes in this blog. This includes notions of how information can become distorted from the original source over time and the value of corroborating evidence when purporting to make statements of fact.

The first notion in particular may relate to this blog entry; analysing the original clinical descriptions of autism suggested by Dr Leo Kanner in 1943. It is perhaps timely that, in a few days, it will be 30 years since Kanner passed away (3 April 1981); indeed coincidental also that World Autism Awareness Day is on 2nd April (I wonder why they did not make it 3rd April instead?). I digress.

From the outset I want to acknowledge that, whilst Kanner's clinical descriptions form the basis for what we know as autism, I am by no means suggesting that he was the first to 'discover' autism given the many and varied texts from further back in history. Indeed, several other papers have suggested autism to have been present to some extent for many years prior to Kanner; although not labelled as 'autism' at the time (a label which did not exist).

I have always been keenly interested in Kanner's original 1943 paper 'Autistic disturbances of affective contact'. So much so, that my PhD drew heavily on his key clinical descriptions of 11 children who presented with symptoms including: inability to relate to themselves, extreme autistic aloneness, monotonously repetitious, anxiously obsessive desire for the maintenance of sameness and limitation in the variety of spontaneous activity. I have used but a few choice phrases from his text which have echoed down the diagnostic halls ever since.

There are however a few other phrases included in his 1943 text which, for one reason or another, did not quite receive the same subsequent acclaim. There are many reasons why such phrases and descriptions did not 'make the final cut' but I assume most were down to the old adage: a cobbler should stick to his last. Kanner was a Psychiatrist in the 1940s and hence specialised in 'disorders of the mind'. Subsequent interpretations of his text (e.g. DSM) have been undertaken specifically with Psychiatry in mind. Read on and you'll see what I mean.

'Food' (p.244) is mentioned in the 1943 text. Six of the children originally described by Kanner presented with various feeding difficulties; ranging from early vomiting, having to be 'tube-fed' and presenting with 'severe feeding difficulty from the beginning of life'. By early feeding problems I am assuming that this means problems with either mother's milk or the early formula milks (if they were even invented at this point). Six out of eleven cases, that's... er, over 50%. OK, he did not have a control group given that this was a case series description. Yet despite this, have early feeding difficulties ever been included in the diagnostic texts for autism? No, not even as an ancillary risk factor. Not once. Not never (not that I know anyway!). I know a few authors have offered potential explanations for early feeding difficulties in autism relating to the mechanical aspects of feeding and the 'perceptual' side of things. I am not saying that these may not be explanatory of what Kanner was perhaps describing. A few days ago however I blogged about a recent study from Harvard on the likelihood of lactose intolerance in cases of autism. Makes you wonder if today's technology were around during Kanner's tenure, would he be reporting lactose intolerance also?

Another example included in the original text. Kanner discusses the fact that 'several of the children were somewhat clumsy in gait and gross motor performances'. Gait and motor problems have similarly not been included in the diagnostic texts down the years. Unlike feeding problems however, there has been a slow realisation that such issues might be of relevance. It has however taken quite a few years for these elements to be 'realised' in cases of autism. One of the most recent studies being this one on the mechanics of gait in autism which is crying out for further replication.

The point I want to make with this post is that aside from going to the source for evidence, the original descriptions of autism from Kanner contained so much more than just behaviour relating to the triad (or should that be 'dyad'?) of impairments. Kanner did what any good scientist does - he observed and recorded things; not just behaviour but also developmental history and importantly somatic issues (see bottom of page 234).

I appreciate that today Kanner's autism has perhaps been 'subsumed' into this larger spectrum of autistic conditions. I often wonder how many of Kanner's original cohort would be diagnosed with autism, or an autism spectrum disorder, or even Asperger syndrome nowadays (bearing in mind that Hans Asperger did not define his patient group until a year later in 1944, and then light years away in Austria).