Dr. Volkmar: The history of autism goes back many years. There is a small literature suggesting that some of the reports of so-called “feral children” in Europe starting in the very late 1700s/early 1800s, eg, Victor, the Wild Boy of Aveyron by Itard, may well have been children with autism who would either have bolted from their home or been abandoned by their families.
CCPR: So the condition is not new.
Dr. Volkmar: No, but it was not until Leo Kanner and Hans Asperger published clear descriptions of the condition in the mid-1940s that people began systematically thinking about it as a special phenomenon apart from the more general concept of mental retardation on the one hand and childhood schizophrenia on the other. There is some controversy about who actually “discovered” autism, but Kanner was the first to publish a description of 11 cases in 1943 (Kanner L, Nervous Child 1943;(2):217–250. http://simonsfoundation.s3.amazonaws.com/share/071207-leo-kanner-autistic-affective-contact.pdf).
CCPR: And what was the essence of Kanner’s description of the disorder?
Dr. Volkmar: Kanner defined two features he thought characterized autism. One was the “autism,” or social withdrawal; the other was this funny category called “resistance to change.” Resistance to change literally can be just that, but it also includes “insistence on sameness”—sort of two sides of the same coin. Further, he described stereotypic behaviors that he saw as an attempt on the child’s part to maintain “sameness.” Basically, he conceived of these kids as being socially rather clueless but overly attuned to and intolerant of changes in their environment. And, of course, by its very nature, social interaction is change. Then, things remained fairly static until the 1970s, when researchers began publishing books and papers about the disorder. Michael Rutter’s work was especially influential.
CCPR: How did Rutter’s work differ from Kanner’s initial description?
Dr. Volkmar: Rutter basically systematized characteristics Kanner had described earlier, and his description strongly influenced the third edition of the Diagnostic and Statistical Manual (DSM-III), published in 1980, which was the first time psychiatry formally recognized autism as a disorder. In DSM-III, the criteria included a) onset before 30 months; b) a pervasive lack of responsiveness to others; c) severe delays in language development or, if language is present, d) peculiar speech patterns that could include immediate and delayed echolalia, metaphorical language, and pronominal reversal; e) atypical or bizarre responses to the environment; and f) no signs or symptoms suggestive of schizophrenia (see lead article for more details about the evolution of the autism diagnosis).
CCPR: DSM-III used a quite narrow definition of autism, consistent with Kanner’s belief that it was a rare disorder.
Dr. Volkmar: Yes, DSM-III called the disorder “infantile autism”; there also was a diagnosis of “residual infantile autism” for people who had once had the diagnosis but lost it. Also, DSM-III created a new diagnosis called child-onset pervasive developmental disorder (PDD), which, like infantile autism, entailed marked social impairment, plus a broad array of intense emotional reactions or odd interactions with the environment, with an age of onset after 30 months to 12 years.
CCPR: How did this change with the next edition of DSM?
Dr. Volkmar: With the publication of DSM-III-R in 1987, there was an effort both to be more specific with respect to criteria and also to create more flexibility to account for different presentations. PDD became an umbrella diagnosis, with autistic disorder under it. Autistic disorder retained the three categories of problems in a) socialization, b) communication, and c) odd behaviors and trouble with change. Again, as elaborated in the accompanying article, each category had specific examples of qualifying behaviors, and a person received the diagnosis based on having “enough” criteria. Also, the specific cutoff of 30 months was abandoned, replaced by occurring during infancy or childhood. In addition, DSM-III-R added PDD, not otherwise specified (PDD NOS), intended for individuals with some symptoms of autism but not enough to meet criteria for autistic disorder.
CCPR: Did you agree with the changes made in DSM-III-R?
Dr. Volkmar: Well, in hindsight, it probably would have been better to use “autism and related conditions” or even “autism spectrum disorder.” But, for many years, the emphasis was on autism as a specific, distinct disorder.
CCPR: What happened next?
Dr. Volkmar: In 1994, DSM-IV came out. I was very involved in that process, and we tried to correct several effects that DSM-III-R had had on how clinicians used these diagnoses. In my opinion, DSM-III-R was overly broad, especially among the more severely cognitively disabled: Many individuals previously diagnosed as having mental retardation were relabeled as having PDD. On the other hand, with its focus on young children, DSM-III-R’s definition did not lend itself to diagnosing older, more cognitively normal individuals. In DSM-IV, autistic disorder still included the same broad categories of social impairment, impaired language, and odd and restricted interests or behaviors, with some changes in specific criteria. The larger change was that PDD was broadened to include Asperger’s disorder, childhood disintegrative disorder, and Rett’s disorder, along with PDD NOS.