Fred Volkmar, M.D. Chief, Child Psychiatry & Director, Yale Child Study Center
When the word “autism” was coined in 1912 by Swiss psychiatrist Paul Eugen Bleuler, originally a follower of Freud, it was understood as a form of “schizophrenia,” a term also invented by Bleuler one year earlier. The irony is that “schizophrenia” was intended to replace the phrase “dementia praecox,” which means early onset of madness, but as research went forward on autism, late in the last century, it became increasingly apparent that autism as a cognitive and social disorder was not a form of schizophrenia but something unique and that its onset was in early childhood. As Dr. Fred R. Volkmar, the eminent director of Yale University’s Child Study Center, points out, Bleuler’s definition of schizophrenia as four A’s—ambivalence, affect, [a loosening of] associations and … autism—confused the picture for a time, and it was not clear that or how autism was different from childhood schizophrenia. Later on in the 20th century and to this day, confusion would also emerge over differentiating between autism and Asperger’s syndrome.
Dr. Volkmar, whose medical expertise includes the history of psychological disorders, is, in addition to being the director of the Child Study Center, the Irving Harris Professor of Child Psychiatry, Pediatrics and Psychology at Yale University School of Medicine and also Chief of Child Psychiatry at Children’s Hospital at Yale-New Haven. He is well aware of the complexity of reasons that have made it difficult to arrive at clear and unambiguous definitions of the related disorders. He notes, for example, that in 1943, when Leo Kanner, the first child psychiatrist in this country, was at Johns Hopkins, he introduced a description of infantile autism in the journal, Nervous Child, but that it was strongly believed—up until the 1970s—that autism was a kind of childhood schizophrenia. In 1944, just one year after Kanner’s paper, Hans Asperger published results of his observation of symptoms that strongly suggested something that was not a subset of autism, a finding that would lead to the eponymous designation of Asperger’s syndrome. It would be Dr. Volkmar, however, in 1994, whose definition of Asperger’s syndrome in the 4th edition of the Diagnostic and Statistical Manual (DSM-IV) would become standard as a set of guidelines for screen testing and diagnosis. In both cases, however, autism and Asperger’s, his work would help push back the period of diagnosis.
As Dr. Volkmar says, research—particularly large group studies done on psychotic children in England in the ’70s based on visual and auditory tasks—confirmed that autism can be detected in the very young, as early as six weeks, and that it has a strong non-cognitive component. Studies of identical and, to a lesser extent, fraternal twins have shown that autism is basically a disorder of social as well as cognitive impairment, and that both autism and Asperger’s reveal “strong genetic involvement.” Although there is still debate about Asperger’s syndrome as a form of autism and data show differences between the two, it is fair to say that both are characterized by deficits in normal social interaction. Most, though not all autistic children manifest severe language difficulty, are intellectually deficient, and lack social motivation and engagement, Dr. Volkmar notes. Non-autistic people use all sorts of physical communication cues—posture, facial gesticulation, tone of voice—whereas the autistic “at the most able level are focused literally on the words” and will miss the appropriate social dimensions. As for those diagnosed with Asperger’s syndrome, they tend to be highly communicative verbally, though focused, idiosyncratically and in a consuming manner, on particular things. They seem very bright, and often are, but they struggle with non-verbal skills.
Early intervention can make a difference, Dr. Volkmar points out, noting that some children diagnosed with autism and Asperger’s have gone on to college. The goal should be to avoid medication, especially for the very young, and to address the challenges of educating children with these disorders through support of special education. Inclusive classrooms have advantages—peers can be great teachers, he has written—but often “there is a lot of teasing or bullying.” Many educational programs have strong behavioral focus, but others have a developmental focus where the child sets the agenda more than the program does. The most effective programs, of course, are those that are individualized and are guided by teachers who are knowledgeable about the latest research. Dr. Volkmar’s own books have attempted to “provide something that is understandable to teachers and parents and bring research findings into the mainstream.” An extensive list of his publications can be found online.#