CHILD DEVELOPMENT
Understanding Autism
Although much is known about autism, misconceptions persist. A case report is presented and
used as a framework for dispelling some common myths about the condition. A simple, practical
model for understanding autism is proposed and recommendations are provided for the practitioner
managing a child with autistic-like features.
LUTISM WAS FIRST described by Kanner in
1943.' The condition has been both fascinating and
confusing to the medical profession and allied disci-
plines. Despite the extensive knowledge that has ac-
cumulated during the years, many myths persist, and
improper understanding remains all too common. The
following case report will highlight some ofthe pitfalls
in making the diagnosis of autism and in interpreting
it properly.
Case Report
A 16-year-old black girl was admitted for evaluation as to
"whether she had a psychosis or a learning disability." Her
grandparents (legal guardians) and the school had requested
help in planning her school program.
She did not say any words until the age of 30 months. At
4 years of age, she had been diagnosed as schizophrenic at
a university center specializing in developmental disorders.
In early adolescence, she had been felt to be schizophrenic
by two psychiatrists, one of whom continued to see her
monthly. Thioridazine had been tried without success. She
was in a school program for the emotionally disturbed but
was mainstreamed for mathematics.
Developmental milestones were not known to the grand-
parents. She reportedly had walked at an appropriate time
From the Department of Pediatrics, The John F. Kennedy In-
stitute, The Johns Hopkins University School of Medicine, Balti-
more, Maryland.
Supported by Project 917, Maternal and Child Health.
Correspondence to: Jon Matthew Farber, MD, Department of
Pediatrics, The John F. Kennedy Institute, 207 N. Broadway, Bal-
timore, MD 21205.
Received for publication June 1983, and accepted November
1983.
CLINICAL PEDIATRICS April 1984
Jon Matthew Farber, MD, Arnold J. Capute, MD
but was clumsy. She achieved independence in self-care skills
prior to the time of admission. She spoke in phrases at age
9. At age 11, she received a psychological and educational
evaluation at another university center. She was felt to have
near-average intelligence but to be functioning at a much
lower level because of emotional disturbance. Evaluation at
a "developmental center" at age 14 was interpreted as show-
ing a "biochemical imbalance" and poor binocularity; no
cognitive testing was performed. A diet low in concentrated
sweets and eye exercises were prescribed but they did not
improve her performance.
Early reports commented upon her autistic-like behavior.
At the time of admission, she still did not like changes in
her environment and would engage in occasional self-stim-
ulatory behavior.
By report, the mother was schizophrenic. Information
about the father was not available.
Physical and neurological examination was normal apart
from mild obesity, poor visual acuity, and mild clumsiness.
She was evaluated by an interdisciplinary team witb repre-
sentatives from pediatrics, psychiatry, psychological testing,
speech and language, special education, liehavioral psychol-
ogy, occupational therapy, and social work. Test results in-
cluded a Wechsler Intelligence Scale For Children-Revised
(WISC-R) with a full-scale IQ of 63, performance IQ of 84,
and verbal of 52. She could repeat eight digits forward and
six reversed (adult-level performance) but not a sentence
from memory at the 8-year level. On the Wide Range
Achievement Test (WRAT) level II, grade equivalents were:
spelling 6.9, mathematics 8.4, and reading single words ("de-
coding") 5.9. Reading comprehension of paragraphs was at
the pre-primer level; she could answer some questions using
rote memory.
All observers noted that her speech was of a "cocktail"
nature. She had several stock questions but did not engage
in meaningful conversation. She did not notice if she was
given an incongruous answer (e.g., green to the question
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"what color is your mother's hair?"). When presented with
a complex question, she would engage in humming and other
"inappropriate" behaviors. When the question was rephrased
more simply, she would attempt to respond, and her behavior
would become appropriate. Answers to many questions were
associative, focusing on key words; for example, her response
to the question "what's the thing to do when you are cold?"
was "to freeze." Her use of language for communication
was therefore at less than a 3-year level.
A diagnosis was made of pervasive developmental disorder
(autism), residual type, using DSM-III criteria. Academically,
her rote skills in spelling and word recognition were judged
not to be truly useful. Given her severe language and social
difficulties, it was felt that she would not be able to live
independently as an adult, and it was recommended that the
school program be aimed towards future sheltered com-
munity living.
Copies of our findings, interpretations, and conclusions
were clearly spelled out and sent to the psychiatrist and the
school. After receiving them, the psychiatrist asked whether
an inpatient stay for treatment of her "thought disorder"
with an antipsychotic medication would be useful. The school
asked whether she should be placed in a college preparatory
track.
Discussion
Myths of Autism
In his original paper, Kanner' listed the following
as important features of autism: inability to relate in
the ordinary way to people and situations; excellent
rote memory; obsessive desire for sameness; good cog-
nitive potential; and intelligent but cold parents. Now
it is known that the last feature is not correct, and
some of the others are not necessary (see below). Rut-
ter^ subsequently described the following criteria for
diagnosis: serious impairment in the development of
social skills; delayed and deviant language develop-
ment; ritualistic and compulsive behavior; and onset
before 30 months. A more recent similar attempt at
standardized classification is that of DSM-III.* The
patient described here was clearly autistic (actual DSM-
III diagnosis: infantile autism, residual state). Nev-
ertheless, this patient has presented both a diagnostic
and a treatment dilemma. It is instructive to look at
five ofthe most common myths of autism, both as they
relate to this case and to autism in general, to see
where the difficulties lie.
Mylh # / ; Autism is an emotional disorder. K a n n e r '
noted in his first set of patients that their parents were
cold, obsessive people, although he did point out that
he felt the condition was innate and organic. Psycho-
dynamic interpretations were very much in favor then,
so his statements as to etiology were ignored. An ex-
200
ample of the psychodynamic approach is that of Bet-
telheim.'* Researchers^'® have been unable to find sig-
nificant parental factors to account for autism, but this
belief persists. The psychological trauma from "blam-
ing" parents for their child's autism is readily appre-
ciated. Abnormal behavior is often equated, erro-
neously, with emotional disturbance, although behav-
ior and emotion are two distinct entities. The girl in
our case did have abnormal behavior, but it was part
of her organic condition of autism.
Myth #2.' Autistic children become schizophrenic adults.
There are several features in common between schizo-
phrenia and autism. Indeed, autism was at one time
equated with childhood schizophrenia, but they are
not similar. The genetics of the two conditions are
different,' and autistic children usually are retarded
as adults, not schizophrenic* One ofthe hallmarks of
autism is delayed and deviant language,^ as was true
of the girl in our case. Her conversational skills and
comprehension abilities were obviously not in line with
her chronological age, but they were in line with her
other language abilities. Her language cognitive age was
markedly depressed. In adult schizophrenia, however,
language capabilities should be at an adult level, with
qualitatively (rather than quantitatively) abnormal
thought processes. Failure to recognize this subtlety
can result in misdiagnosis, and our case had been felt
mistakenly to be schizophrenic.
Myth #3: Autistic children have normal cognitive potential.
Autistic children often are described as not looking
retarded.^ This leads observers to feel that there is a
core of higher intelligence that is prevented from being
manifested by the autistic behavior. If only the behavior
could be removed, the myth runs, then this core of
intelligence would be exposed. There are some autistic
children who are of normal intelligence, but they are
rare. The majority of autistic children are retarded.
The behavior is secondary to the cognitive impairment,
not vice-versa.
Many autistic children, like our case, can have iso-
lated islands of good cognitive skills (splinter skills).
Many have good performance capabilities, and the girl
in our case has normal mathematics abilities and ex-
cellent rote memory. This does not imply, however,
that her other cog^nitive abilities should be comparable;
this would be akin to claiming that someone with a
monoplegia should really have good use of the affected
limb because the other three function normally. In-
telligence is not represented by one IQ number in any
of the developmental disabilities, but this is particularly
true in the autistic population. To say that a 16-year-
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 UNDERSTANDING AUTISM
old with the performance skills of a 13-year-old is of
low-normal intelligence, when her verbal skills are at
a 3-year level, is to markedly misrepresent the case.
Myth #4: Rote abilities indicate true understanding. Many gestural
autistic children, like our case, have good rote mem-
ories. They can thus do well on associative tasks, such
as pointing to named pictures. This can act as an in-
flator of other skills. The girl in our case was reported
to "read" at the fifth grade level, because she could
pronounce written words at this level. Actually, she
was merely decoding, and for her it was like reading
a foreign language. Yet, even after receiving our ex-
plicit reports, the school staff remained confused and
still wondered if she had a potential for college. An
even more striking, yet subtler, example of rote learn-
ing masquerading as understanding was seen in her
conversation. She had learned a number of standard
questions about age, schools, and so forth, which she
readily asked. However, she could not use the infor-
mation in any meaningful way. She could only mem-
orize it for future parroting.
Myth #5: Autistic children are untestable. This helps to
perpetuate the third myth; if you do not adequately
test a child, how can you actually say anything about
intelligence? When our case was tested at age 11, she
was given 3 of the 10 WISC-R subtests, as she could
not obtain scores on the others. Her scores on these
tests were in the average range, and the interpretation
was therefore that she may have average intellectual
potential. The more important finding was that she
could not score on the other 7 subtests, not because
of behavior, but because of ability. If a test geared to
a lower cognitive age had been administered, she would
have been able to answer some questions and receive
a score. 'Untestable' almost never means untestable;
it almost always means the examiner did not aim low
enough.
Model of Autism
Having explored and exploded these myths, what
then is autism? Autism is a developmental disorder
that includes a language impairment; it is a form of
communication disorder.'" It differs from other com-
munication disorders, such as developmental aphasia
or congenital deafness, in the totality of the impair-
ment, which includes both verbal and nonverbal lan-
guage skills. Children with autism and developmental
aphasia differ, as the former have more deviant lan-
guage development, more severe comprehension de-
fects, and defects in the social usage of language.'"
CLINICAL PEDIATRICS April 1984
Similarly, deaf children should have normal nonverbal
language, which is not true of autism.
Nonverbal language skills are involved in social and
communication, so that the autistic child has
abnormal social skills: lack of eye contact, not cuddly
as a baby, more interested in objects than people, etc.
The impaired verbal skills lead to such features as
mutism and delayed and/or stereotypic speech. Be-
cause of delayed language acquisition, these children
often will have pronounced or prolonged echolalia or
pronomial reversal, both phenomena seen to a lesser
degree in the normal child below 30 months (see be-
low). Performance and memory capabilities are also
usually affected, but need not be, so that some autistic
children can have splinter skills. These skills, however,
are not indicative of overall intelligence. As with other
developmental disabilities {e.g., mental retardation, ce-
rebral palsy), the autistic child does progress, but at
his own rate. As language abilities progress, so does
social awareness. As a consequence, behavior improves.
Autistic features are "outgrown," but the underlying
cognitive impairment remains.
Recommendations
Given a better understanding of autism, where does
this lead? First, autism is to be viewed as an organic
developmental disorder, not an emotional condition.
There is often a great deal invested in considering it
to be emotional, because that implies a cure is possible.
However, true psychoses are rarely (indeed, probably
never) seen in early childhood. A diagnosis of psychosis
is usually based on findings that are better explained
on a developmental basis. For example, pronomial re-
versal is commonly seen in autistic children and often
given a psychodynamic interpretation. In actuality,
pronomial reversal is a common developmental finding,
and when seen in the older autistic child, merely reflects
his developmental language delay. Similarly, the ab-
normal behavior can be explained by retarded non-
verbal language development, and is not due to dis-
ordered thought processes as may occur in a cognitively
normal child.
Second, there is a need to obtain accurate IQ scores
and interpret them properly. With all their faults, IQ
scores are still good predictors of future functioning
in autistic children.* 'Untestable' or partial results usu-
ally indicate that the examiner has chosen a test at too
high a level. Similarly, it is necessary to avoid sole
reliance on nonverbal IQ measures, such as the Leiter
or Raven's Progressive Matrices. A child with autism
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 FARBER AND CAPUTE
can have a normal nonverbal IQ and still have severe
cognitive impairment in his language abilities. The
language abilities are of greater prognostic significance
and must be determined.
Third, rote skills should be viewed properly, as iso-
lated abilities. Over-reliance on them will result in an
over-estimation of the child's functioning. Reading
words is different than reading for information, count-
ing out loud is different than having number concepts,
and so forth.
Lastly, parents must be educated early and well.
Autism is misunderstood still, as the present case report
shows. The "mystique" of autism must be removed,
and parents must be given a framework for under-
standing. Autism can best be viewed as a language-
based cognitive disorder. The family here did not un-
derstand their grandchild's condition, and in their
quest for answers, the girl had been treated needlessly
with eye exercises and dietary therapy. Both of these
offered false hope and, by not addressing the under-
lying language disorder, perpetuated the cycle of mis-
understanding. Numerous unscientific treatment
methods abound and strong claims will be made, but
there are no cures. At the present time, only educa-
tional methods (including behavioral modification)
have been demonstrated to be effective at improving
performance. Additional information for parents can
be obtained from well-reasoned literature," and
202
through the National Society for Autistic Children
(1234 Massachusetts Avenue, Washington, D.C.).
References
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1943;2:217.
2. Rutter M. The description and classification of infantile autism.
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autism: proceedings of the Indiana University colloquium.
Springfield, IL: Charles C Thomas, 1971:8-29.
3. American Psychiatric Association. DSM-III: diagnostic and
statistical manual of mental disorders. 3rd ed. Washington,
DC: APA, 1980.
4. Bettelheim B. The empty fortress. New York: Free Press,
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5. Cox A, Rutter M, Newman S, Bartak L. A comparative study
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