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The Rise of Autism

This innovative book addresses the question of why increasing

numbers of people are being diagnosed with autism since the 1990s.
Providing an engaging account of competing and widely debated
explanations, it investigates how these have led to differing
interpretations of the same data. Crucially, the author argues that
the increased use of autism diagnosis is due to medicalisation across
the life course, whilst holding open the possibility that the rise may
also be partly accounted for by modern-day environmental
exposures, again, across the life course.
A further focus of the book is not on whether autism itself is valid
as a diagnostic category, but whether and how it is useful as a
diagnostic category, and how the utility of the diagnosis has
contributed to the rise. This serves to move beyond the question of
whether diagnoses are ‘real’ or social constructions, and instead
asks: who do diagnoses serve to benefit, and at what cost do they
come?
The book will appeal to clinicians and health professionals, as well
as medical researchers, who are interested in a review of the data
which demonstrates the rising use of autism as a diagnosis, and an
analysis of the reasons why this has occurred. Providing theory
through which to interpret the expanding application of the
diagnosis and the broadening of autism as a concept, it will also be
of interest to scholars and students of sociology, philosophy,
psychiatry, psychology, social work, disability studies and childhood
studies.
Ginny Russell is Senior Lecturer at the University of Exeter, in the
UK. She co-leads the Health and Illness theme at Egenis (the Centre
for the Study of Life Sciences) in the College of Social Science and
International Studies, as well as co-leading the Epidemiology and
Qualitative Research stream of ChYMe (the Children and Young
People’s Mental Health collaboration) based at the College of
Medicine and Health.
Routledge Studies in the Sociology of Health
and Illness

Banking on Milk
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Tanya Cassidy and Fiona Dykes

Ageing, the Body and the Gender Regime

Health, Illness and Disease Across the Life Course
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Insane Society: A Sociology of Mental Health

Peter Morrall

Risk and Substance Use

Framing Dangerous People and Dangerous Places
Edited by Susanne MacGregor and Betsy Thom

‘Ending AIDS’ in the Age of Biopharmaceuticals

The Individual, the State, and the Politics of Prevention
Tony Sandset

HIV in the UK
Voices from the Pandemic
Jose Catalan, Barbara Hedge and Damien Ridge

The Rise of Autism

Risk and Resistance in the Age of Diagnosis
Ginny Russell
Performance Comparison and Organizational Service
Provision
U.S. Hospitals and the Quest for Performance Control
Christopher Dorn

For more information about this series, please visit:

www.routledge.com/Routledge-Studies-in-the-Sociology-of-Health-
and-Illness/book-series/RSSHI
The Rise of Autism
Risk and Resistance in the Age of Diagnosis

Ginny Russell
First published 2021
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Ginny Russell
The right of Ginny Russell to be identified as author of this work has been asserted
by her in accordance with sections 77 and 78 of the Copyright, Designs and
Patents Act 1988.
The Open Access version of this book, available at www.taylorfrancis.com , has
been made available under a Creative Commons Attribution-Non Commercial-No
Derivatives 4.0 license.
Cover art work by J.A. Tan. Find more of J.A. Tan’s work at the-art-of-autism.com,
and artofjatan.com
Trademark notice : Product or corporate names may be trademarks or registered
trademarks, and are used only for identification and explanation without intent to
infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
Names: Russell, Ginny, 1965–author.
Title: The rise of autism: risk and resistance in the age of diagnosis / Ginny
Russell.
Description: Milton Park, Abingdon, Oxon; New York, NY: Routledge, 2021. |
Series: Routledge studies in the sociology of health and illness |
Includes bibliographical references and index.
Identifiers: LCCN 2020039810 (print) | LCCN 2020039811 (ebook) |
ISBN 9780367250812 (hardback) | ISBN 9780429285912 (ebook)
Subjects: LCSH: Autism. | Autism–Diagnosis. | Autism–Environmental aspects.
Classification: LCC RC553.A88 R87 2021 (print) |
LCC RC553.A88 (ebook) | DDC 616.85/882–dc23
LC record available at https://lccn.loc.gov/2020039810
LC ebook record available at https://lccn.loc.gov/2020039811
ISBN: 978-0-367-25081-2 (hbk)
ISBN: 978-0-429-28591-2 (ebk)
Typeset in Galliard
by Newgen Publishing UK
For Susan Kelly
Contents

List of illustrations
Acknowledgements

Introduction

1 Establishing the trend

PART I
‘Artefactual’

2 Babies and infants

3 Children

4 Adults

5 Women on the verge of the autism spectrum

6 Beyond the living

PART II
‘Real’

7 Epidemiology and lay epidemiology

8 Risks during conception, pregnancy and birth

9 Factors during infancy, childhood and adulthood

10 Diagnosis

Conclusion

Index
Illustrations

Figures
I.1 Distribution of autism studies by continent from cross-
sectional review. Includes all autism research studies
published in top four autism-specific journals in 2016
I.2 Waves of autism activism
I.3 A model of identification in the clinic
I.4 Diagnostic criteria for autism in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
I.5 Distribution of traits contributing to the autism spectrum
1.1 Post-1970 time trend in estimated prevalence of autism
1.2 Twenty-first-century time trend from prevalence estimates
1.3 National Health Interview Survey data
1.4 Prevalence estimates of autism in European countries
1.5 Prevalence estimates in the USA
1.6 Percentage increase in incidence of autism diagnosis from
1998 to 2018 from general practitioner records
2.1 The Coffee Cup example: Starbucks Autism Awareness
campaign
3.1 Changing boundary for diagnosis in children
3.2 The average age of autism diagnosis in the Avon Longitudinal
Study of Parents And Children (ALSPAC) dataset
3.3 Hacking’s early ideas about looping
3.4 Hacking’s later ideas about looping (adapted from Tekin)
 3.5 Mean age in years of participants with autism by frequency of
study
3.6 Schematic representation of looping effect
4.1 Time trend in incidence of new cases in England by age band
in primary care data
4.2 Areas where there has been a rise in activity centred on
autism as a diagnostic category
4.3 The looping effect of mobilisation and de-stigmatisation
5.1 Percentage increase in incidence of autism diagnosis from
1998 to 2018 by gender
7.1 A model of identification in the clinic
7.2 Change in mild traits and diagnosis in eight-year-olds in 1998
(Avon Longitudinal Study of Parents And Children (ALSPAC))
compared to 2008 (Millennium Cohort Study (MCS)) (top 5%
composite autism-type traits score (CATS))
8.1 Time trend to older motherhood. UK data from the Office for
National Statistics
8.2 Schematic of possible explanatory pathways for association
8.3 Putative looping effect from older parenting
8.4 The time trend in medically induced /elective births in the
USA. Percentage change in rates relative to baseline rate in
1987 (index number, data from Centers for Disease Control
and Prevention)
8.5 Time trend in percentage of pre-term births (data from World
Health Organization: ptb.srhr.org)
8.6 Confounding in epidemiology
9.1 An initial model of stimming as regulatory mechanism
9.2 Antecedents of autistic behavioural states versus autistic traits
10.1 Simple medical model of clinical diagnosis
10.2 Autism ID card
10.3 How diagnosis transforms the frame of view
C.1 New populations have become eligible for autism diagnosis as
time has passed
C.2 The cathedral metaphor

Tables
6.1 Retrospective diagnoses of characters in Winnie-the-Pooh
6.2 Some possible explanatory frames for low mood of adolescent
working in factory
7.1 Putative risk factors for autism taken from correspondents’
theories
8.1 Plausibility check for older parenthood as a contributor to rise
in autism
8.2 Plausibility check for PM2.5 (small particulate matter)
8.3 Plausibility check for late pre-term birth as a risk factor
Acknowledgements

This work was generously funded by the Wellcome Trust as part of

an Investigator Award, Exploring Diagnosis , grant number
108676/Z/15/Z SfZ. I would like to thank the Ex Dx team, my
collaborators on all the studies and the PhD students from whom I
have learnt so much: Abby Russell, Selina Nath, Jennie Hayes, Tom
Lister, Victoria Wren, Elena Sharratt and Rhianna White, as well as
people who were kind enough to read draft chapters: Annemarie
Jutel, Stuart Logan, Mike Michael, Peter Carpenter, Christine
Hauskeller, Ilina Singh, Delphine Jacobs, Su Lovell, Virginia Bovell,
Katherine Runswick-Cole, Adam Feinstein and Steven Kapp. Thanks
also to JA Tan for the cover art, Ann Grand for edits and James Vine
for designing the fabulous graphics.
Introduction

Autism is being diagnosed more often in both children and adults.

The big question is why ?
This book aims to answer that question by offering an account of
the modern-day (post-1990) rise in the use of autism as a diagnosis.
My research in this topic comes from my work as an epidemiologist
and social scientist with a strong interest in the activist counter-
narrative of neurodiversity. 1 My view is partial and situated; 2 my
knowledge spans both the above disciplines but does neither of
them justice. Therefore, I have chosen to address this question with
a focus on what I do know about: my research, which has led me to
reflect on how the work was carried out, who shaped it and why.
The book focuses on my research in the last ten years, much of
which has been carried out in collaboration with various colleagues
and students; some of the empirical work reported here is new and
some comes from published studies.
The post-1990 period has been a time of change and, in high-
income countries, roughly equates to the period sociologists refer to
as late modernity; 3 a time in which identity politics and self-
definition have intensified. This has in turn shaped medicine,
particularly in the field of autism research. I hope this book will
reflect this and be read not only by academics and clinicians but also
by people with autism/autistic people (I will be using these two
terms interchangeably i ) as well as people in autism-related jobs,
educators, health professionals, students and parents of people with
autism.
 The rise in autism diagnoses since the 1990s is a phenomenon of
high-income countries, particularly those in North America and
Europe. We have no reliable data to identify trends in autism
diagnosis for lower- and middle-income countries. According to our
cross-sectional review of published papers in autism research in
2016, 4 we found (but had no space to report) that 85% of autism
research took place in North America and Europe, and 45% of
European research happened in the UK (Figure I.1 ). Very little
research (<1%) originated from either Africa or South America.
There is just not enough data from lower-income countries to
analyse time trends.

Figure I.1 Distribution of autism studies by continent from cross-

sectional review. Includes all autism research studies
published in top four autism-specific journals in 2016.
 In addition, many low- and middle-income countries, including
much of Asia and most of Africa, still consider autism to be a
condition that was almost always associated with an intellectual
disability. In the UK and USA, autism is increasingly being diagnosed
in children with above-average intelligence (Chapter 3 covers the
implications of this). The trend of autism diagnosis in various low-
and middle-income countries may be very different to that in Europe
and North America.

Why is autism on the rise?

The trend of increasing diagnosis of autism since 1990 is established
in Chapter 1 , with data from many settings. The reasons for the
upsurge in diagnosis are hotly debated. Some researchers attribute
the rise solely to artefactual , not actual, increases and others
suspect the rise is both artefactual and real ; in other words there
are more children with autistic-type behaviours around today than
there were in 1990.
The artefactual account of the increased use of autism diagnosis
is partly due to the medicalisation of behaviour at the milder end of
the spectrum to bring it under the banner of ‘diagnosable autism’:
changes in methods of identification, diagnostic substitution,
increased awareness, shifts in understanding, together resulting in
the broadening use of the label. All these things have prompted
increased diagnosis, as many excellent historical and sociological
texts have shown. 5 – 9 This book concentrates on another
mechanism, the increased diagnosis and recording of autism in new
cohorts of people, babies, infants, children, adults, even dead
people: divided by stages across the life course.
Many parents, activists, clinicians and researchers believe that
there is a real rise in autism, as our study, reported in Chapter 7 ,
attests. By ‘real’ I mean that a larger percentage of the population
has severe autistic symptoms ii than in previous generations. In Part
II , I’ll hold open, and attempt to consider some of the evidence for,
the possibility that the rise may be fuelled or partly accounted for by
modern social trends, changes in medical practices or environmental
exposures. In this account, there is an increased risk of autism
because some novel environmental, medical (for example, a new
drug used in pregnancy) or social trigger (such as older parenthood)
disturbs neurodevelopment. Risk factors such as these might also be
associated with more cases of a range of neurodevelopmental
problems, leading to outcomes such as intellectual disability,
attention deficit hyperactivity disorder (ADHD), language delay or
disrupted neurodevelopment across the board, so a broad view is
adopted.
The general consensus in mainstream autism science, among
epidemiologists and most autism researchers, is that the rise in the
use of a diagnosis of autism diagnosis is artefactual. 10 In Chapters 2
–6 , I will describe how autism diagnosis (or pre-diagnosis) has been
extended to types of people it was almost never applied to before
1990. The rise itself has contributed to increased awareness – a
form of looping: 11 the rise prompts more awareness which in turn
fuels the rise. Such looping effects are brilliantly described in Ethan
Watters’s book Crazy Like Us. 12 He demonstrates how Western
psychiatric categories, such as anorexia, depression and post-
traumatic stress disorder, have been relentlessly publicised in Asia,
leading to huge apparent jumps in prevalence in Asian countries.
Also, services directed at autism and the availability of diagnostic
assessment bolster the rates of diagnosis. I will give examples of
some other forms of looping effects, as well as discussing pertinent
modern narratives in autism research that have effectively fuelled
autism’s rise.
The debate over how to account for the rise – whether it is
entirely artefactual, or whether it is both artefactual and real – is a
touchstone of this book, seeking to move beyond the somewhat
tired question of whether diagnoses are ‘true’ neurodevelopmental
differences or social constructions (they are both) to ask, in
conclusion, who benefits from autism diagnoses? And at what cost?
Is autism useful as a diagnostic category and if so, for whom, when
and under what circumstances?
As a diagnosis, autism has many functions: for clinicians, to
organise treatment, services and predict outcomes; for insurance
companies, to process payments; for researchers, as a way to
organise the field; for activists, as a banner to rally beneath; for
lawyers, as a way to decide who is responsible for their actions. 13
But it is also crucial for parents or for autistic adults, in terms of
gaining access to services, rewriting biography and providing an
explanatory frame, giving meaning. More sinister is the benefit for
Autism Inc., the chain of professionalisation and commercialisation
that runs in parallel with the rising use of diagnosis.

Tribes
Autism has inspired a huge amount of ‘tribal’ community, political
and social activism over many decades, 14 as described in Steve
Silberman’s book Neurotribes . Three ‘tribal’ viewpoints of autism
can be broadly and briefly characterised 15 – 17 as occurring in waves
(Figure I.2 ), each in reaction against and resistance to the previous
conceptualisation. Diagnosis positions autism as a disorder but how
people regard diagnosis reflects the waves of autism research and
activism. The bedrock of medical and psychiatric understanding
slowly erodes as the waves lift and lash against it and in turn, the
shape of the bedrock alters the waves.
Figure I.2 Waves of autism activism.

The understanding of clinical, epidemiological and biomedical

scientists in the autism research community was originally that
autism was triggered by cold parenting and should be diagnosed
using the expertise of psychiatry. Today, scientists believe that
autism is a neurodevelopmental disorder that encompasses a
spectrum of differences and should be diagnosed using the shared
expertise of psychiatry, clinical psychology or paediatrics. The first
wave of resistance, breaking against the dominance of psychiatry in
opposition to parent blame, largely prompted by parent activists,
was that parents are the real experts. This wave of autism activism
developed into one that sees autism as a biochemical neurological
condition that clinicians should diagnose, and treat (and cure if
possible). This ‘pro-cure’ wave peaked in the early 2000s. The ‘tribe’
are mostly parents of severely affected children and speak
passionately of the importance of efforts to develop biomedical
treatment for a highly impairing and distressing condition that they
see as akin to a disease 18 and certainly as a disorder. First-wave
thinkers put forward the notion of an autism ‘epidemic’ 19 whose
origin, as argued by fundamentalists in the tribe, was not only
biological but environmental, the consequence of new exposures.
Autistic activism emerged in resistance to the risk discourse of the
first wave, which painted autism as a threat to be feared and as a
tragedy. This wave of thinking is ascendant, and it encompasses a
broadly anti-cure stance, led by autistic activists and allies. This
wave argued for autism as an identity, an integral and important
difference that, although challenging and impairing, should not be
cured and regarded not as a tragedy but as a disability.
Accommodations to support autistic people to live well should be
provided. There are children and adults with real
neurodevelopmental differences, sometimes profound differences
that cause distressing impairments. But distress is also caused by
discrimination which, combined with a lack of adjustment by other
members of society, denies them full participation in the world. This
wave paved the way for the emergence of the neurodiversity
movement and self-identification as autistic. A part of our group’s
work has been to bring together autistic adults influential in the
movement; the authors of a collection put out by Steven Kapp in
20201 which, together with Tom Lister’s PhD research on self-
identification and diagnosis, 20 revealed many engaged adults who
firmly consider autism as identity rather than disorder, promoting
diagnosis but in a less pathologising frame.
In this context, it is clear why the idea of the real increase, an
environmental risk factor that precipitates autism or has a role in
increase of autism or autism traits, is understandably problematic for
some neurodiversity theorists. The environmental trigger theories of
diet, heavy metals and pollution drove the hardcore faction in the
first wave, who seemed, to autistic self-advocates, to be intent on
eliminating people like them. According to Kapp, himself an autistic
activist, arguments against environmental toxins as a risk factor for
autism help to ‘direct parents away from cottage industries based on
rejected and unproven theories that offer dangerous “treatments”
like heavy metal-injecting chelation therapy, chemical castration
(Lupron therapy) bleach enemas and vaccine avoidance (amid other
expensive or at least ill-conceived “interventions”)’.1 Many in the
neurodiversity wave reject causal models that implicate
environmental exposures not only because they are sceptical of the
evidence but also because arguments for rights hinge on
neurological differences (meaning neurological structural differences
with a genetic origin) that are present from, or even before, birth.
One can make an argument for rights based on differences acquired
via exposure (wheelchair users need and deserve ramps in the
present, regardless of whether they were fully mobile at some point
in their lives) but nevertheless, many advocates reject the idea that
autism is a result of an injury.
In different ways, the actions of both the neurodiversity
advocates and the pro-cure tribe seem to adopt, shore up and
dismantle a more medicalised model. 21 Each wave has spawned its
own competing language and associated narratives. I hope to draw
attention to the use of language in medical and resistance discourse
and its influence in constraining the possibilities for thought and
action, even though at times I will be using the aforementioned
language myself, adopting the conventions of some source texts.
The over-arching point is that each ‘tribe’ has a distinct standpoint
on how autism is conceptualised and advocates for autistic people in
particular ways. The result is an epistemic battleground, in which
each faction claims authority over knowledge of autism. Each wave
of thinking has swelled in resistance to what went before, growing
through people who care, yet feel silenced and marginalised.
Perhaps a new wave is even now brewing.
In high-income countries, the post-1990, late-modern period is
associated with a rise in self-characterisation,3 as opposed to the
earlier, traditional modern, period when ordered systems prevailed
and people were told what they were. Perhaps this explains the
misunderstandings over the third-wave autism-as-an-identity and the
traditional view of autism-as-disorder. Proponents of the
neurodiversity movement, especially autistic activists, have reclaimed
autism for their own since 1990 but autism-as-disorder is still
traditionally operationalised by psychiatrists, clinicians and
researchers. 22 All parties have epistemic authority but know things
in different ways. The tribe of those considered expert has grown to
include parents, autistic adults and many types of professionals, all
of whom contribute their own ways of defining autism. The result is
to multiply the ways in which autism is understood and recognised.
The bio-politics of autism illustrate how the same data can be
interpreted in very different ways by different groups to advance
their agendas. The politics of autism are bio-politics, not in a
Foucauldian sense, but because different groups (hybrids of
clinicians, self-advocates, parents and researchers) have mobilised
around the diagnostic category. They influence how information is
disseminated, by whom and why. The ‘tribal’ stories mesh, or
sometimes contrast, with the consensus and narratives of science. A
multi-level view of autism, together with a personal reflection that
underscores my point, will be found in the conclusion. This will help
to answer the guiding question: why is autism on the rise?

What is autism?
I was once lucky enough to attend a lecture given by the legendary
Sir Michael Rutter, often called the father of modern child psychiatry.
A member of the audience asked him, ‘what is ADHD?’
This was the wrong question, he replied. ADHD is a diagnostic
category like any other; a way of putting a boundary round a
collection of signs and symptoms (its ‘symptoms’ being mostly
behaviours). ADHD, he explained, is a useful psychiatric construction
but it does not exist separately from the definition that we give it. It
does not carve nature at the joints but is a pragmatic response,
designed to help children with distressing difficulties. Its boundaries
are in a state of slow flux, as our understanding of the behavioural
traits that comprise the condition evolve in step with research,
 expertise and society’s demands. This was a striking statement from
a leading autism researcher.
Like ADHD, autism can be thought of as a multi-dimensional
collection of psychological traits that interact with each other and the
environment; traits that may alter with development. These traits
are identified from behaviours that recur in multiple settings and at
multiple times. They are bound together not only for medical
diagnostic reasons but also for historical, pragmatic and political
reasons. Figure I.3 is a schematic illustration of how biology
underpins autism but interacts with social and environmental factors
at every level and how in clinical practice autism is identified by
pervasive behaviours rather than biological tests. In common with all
diseases and disorders, autism is both a real neurodevelopmental
difference and socially framed.

Figure I.3 A model of identification in the clinic.

The social construction of autism’s boundaries, vis-à-vis its

neurological actuality, can be illustrated using Covid-19. Like autism,
Covid-19, as a disease entity, can be considered an object around
which a boundary is placed (although it is unclear whether this
qualifies it as a ‘boundary object’, as described by Leigh Star 23 ). In
the UK, a person’s primary cause of death is categorised by the
Office for National Statistics (ONS). The ONS attributes deaths to a
discrete cause, usually a disease, such as cancer, dementia or
cardiovascular/heart disease. Or Covid-19. The record therefore
reports a decision about what that one person died from. Covid-19,
or any other disease, is a distinct cause which, from the ONS
statisticians’ point of view, must be distinguished so that statistical
analyses can be carried out. The reality, in many cases, is that a
Covid-19 infection affects functioning across multiple biological
systems, especially the respiratory system, leaving a person
susceptible to underlying health issues. It is plausible some deaths
resulted from a tipping over due to unrecognised infection by Covid-
19, even if the person were asymptomatic and the infection
therefore unidentified; the infection may have undermined the
person’s defences against their pre-existing conditions, which
predisposed their exacerbation. Inversely, underlying conditions may
make a person more vulnerable to Covid-19. Elderly people with pre-
existing health conditions are the most at risk from Covid-19
infection: pre-existing frailty means vulnerability. People’s biological
and psychological resilience may also be undermined by the
response to Covid-19: the lockdown, social isolation, lack of access
to services, and so on. Distinguishing one ‘cause’ of death is a
pragmatic construction, whereas the interaction of biological and
social systems being tipped over by infection is closer to reality.
I think autism may be a ‘boundary’ object, in that there is a
reality of neurodevelopmental difference. But like Covid-19, and like
most diseases, a continuum is converted to a category, while the
boundaries of ‘what counts’ are permeable and policed, certainly by
medical professions but increasingly, since the mobilisation of
parents, also by charities, autism organisations and autistic adult
self-advocates. There is the ‘interpretative flexibility’ of a boundary
object. 24 There are underlying neurodevelopmental differences, of
course, but there is no ‘real’ or ‘not real’ autism, no correct or
incorrect diagnosis, no misdiagnosis, no under- or over-diagnosis,
because diagnosis depends on where the boundaries are set, and by
whom. There is autism, but how it is identified, described and
classified is a human endeavour and determines what autism looks
like. Autism is what we say it is. If we define it as a multi-
dimensional set of behavioural traits at a certain severity, that is
what it is. There is no autism to be discovered ‘out there’. But that
does not mean it is not an enormously important and useful
construct that describes, and helps meet, impairing and challenging
difficulties.
In his response to the question about ADHD, Rutter
acknowledged that the group of people who are diagnosed with a
condition might change as a slightly different (or expanded)
collection of symptoms is identified. When does a collection of
symptoms become a diagnosis? Robert Aronowitz 25 draws an
analogy with the question of when does a dialect become a
language ? His answer is the well-known quip that a language is a
dialect with an army . There are many discourses about the signifiers
of autism and varying theories of the underlying biological,
psychological and social mechanisms that lead to its development.
Providing a comprehensive definition of autism is problematic.
Autism inevitably means slightly different things to different tribes;
to parents, clinicians, research groups and activists. None of the
tribes are homogeneous; there are many parents in the
neurodiversity movement, for example, and within each there are
different takes. The army of activists of autism, the tribes, has
strongly influenced the definition of autism. The Autistic Self
Advocacy Network (ASAN), for example, lobbied and advised the
workgroup producing the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) and can point to
tangible changes in the DSM criteria that their arguments solidified.
 An account of their actions is included in Kapp’s Exploring Diagnosis
collection.1
Probably the easiest way to answer the question ‘what is autism?’
is to refer to widely used, standardised manuals such as the DSM,
which at the time of writing is in its fifth edition (DSM-5), 26 most
commonly used by clinicians in the USA, and increasingly in the UK,
and the International Classification of Diseases , currently in its 11th
iteration (ICD-11), 27 more commonly used in Europe. For the
purposes of definition, let us consider autism to be what the DSM-5
says it is (Figure I.4 ).

Figure I.4 Diagnostic criteria for autism in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5).

The DSM positions autism as a characteristic of a person’s

development, yet acknowledges that social context affects how well
a person with autism copes, and hopefully thrives. Both ICD-11 and
DSM-5 list two core symptoms of autism: persistent deficits in social
interaction and social communication and restricted, repetitive and
inflexible patterns of behaviour and interests, including enhanced or
diminished sensory perception. If a person shows these behaviours
in different settings, a clinician would be able to give a diagnosis of
autism. Because the behavioural traits show regardless of setting,
they can better be attributed to atypical brain development than to
social context.
The onset of autism typically occurs in early childhood but the
ICD-11 notes that autism may not become obvious until later, which
suggests the underlying way of functioning psychologically may
already be present but that expression is less obvious because of the
particular demands placed on children’s roles at different ages. Of
course, things may also develop differently given the exposures the
child has as they grow up, which clearly affect these patterns of
functioning. The point the criteria make is that autism can exist
undetected in very young children. Both sets of diagnostic criteria
describe behavioural traits as symptoms and look at the impact of
said symptoms. According to the DSM-5, autism might ‘limit or
impair everyday functioning’. This emphasises the impact autism has
on a person’s ability to live a fulfilled and functioning life and paints
autism as a condition that is primarily a set of psychological or
behavioural traits, or an aspect of a person’s character. Autism
affects both other people and the person’s ability to thrive.
Various psychological theories to explain autism have been put
forward, 28 all of which have their supporters and detractors; no
model seems comprehensive. 29 The merits of the various theories,
many of which seem plausible, are not my focus. Autism might stem
from sensory-processing differences, 30 including enhanced
perceptual functioning, 31 weak central coherence, 32 lack of theory
of mind, 33 an extreme male brain, 34 defects in the mirror neuron
system 35 or the impairment of executive function, 36 , 37 to name
but a few. In a slow state of flux, its theories and diagnostic tools
are somewhat circular or tautological. We study autism and derive a
new psychological theory or diagnostic test. If this is how we then
understand or measure autism, the new test or theory starts to
Another random document with
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 “Oh, a tent will be good enough for the card-players!” was the
contemptuous reply.
“I never heard of such management! I shan’t come to this blessed
ball!”
“Oh yes you will,” returned Miss Valpy, serenely. She was already
at work, collecting and piling up newspapers. “Think of the prawns
and pomphret coming all the way from Bombay, and how
disappointed they would be not to see you!”
“Ah, and the Agra beauty who is also expected—Miss Glossop;
she will cut you all out! Ha, ha, ha!” retorted Colonel Sladen, with
angry exultation.
“That’s what people generally say of a girl they have never seen,”
rejoined Miss Valpy, coolly sweeping spills off the chimney-piece.
“Now, I have seen her. There are twenty prettier faces in Shirani.”
“Including the face of Miss Valpy!” with ferocious sarcasm.
“It is extremely kind of you to say so,” making him a mocking
curtsey, “and for once I am quite of your opinion.”
Colonel Sladen could not find any appropriate retort beyond some
inarticulate emotional noises.
“Fanny”—to her sister—“help Mrs. Glover and Mrs. Bell. Abdar”—
to a servant—“take out all the chairs into the verandah, and send in
the coolies to lift the table.”
Thus the smoking-room was stormed, and its lawful tenants
scattered abroad by bold, domineering, and unscrupulous women. It
was true that every department had been told off; the senior ladies
had undertaken the supper-room. There were to be little tables for
four—quite a novel departure; and on the day of the ball there was
scarcely a small table left in any private house in Shirani—the
bachelors had borrowed every one, as well as armchairs, rugs, and
draperies. Rookwood was almost swept and garnished, in answer to
the demands of Mrs. Brande’s “boy” Mark. Mrs. Langrishe, careful
soul, had declined to lend one single chair or candlestick. It would
have established a precedent. She, however, was good enough to
spare her niece, who demonstrated that she could work hard, and
decorate, and arrange flowers, when she pleased, and was full of
clever expedients. She and Toby Joy presided over the
arrangements of the long verandahs, and divided them with screens,
palms, and sofas, hung up lamps, flags, and draperies, and devised
numbers of sitting-out nooks with curiously sympathetic details and
elaborate care. Their merry bursts of laughter continually penetrated
to the ball-room, where a large party, by means of ladders,
hammers, and nails, were festooning the walls with miles of bazaar
muslin. Each department had its own special staff, and they
embellished according to their collective taste, and in friendly rivalry
with their neighbours.
One gang of workers visited another in order to offer their opinion
and encouragement, and most of the young people enjoyed the
decorations every whit as much as the grand result—the ball itself.
Honor, Mrs. Sladen, and half a dozen men and maidens were
posted to the reception rooms and card-tent, and, strange to say,
Honor and Mark Jervis shared the same hammer and bag of nails.
Personal history has its epochs: brief seasons, during which life is
fuller than usual. Never had the life of these two young people
seemed so fruitful of pleasant events as at the present time!
Miss Valpy, the valiant leader of the forlorn hope which stormed
the smoking-room, was resting from her labours. Lunch for the
workers was to be served in an al fresco fashion in the back
verandah. Meanwhile she reposed in a coign of vantage, an
interested and lynx-eyed spectator. She did not rest alone; her
companion, Mr. Skeggs—the youth who considered a young man a
reward in himself—lolled lazily beside her.
He was a little afraid of Miss Valpy, her sharp tongue occasionally
penetrated the rhinoceros hide of his conceit. But somehow the other
girls had not encouraged his assistance, which—to tell the truth—
had chiefly consisted in dropping packets of tacks about the floor
and lavishing uncomplimentary criticism.
“This ought to be a ripping ball,” remarked the youth complacently.
“Awfully well done. Some of them are working like niggers.” And he
grinned like a schoolboy.
“I am glad to see that you have a generous appreciation of other
people’s efforts,” rejoined the young lady sternly.
“Ah, well, yes”—stroking his exceedingly faint moustache. “I say, I
wonder who will be the belle to-night? Who do you think the prettiest
girl in Shirani? I bar the married ladies.”
“That is something very novel. Prettiest girl,” she repeated
speculatively. “Well, Miss Clover is the most strictly good-looking, her
features the most correctly in drawing.”
“Yes; only she always looks as if she was dressed up to sit or
stand and be stared at, like a wax figure with a label, ‘The public are
requested not to touch.’ You could not imagine her playing a hard set
of tennis, or riding to hounds, or braving wet weather.”
“No”—sarcastically—“I fancy she would ‘come off’ badly.”
“Miss Paske is the most lively of the lot. She has such a piquante,
wicked little face. On the whole I give her the preference. I like to talk
and dance with her, but I funk a tête-à-tête or a long walk, for she is
just the sort of girl who would propose for a fellow like a shot.”
“I am sure you need not be the least uneasy or afraid of putting
temptation in her way,” rejoined Miss Valpy. “You may enjoy her
company with impunity. You would not suit her at all, as you are
neither rich, good-looking, clever, or, indeed, distinguished for
anything but an enormous amount of conceit; and the amusement it
affords us is your only redeeming quality.”
Mr. Skeggs again stroked his little moustache, blinked his white
eyelashes fatuously, and giggled like a girl.
“Crushed—not to say squashed,” he groaned.
“You admire Miss Paske,” continued the young lady scornfully.
“Just what I would have expected of you! Now, in my opinion, she is
not to be named in the same hour with Honor Gordon. What lovely
eyes she has!”
 “Yes; Miss Gordon with her fiddle and her figure is hard to beat. As
to her eyes—I suppose they have never happened to scorch you?
She is too stand-off; she is a woman’s girl. To tell you the truth, she
frightens me.”
“Poor timid little soldier! No doubt you mean that she never flatters
you; and I admit that her honest frankness sometimes takes away
my breath. However, she does not terrify other men—for instance,”
and she paused expressively, “Mr. Jervis.”
“No;” pursing up his mouth and raising his eyebrows. “I should not
say he shrank from her. And who do you consider the best-looking
man in Shirani, Miss Valpy? Your taste is so cultivated.”
“Present company always excepted?” with a mocking glance out
of the corner of her eye.
He nodded with a solemn acquiescence.
“Mr. Jervis, of course,” was her promptly off-hand opinion.
“Oh, come—I say,” expostulated the youth.
“Yes, I will say that he is extremely handsome; not in the big
moustache, hooked-nose, bold brigand-style. He has a noble air; the
shape of his head, the cast of his features, the expression of his
eyes, embody my idea of a hero.”
“A hero!” ejaculated her listener. “Great Scot! A pity he has no way
of showing what stuff he is made of, beyond beating buffaloes away
from old ladies.”
“Yes, it is a pity. However, his opportunity may come yet. It is also
a still greater pity that one can never praise one man to another.”
“Well,” nursing his knee meditatively, “I will admit that Jervis is
passable, and looks clean bred——”
“Thank you, that is very kind of you. Does it not strike you that he
is afflicted with an old-fashioned infirmity, and is decidedly shy?”
“Shy!” he almost shouted. “Jervis shy? Ha, ha, ha!”
“Well, he is with ladies.”
 “Oh, you may call it by whatever name you please. I call it
fastidiousness. At any rate he is not shy with men. No fear! Only last
night at the club some cad made a caddish remark, and it was not
our hoary secretary who took it up and went for him, or any of the old
chaps, but Jervis. By George, he gave him pepper. Went slap down
his throat, spurs and all. A man’s man you know, and popular. He
can sing a good song, make a rattling good speech, and is as active
as a cat; you should see him take a run, and jump standing on the
billiard-room chimney-piece.”
“What, Jervis? My Jervis?” in a tone of affected horror.
“Ahem! Well, I am not so sure of his being your Jervis,” drawled
Mr. Skeggs.
“No; and I am positively certain that he is not, in the sense you
mean. I must confess that I should like to study him.”
“Would you?” sarcastically. “You will not find him easy to classify or
to fit into any of the usual pigeon-holes; he is a fellow who has a
singular gift of self-control—consumes his own smoke, you know.”
“Why you have been unbending your great mind and studying him
yourself! What do you make him out to be?”
“I make him out to be a curiosity—a mixture of an Arcadian
shepherd, a London swell, and the rich young man in the Bible.”
“You overwhelm me completely, especially by your last simile. Why
the rich young man in the Bible?”
“Because he kept all the commandments.”
“Oh!” drawing a long breath, “he must be as wonderful a rarity as
the great auk. As for an Arcadian shepherd, I see what you mean.
He has got what some one called an out-of-door mind. I have not. I
should loathe Arcadia, and green swards, and be-ribboned crooks,
and skipping lambs. To let you into a dead, dead secret, I can never
see a lamb without thinking of mint sauce!”
“Shame! Shame!” exclaimed Mr. Skeggs, in tragic tones. “Well,
Miss Gordon,” to Honor, who had approached their nook, “how are
you getting on with that grand scheme of mirrors and draperies?”
 “Very badly. It would have been finished long ago, only some
unprincipled people from the ball-room made raids on me, and
carried off both my hammers, all my pins, and two of my best
Phoolcarries. What do you call that?” appealing for sympathy to Miss
Valpy.
“I call it a beastly shame,” said Toby Joy, who had joined her,
speaking with much virtuous indignation—Toby, who himself had
been one of the most audacious robbers.
“I call it, Honor among thieves,” remarked Jervis, who happened to
be passing by.
Miss Valpy looked after him attentively. No, that young man was by
no means shy.
“I have made no end of beautiful kala-juggas,” continued Toby,
complacently; “there ought to be half a dozen engagements to-
night,” and he nodded his head and rubbed his hands ecstatically.
“I thought kala-juggas were not allowed,” retorted Miss Valpy,
severely.
“Fine man traps,” growled Colonel Sladen, who had just arrived to
offer criticism and obtain lunch. “But girls don’t go off as they used to
do in my bachelor days. Girls,” looking hard at Miss Valpy, “are a
drug in the market.”
“There is another view, that may not have occurred to you,” she
answered, snatching up the gauntlet thus flung in her face. “They are
undoubtedly more difficile than when you were a young man. They
may have heard the good old motto, ‘Look before you leap!’”
Toby Joy sniggered audibly, and Colonel Sladen, turning savagely
upon him, demanded, “what the devil he was laughing at?”
Toby, slightly cowed by the cantonment magistrate’s beetling
brows and fierce demeanour, blandly answered with an impudent
twinkle—
“I was only thinking of something I was told just now. Mrs.
Tompkins’ English-speaking Bearer announced to her to-day that the
goose had four pups!”
 There was a shout of laughter at this startling item of natural
history; but Colonel Sladen was still unappeased, and would have
pitilessly pressed home his question, but for Mr. Skeggs, who cried
with great presence of mind—
“There is Jervis coming back; what is he saying? Ah!”—with a
gesture of delight—“Lunch—lunch—lunch.’ Shows he is an alien, or
it would have been ‘Tiffin—tiffin—tiffin.’”
“Ladies and gentlemen,” said Jervis, making a profound bow,
“luncheon awaits you; and Mrs. Loyd requests me to announce that
as you are here to work and not to play, you are only allowed twenty
minutes for refreshments.”
“Mrs. Loyd is as bad as an East End sweater,” grumbled Mr.
Skeggs, handing Miss Valpy down from their mutual perch.
“You may tell Mrs. Loyd from me, that I won’t work a second over
the eight hours,” cried Toby; and, offering his arm to Miss Paske,
they waltzed across the ball-room, “just to try the floor.”
“Pray observe,” whispered Miss Valpy, as she and her escort
seated themselves before a recherché cold luncheon, “how your
man’s man, Mr. Jervis, takes care to secure a place beside a
woman’s girl. Can you explain that?”
“No,” seizing a pair of carvers as he spoke. “Just at present I
prefer to explore the contents of this most interesting-looking raised
pie.”
 CHAPTER XXIX.
MARK JERVIS IS UNMASKED.

At nine o’clock—Indian balls are punctual and early—many lights

were to be seen converging in all directions towards the club. The
oldest inhabitant scarcely recognized it, it was so completely
metamorphosed, and turned back to front and upside down. The
general effect was dazzling—Persian carpets, rich draperies,
Chinese lanterns, Japanese screens, great palms, abounded in the
verandahs, and the ball-room was a blaze of candles, mirrors, and
pink muslin. The reception rooms were blocked up by girls and men,
busy with programmes and pencils.
Among the girls, no one was so closely besieged as Honor
Gordon. She was looking quite lovely, in a new white ball-dress, with
a diamond star among her dark locks (Uncle Pelham’s birthday gift).
As for Mrs. Brande, in a black gown, no one had ever seen her
attired to such advantage. She was both handsome and dignified in
her velvet and diamonds, so different to her usual parti-coloured
“reach-me-down” costumes. Honor had composed the costume, and
it did her credit.
Dancing commenced with all the go and briskness of a hill ball.
There were no lazy, lounging men in doorways, and but few
wallflowers; moreover, there were a good many new faces, and not a
few pretty new frocks. It was going to be a brilliant success.
“I have come to Shirani for six seasons,” said Mrs. Brande to Mark
(they were sitting out a dance), “and I ought to know the club well.
But I give you my word I don’t know which room I am in!” (A higher
compliment was impossible.) “I have never seen anything like this!
Where did you get such grand ideas? and such extravagant notions,
eh? for I may say that you have managed this ball.”
Mark laughed rather constrainedly, and made no reply.
 “So I hear your cousin is engaged to Miss Potter?” continued the
lady.
“So I am told—but not by himself. I rather expected him here to-
night.”
“Money to money, of course,” pursued the matron, discontentedly;
“and poverty marries poverty. There is Honor—she is so afraid of
what people may think, that she is barely civil to any one who has a
penny beyond his pay. She is downright stand-off with Sir Gloster
and Captain Waring. She will marry a pauper, of course, if she ever
marries, and be poor and proud till she goes down to her grave!”
Mark’s eyes followed Mrs. Brande’s fond glance, and rested on a
radiant vision with laughing eyes, who was endeavouring to arrange
a dispute between two partners. She did not give one the impression
of being either poor or proud, at present.
Yes, the dance was going off splendidly. The new-comers had all
been provided with partners; the refreshments were perfect; there
was not too much salt in the ices, or sugar in the cup. The setting-out
arrangements were greatly appreciated, and the excellent band was
sober to a man.
One of the strangers had been waltzing with Honor Gordon; he
was a brisk young fellow, who was going to be something some day,
and was seeing the world as a preliminary step. He kept his eyes
open, and carried a note-book, and had run up to Shirani in order to
visit his brother, and gather statistics and local colour. As they came
to a halt, he panted out rather breathlessly—
“So you have got that fellow Jervis here?” nodding to where he
was standing, exactly opposite. “Jervis, the millionaire, as of course
you know?”
“Oh no; it is his cousin, Captain Waring, who goes by that name.”
“He certainly was giving that impression at Simla, and was about
to be engaged to an heiress on the strength of it; but I put a stop to
his game,” said the little man, complacently.
 “You did! And may I ask why?” regarding him with great
astonishment.
“Why? Why should I not expose an impostor?”
“I think we must be at cross purposes, and speaking of different
people,” said the young lady, rather stiffly.
“I think not; but we can go into that later. Do not let us lose this
capital waltz.”
When they had taken two more turns round the room, they came
to a halt, and he suddenly recommenced—
“Waring has not a penny to bless himself with. Nothing but debts.
He left the Rutlands a ruined man, ruined by his own folly.”
“And Mr. Jervis?”
“Is the rich young man,” he rejoined impressively.
His companion’s incredulity was so plainly depicted on her
countenance, that he added—
“Yes, I am not joking. That good-looking young fellow over there,
near the door, who is talking to the girl in pink. I came out with him
on board ship last October. He and Waring were going to do a tour—
Waring was a sort of companion, and genteel courier. I must say that
the young fellow was shamefully mobbed by a lot of snobs, who
believed him to be a second Count de Monte Christo. He is really the
adopted son of a rich City man, called Pollitt—Pollitt’s barley, you
know,” with an explanatory nod—“and he will probably have an
immense fortune. He is naturally fond of a quiet life, and seemed to
loathe all display or ostentation. Some of the women drove him to sit
all day in the smoking-room. They accompanied him fore and aft,
and even down to the engine-room. For, you see, he is a good-
looking, gentlemanly boy; none of the poultry grain about him, eh?”
Honor felt as if she was in a dream; her head was reeling. All her
ideas about the position of the two cousins were thus suddenly
reversed. The news was indeed a revelation, and extremely difficult
to realize.
 “I suppose you are quite in earnest,” she faltered at last. “But do
you know, that Captain Waring and Mr. Jervis were here together for
weeks, and neither of them ever gave us a hint of your version of the
story. It was Captain Waring who made plans, entertained, and
lavished money—”
“Yes, he was always a first-class hand at that! He spent Jervis’s
money, I do assure you. Jervis lay low for the sake of a quiet life; he
has no expensive tastes. But it was all a plant!”
“Then, if what you tell me is correct, I think I should call it a
shameful hoax,” said the young lady, inwardly writhing under the
sting of many memories. “It was abominably deceitful of Mr. Jervis.”
“Did he ever tell you or any one that he was a pauper?”
“No!” she admitted reluctantly. “I cannot say that he did; but he
acted the part, which was all the same.”
“Ah, my dear Miss Gordon, surely you have often heard that
appearances are deceitful. Positively you seem quite annoyed to find
that Jervis is a very rich man.”
“I am,” she rejoined with indescribable dignity.
“Your state of mind is deliciously unique! How would it have been,
had he pretended to be rich, and turned out to be a beggar?” And he
eyed her with irritating steadiness.
“He has taken us all in; it was too bad of him! And if he is so
wealthy, what can have detained him at Shirani? He has been here
more than two months, and seems to be a fixture. He came in April,
and has never left the station for a day. Every one thought it was
because he could not afford to move about. What does it mean?”
and she in her turn surveyed him with searching eyes.
“Ah!” with a laugh, “that riddle is quite beyond me; but I think, if
you were to apply to some young lady in Shirani, she might answer
the question. Let me suggest his present partner, the girl in pink?”

END OF VOL. II.

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