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Historical perspectives on autism
Uta FrithUCL Institute of Cognitive Neuroscience
12th June 2008
Priory Court: 1st Dame Stephanie Shirley Lecture
Autism
Setting a historical context for our knowledge
The time line and three centenaries
2020 - 1920 - 1820.......even earlier
How far can we go back in time?What early sources are there?What accelerated our current knowledge?
Leo Kanner (1943)
Hans Asperger (1944)
Each independently identified and named the syndrome
Landmark date 2020 1943/44 1920 - 1820.......
How did knowledge of autism begin?How it has changed over time?
Kanner’s evocative descriptions of the core features of autism
• Autistic alonenes• Insistence on sameness• Islets of abilities
2020 - 1920 - 1820..1805..1790 Further back in time
Some suggestive examples
Short description of a boy at Bethlem Hospital (1805)
Wild boy of Aveyron (ca 1790)
2020 - 1920 - 1820... ... ... ... ... ... 500Even further back
The holy fools of the Eastern Church
From 4th Century
Isidora, Simeon, Prokopius, Basil
What can be gained from historical analysis?
Has autism always been with us?How did people in the past cope?What are the universal features?- independent of cultural context
But, we cannot proceed unless we havedetailed case descriptions
The case of Hugh Blair of Borgue (ca. 1708 - 1765)
A family feudBrother began civil suit
to have Hugh’s arranged marriage annulledon grounds of mental incapacity
Court annulled marriageHugh Blair’s mental incapacity confirmed
Statements from 29 witnessesDirect examination
2020 - 1920 - 1820 - 1720
Contemporary portraits by Henry Raeburn
Kirkudbright 1792
The Edinburgh court in session
William Hogarth: His servants painted ca. 1750
Descriptions of odd behaviour
• was teased and bullied• took no notice of strangers• never took part in conversation• visited neighbours at all hours• gave unwanted gifts
• insisted on same place in church • went to all burials whether invited or not• collected useless sticks• carried stones from heap to heap• watched water dripping
• could read and write• had prodigious memory
Autistic aloneness
Insistence on sameness
Islets of ability
Autism is not new
Distilling the essence of autism across time need to look beneath the surface
of behavioural descriptions
Autism is universal despite different cultural manifestations
Explanations of odd behaviour
Autistic aloness
Insistence on sameness
Islets of ability
Inability to attribute mental statesto self and others - mindblindness resulting in lack of reciprocal social interaction and communication
Good perceptual processing Attention to detail
Adequate basic information processing capacity
Going Fast forward in Time...1745 ... ... 1985
The mindblindness hypothesis
Mentalising aka Theory of Mind aka mind-reading
The ability to attribute mental states (beliefs, desires)To self and others and predict behaviour on the basis of mental states rather than real states of affairs
If dysfunctional, then lack of reciprocal social interaction, poor communication - can explain autistic aloneness
Mind-blindness or lack of “Theory of Mind” or “impaired mentalizing”
• Not putting yourself into someone else’s shoes• Not recognising that what another person knows, thinks or
feels is different from what you know, think or feel• Not being able to predict what another person will do on
the basis of what they know, think or feel• Not recognising that inner intentions govern others’ actions• Not being aware of your own knowledge, feelings
Sally has a basket. Ann has a box. Sally puts a marble in her basketSally goes out.
Naughty Ann transfers marble into her own box.
Sally comes back. Where will she look for her marble?Where she thinks it is!
Hugh Blair failed test of Theory of Mindon 16 July 1747
Judges asked questions in writing and asked himto write his answers down
He did not realise that he knew something that judges did not know and that they wished to know about.
He copied the questions!
Clerk’s writingYou are not to copy what is set before youbut write an answer to this question….
16 July 1747
Hugh Blair’s writingAnswer the followin questionWhat brougt you to Edinbrugh
Clerk’s writinganswer the following questionWhat brought you to Edinburgh?
Hugh Blair’s writingYou are not to coppy what his set before youbut write an answer to this question...
Fast Forward Again Fifty years after Hugh Blair Back to the time line 2020 - 1920 - 1820
1820
The historical context around 1820
Portrait and landscape by Constable
What achievements were new?
Ampere studies electromagnetismFaraday invents electric motorFirst fossil recognised as dinosaurBabbage invents difference engine
What happened?
Napoleon banishedRegency period (George IV)
1820 - 1920 - 2020
1820
Franz Josef Gall (1758 - 1828)Mind has a physical seat in the brainBrain controls emotions and actions
Johann Friedrich Herbart (1776 - 1841)Mental phenomena can be studied objectivelyPrinciples of education
1820 - 1920 - 2020
What knowledge relevant to autism?
The historical context around 1920
The Mechanic by F. Leger
What achievements were new?
Einstein completes his theory of relativityRutherford split an atom of nitrogenInsulin extracted to develop diabetes treatmentVitamin D discovered to treat ricketsTuberculosis vaccine
What happened?
WWI is overBolshevik Revolution in Russia
A modern skyscraper
1820 - 1920 - 2020
1920What knowledge relevant to autism?
Neurological syndromes and psychoses
Emil Kraepelin (1856 - 1926) “dementia praecox”
Eugen Bleuler (1857 - 1939) “schizophrenia” and “autism”
1820 - 1920 - 2020
The 20th Century Sources
In ViennaTheodor Heller 1908
– dementia infantilis– disintegrative psychosis
First recognition of psychiatric disorders in children
The 20th Century Sources
G.E. Suchareva 1926 schizoid psychopathyrelationship to “Dementia praecox”congenital brain disordercerebellum, basal ganglia, frontal lobes
In Moscow
“Schizoid Psychopathies of Childhood”
Grunya Efimovna Suchareva (1891-1981)Die schizoiden Psychopathien im Kindesalter
1926 Monatsschrift für Psychiatrie und Neurologie, Bd. 60
Translated by Sula Wolff
Suchareva - anticipating Asperger
Description of 6 boys aged 10 to 13 years
seen over 3 years in Moscow clinic • Characteristic mode of abstract thought, absurdities, eccentricitiesAutistische Einstellung • Poor social adaptation; avoidance of peers; loners• Superficial emotions; hyper- and hyposensitivity• Poverty of expressions (face, voice)• Perseveration; echolalia; obsessive tendencies• Motor clumsiness, mannerisms, poor voice modulation• Differences to schizophrenia• Obvious brain basis of symptoms
This work was largely forgotten
After 1920
Pediatricians, psychiatrists, neurologists in many places started to be interested in children with ‘psychotic’ symptoms
Was it only a matter of time for an inspired clinician researcher to identify autistic children among the large group of mentally handicapped children?
Leo Kanner (1894- 1961)
1943Autistic Disturbances of Affective Contact
Enduring characterisationAutistic alonenessInsistence on samenessIslets of abilities
Assumed biological basis but seduced by refrigerator mother theory
Kanner’s concept of autism was unchallenged for ca. 50 years Now it refers to a narrowly defined subgroup on the autism spectrum
Hans Asperger1906 - 1980
1944Die autistischen Psychopathen im Kindesalter
Asperger assumed that disorder •has genetic basis •is life-long •coexists with high intelligence
Proposed that educational treatment has to be specially adapted for children
Almost forgotten, but rediscovered in 1990s
Scheerer, Rothmann & Goldstein 1945a neglected landmark paper
• Single case description of a boy• Detailed neuropsychological study• Contrast to Kanner’s autism• Cognitive, not emotional disturbances are seen as primary• Original ideas on impairment of abstract abilities,
anticipating ideas on executive dysfunction• Attempt to explain special abilities as abnormal perceptual
processes
Kurt Goldstein 1878–1965 Neurologist
A case of ‘idiot savant’: An experimental study of personality organization
Stephen Wiltshire drawing from memory
Stephen spent 30 minutes taking in 360 degrees of Tokyo skyline from the roof top of Roppongi Hills (270 meters up). Over the next seven days he drew, from memory, a remarkably accurate panorama of the Tokyo skyline
A scientific revolution1960s
• Autism a form of mental retardation• Due to brain pathology rather than poor parenting• If so, social-emotional problems may be explained
as consequence of abnormalities in perception and thinking
• If so, new information processing models can be applied
The 1960s Beginnings of psychological experimentation
• Removing stigma of poor parenting• More attention to intellectual problems• Less attention to affective problems• Main target language problems• Intervention by operant conditioning
Beate Hermelin and Neil O’Connor“Experiments with autistic children” (1970)
Information processing models Uneven profile of abilities
Specific deficitsgood memory for meaninglessvs poor memory for meaningful material
Conclusionsnot peripheral input/output problemsbut central coding difficulties
How far did the early experimental work “explain” autism?
Main features of cases studied in the 60s– Delayed language, no speech, poor speech
• Ideas on disturbance of semantics and pragmatics
– Learning disability• Study of memory, attention, perception, motor skills and learning
• Attempts to differentiate autism from other syndromes with intellectual impairments were only partially successful
• Social difficulties remained the big unknown
The historical context for the mindblindness hypothesis
How did the hypothesis come about?Researchers were turning against BehaviourismUp to then Psychology was the Study of BehaviourNow the Study of Mental Life Study of mental states as they influence behaviour
e.g. pretence, deception, belief, knowledgeJohn takes his umbrella - because he thinks it’s raining,regardless of whether
it is actually raining
1978 David Premack and Guy Woodruff: Does the Chimpanzee have a ‘Theory of Mind?’1983 Heinz Wimmer and Josef Perner: Beliefs about beliefs
The natural life of the mindblindness hypothesis
Step 1 Novel predictionChildren with autism fail to understand False Beliefs while they understand False PhotographsConfirmation (Baron-Cohen, Leslie & Frith, 1985)Since 1985 many more confirmations
Step 2 Negative findingsMeta-analysis of studies (Happé 1994)Children with succeed on False Beliefs with 5-year delay
Step 3 Modifications Individuals with autism can learn about mental states, but still lack intuitive mindreading (e.g. Frith 2003)
Step 4 ExtensionsInvestigations of mind reading in other animals
In autism
Physiological testAre their functional differences in relevant brain regions?Anatomical testAre there structural differences in relevant brain regions?
Surprising findingNo matter what the task a specific neural system is activated during mentalising
A major step forward In the 1990s Brain imaging methods become available
Brain imaging was used to visualise brain system that is active during mentalising
STS-temporal-STS-temporal-parietal junctionparietal junction
Basal temporal, periamygdaloidamygdaloid
Castelli et al., 2000
ParacingulateParacingulate sulcussulcus
Basal temporal
Mentalising systemMentalising system
Evidence for brain abnormality in ASD linked to mentalising failure
Asperger and HFA group show reduced
brain activation in mentalizing system but equal activation in visual system
Components show strong connectivity in the normal brain
But weak connectivity in the autistic brain Castelli et al. 2002
functionally different in autism- less activated in autism during mentalising
structurally different in autism
- smaller volume
Medial prefrontal region
Recent developments from mid-1990s
• Search for genetic and other biological causes• Systematic search for intervention• Continued development of diagnostic instruments• Availability of brain imaging techniques allow
building bridges from cognition to brain• Brain abnormalities may distinguish subgroups,
but have not done so yet
The mirror neuron deficithypothesis
• Can a deficit in this system explain autism?– Can perhaps explain lack of emotional resonance, and
lack of learning by imitation, – but not uneven cognitive abilities, savant talents,
executive dysfunction
• Open questions– How is empathy related to mentalizing?– How is introspection into own mind related to reflection
about other minds
Has there been progress inexplaining the nature and causes of autism?
100 years ago
autism not recognised at all
50 years ago
psychosocial origin presumed - not brain abnormality
Now
slow but steady progress towards identifying brain abnormality, genetic risk factors and other putative causes
Leo Kanner - the legacy
The name
A clinical entity
Nuclear cases as anchors
Hans Asperger - the legacy
• The interest in highly intelligent individuals– Focus of neuropsychological studies, possibly to the
detriment of studying other individuals with ASD
• The case of extreme male intelligence– Simon Baron-Cohen’s theory of the Extreme Male Brain
and Systemizing (vs. Empathizing)
Kurt Goldstein - the legacy
• Work on frontal lobe dysfunction
• Modularity of mind
• Mystery of the savant
Hermelin & O’Connor - the legacy
• Apply neuropsychological methods
• Explain savant intelligence
Mindblindness hypothesis - the legacy
Other hypotheses are needed as well
Could be used to identify phenotype
Need for standardised test of Theory of Mind
2020
What knowledge relevant to autism?
– Genetic blueprint– Visualising structure and function of the living brain– Increasing knowledge about the social brain
and its evolutionary origins
1820 - 1920 - 2020
Autism recognised as one of the most prevalent neuro-developmental disorders, with a basis in the genes
Close to finding biological causes
Close to identifying phenotypes and genotypes
Early diagnosis and intervention
Better educational treatments
1820 - 1920 - 2020
2020 (as seen in 2008)
What progress has been made?