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Thursday, Oct. 23, 2003
No rush to judgment
Views across the 'autism spectrum'
By ROWAN HOOPER
In a meeting in Heidelberg earlier this month, science historians concluded that German science between 1933 and 1945 was exploitative and unethical. The organizer of the meeting, Wolfgang Eckhart, head of history of medicine at the University of Heidelberg, said in Nature last week: "We have proven that the DFG [Germany's main research agency] was willingly involved in the full range of medical crimes during the Nazi era."
It is perhaps not surprising that scientists in Nazi Germany suppressed ethical concerns. (That's putting it mildly: A letter from one scientist to the head of the medical section of the DFG praises the "excellent conditions for researchers in Auschwitz.") But what is surprising is that amid the atrocities of the Third Reich, there was a clinic in Vienna that treated autistic children with extraordinary gentleness and intuition.
The director of The Vienna University Pediatric Clinic had a Heilpadagogik (therapeutic pedagogy) department, and its head was Hans Asperger.
Asperger recognized that some autistic children, far from being parasitic on the Nazi state, had remarkable gifts. It is this "higher functioning" autism that he is now known for, but his work, published in German in 1944, was not discovered for 40 years. That happened in the 1980s when a London Institute of Psychiatry researcher, Lorna Wing, published a study on autistic children and "Asperger's Syndrome."
Since then Asperger's Syndrome has been diagnosed more and more frequently, and there has been a sudden rush of new psychiatric disorders.
The "disorder rush" has worried many. The response of Stephen Longworth, a GP in Leicester, England, is typical: "Could someone please tell me where shyness ends and 'social anxiety disorder' begins?" he wrote in the British Medical Journal. "Isn't this just another appalling example of the creeping (galloping?) medicalisation of everyday life? Would it be written about at all if suggested treatments didn't include expensive SSRIs?"
SSRIs are Selective Serotonin Reuptake Inhibitors, drugs like Fluoxetine (also known as Prozac) that block the re-uptake of serontonin and are prescribed for conditions such as depression and obsessive compulsive disorder. It is a huge market. How huge? Well, with the number of U.S. depressives forecast to reach 48.1 million by 2005, there's lots of money to be made.
Asperger's and autism are behaviorally classified and there is some overlap between them. There is, some researchers maintain, a spectrum of symptoms. "Autistic spectrum disorders share a triad of impaired social interaction, communication and imagination, associated with a rigid, repetitive pattern of behavior," Lorna Wing wrote in the BMJ in 1996.
But the existence of the spectrum is controversial. Thomas David Simpson, consultant child and adolescent psychiatrist at the Tavistock Clinic in London, said in the BMJ this year that considerable doubt remained about an autism spectrum.
"In autism," he wrote, "children are socially withdrawn, while in Asperger's Syndrome they usually desire social contact but cannot negotiate social rules: The danger of confusing Asperger's syndrome with autism in a broad definition is that not only that it might hamper research but that it risks over diagnosis. A growing problem in child psychiatry is where parents of troubled children increasingly demand diagnostic certainty at the risk of error."
Diagnostic certainty is difficult because the causes of autism and Asperger's are unknown. Autism ("self-ism") is characterized by impairments in social functioning and interactions: Perhaps the disorder occurs because other people (other "selves") are not interpreted as such by the brain?
This is just what Yale researchers found in 2000. Robert Schultz, director of the neuroimaging research program in autism at Yale, lead a team that used functional magnetic resonance imaging to study brain organization in autism and Asperger's patients.
The team found that the patients perceived faces as if they were objects. One of the characteristics of the disorders is the difficulty in recognizing other people by their faces.
The three-year study resulted in the discovery of reduced activation in the fusiform gyrus -- the face-processing area of the cerebral cortex. Researchers also observed increased activation in an adjacent region of the brain that processes non-face objects.
"This finding is very compelling since it fits with our clinical experience of autism," Schultz said. "Persons with autism and Asperger's have very little interest in people, and our study shows that this disinterest is reflected in the manner in which the visual processing centers are organized in their brains."
Schultz stresses that he doesn't know whether this difference in brain organization and function is at the heart of the cause of autism and related disorders, but speculates:
"Of the things that the developing child routinely encounters, the human face is probably the most frequent and important," he said. "The ability to recognize and remember people by their face is critical for all types of interpersonal relationships. The face conveys many important types of information, including a person's age, sex and emotional state. Decoding this information is critical to successful functioning within a group. It is precisely these things that are so difficult for these patients."
Hans Asperger's work, conducted in the unethical climate of German science 50 years ago, was remarkable for its compassion and insight. Today his work -- and that of his successors who explore autism -- has direct bearing on the most profound of biological mysteries: the development, organization and function of the human brain.
Asperger's syndrome is explored in "American Normal" (Copernicus) by Lawrence Osborne and in the novel "The Curious Incident of the Dog in the Night-Time" (Jonathan Cape) by Mark Haddon. Rowan Hooper is a researcher at Trinity College, Dublin. He welcomes comments at firstname.lastname@example.org