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William 83 Bleuler, a

William 83 Bleuler, a Swiss psychiatrist who had published a very influential book on schizophrenia some years earlier. Bleuler argued that “autism,” defined as a persistent withdrawal from reality, was one of the cardinal symptoms of schizophrenia. Kanner and Asperger believed that the impairments in social interaction seen in the children they were describing were similar to the “autism” seen in schizophrenia. But Asperger used the term “psychopathy” to argue that this was a feature of the child’s personality, not an illness like schizophrenia. He did not acknowledge Kanner in his article, suggesting that the two had arrived independently at a similar description. The group identified by Asperger were all verbal, whereas of the eleven children Kanner wrote about, only five were fluent. These fluent children closely resembled the children described in Asperger’s paper. This marked the beginning of much overlap and confusion between the terms, a confusion that still exists today. There has, in fact, been much controversy in academic circles as to whether AS and autism are different disorders. To some extent, this is not a helpful debate. The more important issue is whether it is useful to differentiate these two types of ASD. Or should all such children be given the label “high-functioning autism” or “autism spectrum disorder”? Whether or not autism and AS are “really” different requires an understanding of the underlying causes that is well beyond our current knowledge base. According to DSM-IV, the key differentiating feature between autism and AS is that children with AS “lack clinically significant cognitive and language delays.” Children with AS develop speech at roughly the appropriate time; single words are used spontaneously and usefully by around one year, and spontaneous phrase speech with a verb appears by three years of age. The emphasis here is on spontaneous and useful speech as opposed to echolalic speech, which is simple parroting of what another person has said or what the child may have heard on TV. Children with autism may speak early, but the speech is usually echolalic and not spontaneous. One way of thinking about these disorders is to think of autism as AS with an added impairment in language. The differences between autism and AS with respect to their clinical presentation and their outcome perhaps stem from this fundamental difference in language ability. There is also some evidence that children with AS have fewer autistic symptoms and are able to function better in the community than children with autism. However, a subgroup of children with autism can also develop fluent speech, though by definition they do so at a later age than children with AS, between four and six to seven

84 A MIND APART years of age. Once these children develop useful speech they come to resemble more and more the AS children and may eventually catch up to them. On the other hand, both AS and autism appear to arise from a common set of genetic mechanisms. Children with AS can have siblings with autism and children with autism can have siblings (and even parents) with AS. There is also no evidence that treatment needs are any different, though children with autism need speech therapy whereas children with AS are already able to talk. For them, therapy needs to focus on the social use of speech. Therefore, making the distinction between AS and autism may be useful not only in predicting outcome for the child, but also in choosing a focus for treatment. * * * “And I saw the round doors going east through the windows of the round doors going west. And I saw the round doors going west through the windows of the third coach with gray on the round doors going east. And then I got in the round doors going east.” “Who was with you?” “Joe and Claire.” “Who are they?” I had heard about Pamela, but not these two. “My cousin. My three-year-old cousin.” “Who was three years old?” I ask, expecting clarification. “Then we got downtown at 4:15.” I sit back in the conversation, resigned. I must be content to go for a ride, still confused about the meaning of the different shapes and colors. The train is going awfully fast, but I dare not pull the brake handle to slow it down. I have long ago given up asking about depression. As I listen to William, I realize that I am not part of this conversation. Indeed to even call it a conversation is perhaps inaccurate. I am being talked at, not with. William and I do not share a common framework, a set of rules, for the creation of shared meaning. As a listener, I experience a profound slippage between what is said, which I can perfectly well understand, and what is meant, of which I still have no clue. What is not being said is as important to the meaning of the conversation as what I hear, but I cannot figure out what that is. I have the sense that there is meaning to this, but it eludes me. I try to project all kinds of meaning onto the torrent of language to imagine what is not said, but none of my conjectures seems to fit. I am, in effect, a passive participant as words are flung at me. I can well imagine how this type of interaction