Did Lorna Wing think Asperger’s syndrome was distinct from autism?

Asperger, Wing,

Lorna Wing (1928-2014) was a British psychiatrist who is heavily associated with introducing the diagnosis of Asperger’s syndrome to the English speaking language. She is often taken as thinking that Asperger’s syndrome was a distinct diagnosis from autism, as opposed to being two different names for the same thing. This was an objection that was raised by a reviewer of one my recent articles (Scientific Perspectivism and Psychiatric Diagnoses: Respecting History and Constraining Relativism”, European Journal for the Philosophy of Science, OPEN ACCESS LINK). In this blog post I will outline how, firstly, Wing did not introduce Asperger’s syndome to English language psychiatry and, secondly, that Wing did not think it was a distinct diagnosis to autism.

In 1981 Wing wrote a paper named “Asperger’s syndrome: a clinical account” (Wing 1981). In this paper she describes Asperger’s account (although she arguable significantly distorted Asperger’s account, interpreting it in line with Anglo-American notions of child development, seeing it as a developmental disorder and dismissing Asperger’s claim that it was a personality disorder as meaningless). She also describes how she has met multiple patients who fit what she takes as the diagnostic criteria. This was not, however, the first English language publication on Asperger’s syndrome. Whilst Asperger’s work in the 1940s, 1950s and 1960s was largely only known within Germany and Japan it was mentioned within a small number of sources within English language psychiatry. To my knowledge, the first widely read publication on Asperger’s syndrome in the English language was Van Krevelen’s 1971 paper in the first issue of the Journal of Autism and Childhood schizophrenia (the journal which Leo Kanner started and edited, and had most of the main people writing on autism and childhood schizophrenia on the editorial board. Van Krevelen argues that Asperger’s syndrome and autism are unrelated largely because Asperger’s syndrome is a personality disorder (a claim which Wing rightly or wrongly dismisses)). Major names in relation to autism and childhood schizophrenia would have known about Asperger’s syndrome from this publication, so it is not true to say that Wing introduced Asperger’s syndrome. It is, however, certainly true that it was Wing’s 1981 paper which then lead to the popularisation of the diagnosis of Asperger’s syndrome.

As much as Wing’s 1981 paper on Asperger’s syndrome vastly increased the interest in Asperger’s syndrome, did she think Asperger’s syndrome was distinct from autism? Wing makes multiple statements that show she though Asperger’s syndrome was not distinct from autism. In Wing and Gould’s (1979) pioneering Camberwell study which introduced the autistic spectrum Wing checked her study to see if any of the groupings she had identified corresponded to groupings that had been picked out by previous psychiatrists. Of all those checked, she says she could only detect Kanner’s autism. One of the previously employed diagnoses which she was looking for in that 1979 study was Asperger’s syndrome and she said she could not detect it. In a later publication she gives more precise figures of what she meant by ‘could not detect’, saying that in her study “2 children (0-6 per 10000 aged under 15) showed most of the characteristics of Asperger’s syndrome, though they were in the mildly retarded range on intelligence tests, and 4 (1-1 per 10000) could have been diagnosed as autistic in early life, but came to resemble Asperger’s syndrome later” (Wing 1981, p.120). Wing and Gould believed they could detect Kanner’s autism but felt they could not detect Asperger’s syndrome, so Wing and Gould in 1979 rejected Asperger’s syndrome as a viable diagnosis.

In her 1981 paper she refers back to her 1979 study: “When all children with this cluster of impairments were examined [in her 1979 study], it was found that a very few resembled the description given by Asperger and some had typical Kanner’s autism. A number could, tentatively, be classified as having syndromes described by authors such as De Sanctis (1906, 1908), Earl (1934), Heller (see Hulse, 1954) and Mahler (1952)… The justification for regarding them [all those diagnoses, including Asperger’s syndrome] as related is that all the conditions in which the triad of language and social impairments occurs, whatever the level of severity, are accompanied by similar problems affecting social and intellectual skills. Furthermore, individuals with the triad of symptoms all require the same kind of structured, organized educational approach, although the aims and achievements of education will vary from minimal self-care up to a university degree, depending on the skills available to the person concerned” (1981, p.123-124). She continues, “the full range of clinical material can be subdivided in many different ways, depending on the purpose of the exercise, but no aetiological classification is possible as yet. Sub-grouping on factors such as level of intelligence (Bartak & Rutter, 1976) or on degree of impairment of social interaction (DeMyer, 1976; Wing & Gould, 1979) has more useful practical implications for education and management than any based on the eponymous syndromes mentioned above [including Asperger’s 1944 syndrome]” (1981, p.124). Thus Wing is arguing that there is no important distinction between Asperger’s 1944 syndrome (or Wing’s 1981 Asperger’s syndrome) and the wider autistic spectrum. On the contrary, she is suggesting that other factors are much more important and is she arguing that Asperger’s syndrome is not a separate diagnosis.

In later publications Wing gives further detail on views on Asperger’s syndrome and why she wrote her 1981 paper on it. “My original purpose, as someone just beginning to consider the nature of this condition, was to emphasize the strong possibility that the syndrome was part of the autistic spectrum and that there were no clear boundaries separating it from other autistic disorders. However, since then, various workers have tended to the belief that Asperger syndrome and autism are different conditions—quite the opposite of my intention” (2000, p.418 emphasis added). She lists many multiple diagnoses which had been previously employed in the past, including Asperger’s (1944) syndrome, and writes that “It is, of course, possible that any one of these professionals might, by chance, have identified a specific syndrome unrelated to the others. It is equally, or perhaps more, likely that none of them did” (2000, p.421 emphasis added). On a similar notes, she writes that “The most reasonable approach to classification is to recognize that although there may be sub-groups that are specific and separate at some level of discourse, at present these have not been identified” (2000, p.424). This shows she is sympathetic to the possibility that subtypes of the autistic spectrum might be possible but they have not yet been identified (including Asperger’s syndrome). Additionally, most of these quotes relate how the clinical picture of Asperger’s syndrome relates to the wider autistic spectrum. Wing also considered aspects beyond the clinical picture, such as causal claims and treatment responses. She writes that “I (Wing, 1998) listed the various levels at which differences could in theory be defined, ranging from the most fundamental level of original aetiology, via neuropathology and neuropsychology, to overt behavior and response to treatment. The conclusion was that there were no consistent and reproducible differences between Asperger syndrome and autism at any of these levels, however each was defined, apart from those that were the direct consequences of the criteria used” (2000, p.421).

What, however, was Wing’s motive in writing about Asperger’s syndrome and using Asperger’s syndrome in a diagnostic context? Her intension was desiring to employ a new diagnosis which did not have some of the associations of autism. In her 1981 paper she writes that “is there any justification for identifying Asperger’s syndrome as a separate entity? Until the aetiologies of such conditions are known, the term is helpful when explaining the problems of children and adults who have autistic features, but who talk grammatically and who are not socially aloof. Such people are perplexing to parents, teachers and work supervisors, who often cannot believe in a diagnosis of autism, which they equate with muteness and total social withdrawal. The use of a diagnostic term and reference to Asperger’s clinical descriptions help to convince the people concerned that there is a real problem involving subtle, but important, intellectual impairments, and needing careful management and education” (1981, p.124, emphasis added). She is more explicit on this point in later publications. “in our clinical work, my colleagues and I see many children and adolescents such as the ones Asperger described. Their parents will not consider a diagnosis of autism, but what they have heard about Asperger syndrome strikes a chord with them. We also see a small but steady flow of adults who come to seek advice for themselves because something they have read or heard makes them think they have Asperger syndrome. When the diagnosis is confirmed and the implications, positive as well as negative, are discussed, in almost all cases the individual concerned is immensely relieved to have an explanation of why he (or occasionally she) has felt different from others all his life. They are mostly willing to accept the relationship to autism when this is put into context… Such individuals would never have asked for a referral if the only label available had been autism as it is usually described (2000 p.419-420). She also writes in relation to her 1981 paper that “I agreed that the syndromes within the autistic continuum could not be clearly differentiated, but put forward two main reasons for the limited usefulness of the label Asperger’s syndrome in current clinical practice. The first, also emphasised by Szatmari et al. (1986), is that the diagnosis of autism is, in the minds of many lay people, synonymous with total absence of speech, social isolation, no eye contact, hyperactivity, agility and absorption in bodily stereotypies. There is a lack of understanding of the wide range of severity and the widely differing manifestation of the basic impairments. For this reason, parents without special experience tend to overlook or reject the idea of autism for their socially gauche, naive, talkative, clumsy child, or adult, who is intensely interested in the times of tides around the coast of Great Britain, the need for the abolition of British Summer Time, or the names and relationships of all characters who have ever appeared in a television soap opera, such as ‘Coronation Street’. The suggestion that their child may have an interesting condition called Asperger’s syndrome is much more acceptable. That this is closely related to autism and is in the autistic continuum can be explained gradually over the course of time, and the parents can then be introduced to their proper reference group of other families with similar problems through the National Autistic Society. The second reason is that professional workers without special experience of autism, including psychiatrists working with adults, also tend to have a narrow view of the clinical picture. Many of them think of autism as a condition of childhood and do not automatically include it as a possible diagnosis when seeing adults. The various recent papers on Asperger’s syndrome have attracted attention from adult as well as child psychiatrists because of its novelty value in English-language publications, whereas papers on autism would probably have been read only by people working with children. As a result of using the Asperger label there has been an increase in awareness that an autistic person of normal intelligence can be undiagnosed in childhood but be referred to a psychiatrist in adult life. Attention has also been drawn to the fact that such people can develop psychiatric illnesses and that the presence of the developmental disorder as well as the adult illness complicates treatment and management” (1981, p.171). She promoted the term Asperger’s syndrome simply because other terms had undesirable connotations.

References

Van Krevelen, D (1971). Early infantile autism and autistic psychopathy. Journal of Autism and Developmental Disorders, 1(1), 82-86.

Wing, L., & Gould, J. (1979) Severe Impairments of Social Interaction and Associated Abnormalities in Children: Epidemiology and Classification. Journal of Autism and Developmental Disorders, 9(1), 11-29.

Wing, L. (1981). Asperger’s syndrome: a clinical account. Psychological Medicine, 11(1), p.115-129.

Wing, L. (2000). Past and Future Research on Asperger’s Syndrome. In A Kiln. F, R, Volkmar. S, S, Sparrow. Asperger Syndrome (pp.418-432) London: Guilford Press.

Report on presentation at Philosophy and Mental Health Workshop, Accrington

History, Kanner, Neurodiversity, Philosophy

Back in April I presented alongside Rachel Cooper at an event set up by Accrington and Rossendale College. I wrote this blog post for the Lancaster University Bioethics and Philosophy of Medicine Blog but I thought I would reproduce it here since I mainly spoke about the History of Autism. Details on Rachel’s talk can be found on the Blog post.

My talk was entitled Lessons for today from the history of autism. The first half of my presentation was largely a re-cap of my previous criticism of Neurotribes (https://www.sciencedirect.com/science/article/pii/S1369848616300954). In this book Silberman (2015) argues Leo Kanner’s original description of autism (1943) was of a disorder that was “vanishingly rare” and “monolithic by definition”. Silberman argues that Kanner’s ‘autism’ was quite unlike the condition described as autism today. He claims that modern notions of autism have a significantly better scientific foundation and are much more suitable for neurodiversity than Kanner’s approach was.

However, in this paper I argued that when properly understood Kanner’s autism is much more like the autism that is described today than Silberman acknowledges. I argue that it is crucial to appreciate that Kanner considered autism to be a subtype of childhood schizophrenia (Kanner 1969). I argue Kanner thought it was only vanishingly rare in the sense of it being a rare subtype of the fairly common childhood schizophrenia. I accept that Kanner’s autism did have quite restrictive symptoms (even if it was not monolithic) but I situated it as being a subtype of a much less monolithic childhood schizophrenia which shared many symptoms of Kanner’s autism but did not require the stringent diagnostic criteria. Silberman claims that adherence to Kanner’s views prevented the full autistic spectrum being recognised for many decades but, if you consider Kanner’s views on childhood schizophrenia, it looks like Kanner endorses a position quite like a spectrum.

In the second half of my presentation I discuss some of my more recent research. I outlined Lauretta Bender’s (1956) approach to childhood schizophrenia and considered how elements of her approach fit modern psychiatric evidence surprisingly well. Additionally, they could be used to formulate alternative approaches to neurodiversity, one based around meaningful subtypes with nuanced inter-relationships between them, rather than an account of neurodiversity based around the DSM-5 spectrum which lacks subtypes.

As far as I was aware, none of the audience were professional historians or philosophers. I found it positive to deliver my work to a wider audience, getting the findings of my research out to a wider audience. Some of that audience were mental health professionals or training to become mental health professionals, thus some are or would be interacting with autistic people regularly in their line of work. As a historian and philosopher my work often can be a bit removed from actual practise, thus it was good to be speaking to and opening dialogue with individuals who have much practical hands on experience of working with autistic individuals. The audience were engaged and asked interesting questions. These included questions about alternative ways of thinking about diagnosis, what the value of diagnosis was, how to keep in focus the aspects of the individual not covered by the diagnosis and even if diagnoses were needed at all. I think these are all important questions and it was good to see questions about them. Overall, I feel that academics often do not engage sufficiently with the world outside academia. It was very encouraging to attend a talk which was so well attended by an audience who asked engaging questions so I feel the whole process was very much a worthwhile experience.

Reviewing Madness A History

History, Secondary History

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Petteri Pietikainen’s 2015 Madness: A History intends to provide a general history of psychiatry, the author intending it the first general history since Shorter’s 1997 A History of Psychiatry (presumably Pietikainen started this book before Scull’s recent book came out). The scholarly quality appears to be first rate, a well researched analysis with lots of well thought out arguments. It also covered some ground which I’d not seen discussed elsewhere. On this basis the book is recommended. I do wonder if some of the material is too specific for a general history, such as the chapter on cold war psychiatry which included a section on various attempts at mind control, or the 1960s research into sensory deprivation. To my mind, these are not so crucial as an in depth discussion of the origin and evolution of the DSM, which is present just not as long as I’d like (though that is my specific interest so I might be biased). Basically, providing one reads the book without the assumption that the book will provide THE full history of psychiatry then it is recommended.

The part I found most interesting was Pietikainen’s remarks at the end of the book. He is broadly critical of two relatively recent trends. Firstly, modern focus upon what he calls the “worried well”, which are roughly people with relatively minor psychological issues. This he considers problematic because it can make people with relatively minor issues believe they have serious problems, “influence the person’s self-understanding and potentially cultivate a culture of vulnerability, no matter if it is done with a benevolent purpose”. Meanwhile, this distracts from helping people with more serious issues. Secondly, and relatedly, insufficient care for the more seriously mentally ill, especially after the 1980s “dismantle [of] the Keynesian welfare state”. Since then, “a solid infrastructure of mental health services is still missing in most if not all western countries. As a consequence of deinstitutionalization, homelessness skyrocketed, for example in the UK and the United States, and a growing number of mental patients ended up on the streets, in jails or in shelters for the homeless”. In contrast to some recent histories of psychiatry (especially recent histories of autism), this history suggests that in some important reguards things have actually got worse for the severely mentally ill. Recognising the good intentions behind community care, Pietkainen suggests this ultimately can result in simply not really doing anything to help the mentally ill. “If the mentally ill do not have a safe place to go and receive treatment – other than pills – then how does ‘community care’ differ from systematic negligence?… We have gone around full circle and are back in a world that has uncanny resemblances with the ‘pre-confinement’ era, with the exception of psychiatric pills, patient organizations and the individual ethos of self-management”.

Being a 1930s onward historian and primarily dealing with psychiatric classifications rather than psychiatric care, I’m not really in a position to judge the accuracy of these claims. I do, however, find them fascinating: the idea that without realising it through dressing up our modern situation up as community care and user led care we have returned to situation which most people would be deeply upset about if we realised it had happened. It makes one think about the power of concepts to shape perception, that by portraying (presumably in good faith) many modern innovations in a positive light modern psychiatry has only concealed how badly they are not working. Ultimately, I cannot judge if Pietkainen is exaggerating these claims, so I treat them with caution, but I cannot rule out the possibility they are partially or even wholly true. If so, his message is important and deserves a wider audience.

Robert Spitzer

DSM, Reliability, Validity, ,

Robert Spitzer (1932 to 2015) died last Friday (25th December).

Plausibly, Robert Spitzer could be described as the most influential figure in psychiatry of the last 50 years. He made contributions in many different areas. Most media reports focus significantly on his contribution in removing homosexuality as a diagnosis, something which certainly deserves praise. His biggest contribution, which I will discuss, is his influence on the DSM.

Robert Spitzer was the chairman of the task force for the DSM III and DSM III R. This process has been discussed by historians, some of whom go into specific details the about exact steps Spitzer took (Kirk and Kutchin’s The Selling of the DSM is a good overview). Rather than discuss that, I wish voice my thoughts about whether DSM III was a positive step or not (it is important to note that Spitzer was partially reacting to and redirecting existing desires for change, he was not fully responsible for all the changes).

DSM III (compared to earlier editions) brought much more standardisation to classification of mental illness. The diagnostic criteria in DSM III were much more detailed than those of earlier DSMs, the description of each mental illness being assigned many more pages. This was partly intended to improve reliability, to increase the degree psychiatrists agree about which mental illness the patient exhibits.

DSM III also went someway to reduce the impact of psychoanalytical approaches. DSM III intended to be a-theoretical (though it failed in this), but it certainly placed the emphasis on describing symptoms and how they cluster rather than basing classification on causes (be them psychoanalytical, cognitive psychological or biological). This was partly intended to then allow studies which might improve validity, finding the actual underlying causal basis (rather than speculative psychoanalytical causes).

These two DSM approaches, broadly present also in later editions, resulted in major problems. Firstly, it contributed to removing the subjectivity of the patient from psychiatry, standardised criteria not capturing the aspects of patient which were specific to himself or herself (including symptoms not mentioned by the diagnostic criteria). Secondly, by making the diagnostic criteria more specific, it then meant alternative formulations of psychiatric classifications, potentially superior ones, stopped being employed for diagnosis or for studies. Thirdly, very few DSM psychiatric diagnosis have had their causal basis established. Fourthly, it resulted in high levels of co-morbidity with associated difficulties of establishing which symptoms should be part of which diagnosis.

Despite these problems, I believe Spitzer’s influence was a step in the right direction, but his influence went too far. Standardisation is generally a good thing for creating scientific reliable generalisations, which can then be modeled to specific contexts in a more reliable way. So in this sense I think the DSM III had to happen. I think it went wrong by blocking out alternative psychiatric classifications. We need modify the psychiatric classifications we employ and try new approaches, modeling symptoms and how they cluster in many different ways. This would be ideally done using multiple classifications system at the same time, though each variation needs standardisation. So Spitizer’s contribution of standardisation was a positive one, but the psychiatric classifications should not have been set in stone. Instead, we needed to develop further sophistications in our approach to classification, rather than stopping with the important step of standardisation. If Spitzer had to happen then we now need to move beyond him, take his contribution and use it in new ways, further innovating how we approach classification.

Kanner vs Despert – Round 2

Despert, First Descriptions, Kanner

A new article by Dan Olmsted and Mark Blaxill has just been published which partly responds to my own article. They intend their article as an objection to my claims but I believe it broadly supports what I say.

I argued Leo Kanner conceptualised an initial idea of autism after reading Louise Despert’s 1938 article. Her article effectively is a bridge between 1930s notions of childhood schizophrenia and Kanner’s 1943 notion of autism. 1930s childhood schizophrenia made a set of claims, Despert’s 1938 paper partly modified them in ways which was quite close to Kanner’s 1943 autism and then Kanner made further modification to conceptualise his notion of autism. As I said in my article, Kanner built on Despert. Olmsted and Blaxill’s article has very helpfully found in the archives some letters written between Despert and Kanner. Written in 1943, just after Kanner’s publication on autism, Despert praises Kanner’s paper but objects to his claim to have discovered something new. She appears to think she has already described something like autism. Kanner, in a letter sent a few days later, praises Despert’s work but argues his own paper contains an important additional claim – the children showed the symptoms from birth, whereas Despert’s children only showed some symptoms from birth. As I wrote, Kanner’s “innovation was realising that actually no onset took place, all symptoms were presentfrom birth. Generally, it was believed all symptoms of all childhood schizophrenia occurred after a period of normality, but then Despert claimed some childhood schizophrenics had some symptoms present from birth, and finally Kanner claimed some childhood schizophrenics had all symptoms present from birth, renaming those childhood schizophrenics as autistic.” (2275-2276).

At this point we need ask, what does it mean to describe something first? Kanner’s autism has also undergone major modifications by later psychiatrists, so in a sense you could say that Lorna Wing really discovered autism, since her notion seems closest to our own (but then Wing’s notion has undergone minor modification). This is why I concluded by saying “Who wrote the original account of autism? This is not a helpful question. Kanner and other child psychiatrists worked within scientific communities, engaging in a mutual process of borrowing and expanding ideas” (2276). I think the archival material Olmsted and Blaxill have produced nicely show this borrowing and expanding process, a process that does not easily fit notions of “who first described something”.

Reviewing Kanner’s In Defense of Mothers

History, Kanner


Kanner’s In Defense of Mothers arrived last week, having been ordered from America. It was published in 1941, two years before he developed his notion of autism. This books is very different in focus to most his writings, unusually being primarily about children who did not see psychiatrists.

The message is primarily ‘let children be children’, and to a lesser degree ‘let mothers be mothers’. He seemingly has a notion of natural mothering and believes this is distorted through bad advice given by various sources of supposed experts on mothering. He tells mothers not to insist on rigid diets, not to overburden the children with work, not to interfere dramatically in the child’s social life (i.e not decide who their friends can be), trying to counter various cultural sources who insist the mother must perfectly raise children lest the child ends up neurotic and delinquent. He thinks society should just let mothers be mothers, which would mean mothers would let children be children, a good route to healthy children in Kanner’s view.

There was very little about psychoanalysis in the book. The specific claim that poor mothering causes mental illness (such as childhood schizophrenia) was not really discussed (there were some ambiguous passages related to this but much more moderate than what came later). Whilst such claims really took off around 1950, it seems they were of little significance in the early 1940s.

The guiding principle throughout the book was ‘put the child in context’. If the child does something bizarre then there probably is good reason for this, talk to the child, try to understand what is happening with their life, but do not take this as a sign of some ominous symptom that must be immediately countered. This looks like Kanner taking a Meyerian approach, emphasising the individual as a whole who must be understood contextually, rather than more common approaches of just interpreting everything under one pet theory, something some child psychaitrists did and Kanner hated.

It was interesting to see Kanner would often describe the family in political terms, outlining a democracy as an ideal family where the child was an active member who was listened to. This contrasted with totalitarian families where the exact path the child must take was laid out in advance by the parents. Written in 1941, using such political terminology was understandable.

Overall, I’d put In Defense of Mothers as Kanner’s least valuable book to read, measured by all those published since he became a child psychiatrist. It does not particularly illuminate Kanner’s views, at least not more so than his 1935 text book, which goes into much more detail. It does give some nice social history though, giving a good feel for early 1940s American approaches to childhood.

The History of Secondary Histories of Autism

Secondary History

Over the next few months I’ll be reviewing some secondary history texts, so firstly I’ll outline a brief history of the secondary history. I’m only counting work written from 1980 onwards, since this is when the major steps towards our modern autism started (for earlier histories see some of Kanner’s and Eisenberg’s texts). All texts I refer to below are listed here: http://samfellowes.com/Historyofautismbibliographies/Secondaryhistory/Index.html

The earliest histories were written by medical practitioners. Sanua (1983) has other agendas than strictly writing a history but he gives an excellent account of the relationship between autism and childhood schizophrenia. Lorna Wing (1997) describes the basics but focuses too much on Kanner and Asperger, though I think her understanding of Kanner is more nuanced that some historians claim. Wolff (2004) is brief and also focuses too heavily on Kanner and Asperger, though she does give a good account of her own work.

The watershed came with Nadesan (2005). This was the first book length history of autism, additionally, it was written by someone who was not a medical practitioner, by someone who is not an important historical figure, unlike Wing and Wolff. Nadesan discusses of concepts of child development prior to autism and discuss how concepts of autism change over time due to changing theories in psychology, also giving wider cultural context to why those theories in psychology changed. Whilst not perfect the book was a massive step forward.

Except for Grinker (2007) (who is worth reading but is not primarily intending to write history), there was a major gap of four years between Nadesan’s book until what I call the first golden age started. 2010 saw books by Feinstein (2010) and Eyal et al (2010). Feinstein interviewed many historical figures whilst Eyal et al described in great detail the wider socio-medical changes and how this impacted concepts and classifications. 2010 also saw Jacobsen’s (2010) article which compared Kanner with Bettelheim and relates their work to modern autism. The next major publication was Silverman’s (2012) book. I believe her book is the least ground breaking of the four history of autism books, covering less new material than the others, but I believe it the most well developed and factually accurate. 2013 saw ground breaking articles by Verheoff (2013) and Evans (2013), both describing how wider theoretical changes in psychiatry influenced the changes to the classification. 2014 saw Evans (2014) provide background to 1950s and 1960s British psychiatry whilst Hollin (2014) and Verhoeff (2014) are the first history papers to cover beyond the 1980s in detail. I’ve missed out Neumärker (2003), Silverman (2010), Blacher & Christensen (2011) and Raz (2014) because they are very specific in their focus, though they are all still worth reading.

So far, to my knowledge, at time of writing (July), there has only been one secondary history publication in 2015 (my own, Fellowes (2015)). Perhaps the first golden age has ended. Alternatively, perhaps the second half of 2015 will see many publications; another of my articles will be submitted soon and Bonnie Evans’ book is due out in 2015. The history of autism has come far, especially since 2010, and I personally can identify many areas not yet covered. From where I sit, a continued stream of publications seems more likely than the field dying at this point – existing texts have raised many questions and it will be historians who read those secondary histories published during this first golden age who will produce the next wave of research.