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.
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.