A Retrospective analysis of clinical case records of Autistic Psychopaths diagnosed by Hans Asperger and his team at the University Children's Hospital Vienna

Kathryn Hippler and Christian Klicpera Phil. Trans. R. Soc. Lond. B (2003) 358, 291 - 301.

To date, it is questionable whether the diagnostic criteria for Asperger Syndrome (AS) as stated by ICD-10 or DSM-IV still reflect Asperger's original account of 'autistic psychopathy' (AP) from the 1940's. The present study examined 74 clinical case records of children with AP diagnosed by Hans Asperger and his team at the Viennese Children's Clinic and Asperger's private practice between 1950 and 1986. The characteristic features of the children are outlined, including reasons for referral, parental background, behavioural problems, cognitive functioning, communication and interests. Results show that the patients of Asperger described in our study represent a subgroup of children with very high intellectual functioning, specific circumscribed interests, and talents but impaired social, communication and motor skills. Sixty-eight per cent of the sample met ICD-10 criteria for AS, while 25% fulfilled the diagnostic criteria for autism. Implications for the diagnosis of AS are discussed.

Asperger (1944, 1952) believed that AP was a constitutionally based personality disorder merging into the 'normal' continuum, that is, a group of eccentric, withdrawn, but often highly gifted, individuals who manage social integration despite their somewhat odd social interaction or communication. He saw AP as a life long, stable type of personality without the quality of a progressing fragmentation of personality typically seen in schizophrenia. Also, he stated that it was possible for 'autistic psychopaths' to form certain close interpersonal relationships in their course of their life while schizophrenic psychotic individuals were more likely to lose their ability to form close relationships over time.

Wing observed some additional items in the developmental history of children with AS (e.g. a lack of interest or pleasure in human company in the first year of life) and pointed out that AP may also occur in individuals with learning disabilities. This was, in fact, mentioned by Asperger in his 1944 paper but seems to have been overlooked by researchers and even Asperger himself in his later papers.

In contrast to DSM-IV and ICD-10, the criteria of Gillberg and Gillberg (1989) and those of Szatmari et al. (1989) do not require 'normal' early development for a diagnosis of AS to be made, and view language and communication peculiarities as a defining feature. Additionally, Gillberg and Gillberg proposed that motor control problems (poor performance on neurodevelopmental examination) have to be present.

In the German language, 'psychopathy' did not quite have the negative connotation it now has in English. It was merely a term for describing personality disorders and did not seek to stress the patients' proneness to criminality.

What Asperger called 'autistic malice' was observed in seven patients (15%); these children were described as seemingly good observers, showing intentional acts of malice, with malicious pleasure and apparent pride in what they had done. Some of the children were said to 'experiment' on others, that is, they seemed to do things on purpose to see how others reacted or to provoke a certain reaction. Eight children (17%) were reported as being hypersensitive towards criticism and jokes by others. For nine patients (20%) sensory deviances were so striking that they were mentioned in the files (e.g. hypersensitivity to certain noises, obsession with smells).

For 38 cases, measured VIQ and PIQ could be compared. VIQ and PIQ were rated as discrepant if a 9 point difference or higher could be observed between the two measures. Applying this rule, 48% showed a higher VIQ than PIQ, whereas 18% demonstrated the opposite pattern. For 38%, VIQ and PIQ measures showed no significant differences.

Special gifts and abilities
Nineteen percent of the 46 children with detailed files were reported as being capable of original, sometimes even philosophical, thinking processes. Fourteen percent were said to have a special gift for abstract thinking and logical reasoning. A special insight into themselves (self-reflection and consciousness) was reported for another 17%. These children were described as being capable of looking at themselves from an outside or dispassionate view, but Asperger often mentioned that they did not draw conclusions from these insights and could not use them in the social context (i.e. see themselves through the eyes of others and behave accordingly). An outstanding mathematical talent was reported in 23%. Some children were said to invent their own calculation methods that were highly complicated but did not always lead to correct results. Other abilities mentioned included eidetic memory (14%) and musical or artistic talent (12%).

The most common profession among fathers of children with AP was technical professions, which is significantly different from the control group. The most frequently seen profession for fathers in our sample was engineer or electrical engineer.

In 32 files, a short description of the impression the staff had of the parent's personality was available. Some resemblance between the child with AP and one or more family members was observed in 53% of the sample. Fourteen fathers (52%) were reported as being similar to their child in personality (e.g. aloof, odd, 'nervous') showing deviant behaviours or low social competence. Additionally, for four mothers (15%) and two siblings (7%) similarities with the presented child were mentioned.

Information about the mother's pregnancy, the child's birth, and his/her early development was available for the 46 cases with detailed files from the ward. Twenty-eight percent of the mothers had had difficulties during pregnancy, including bleeding, infection, or extreme nausea. In 33% of the cases, difficulties during birth were reported. Twenty-six percent of the children were late in being potty trained, or had phases of enuresis or soiling during their early childhood. Only 11% were reported as having been delayed in their motor development. By contrast, 20% of the children showed language delay (first words after two years). It was mentioned that seven children (15%) started to talk quite unexpectedly, that is, they did not talk at all until a certain age and were then suddenly capable of saying a number of words or even whole sentences. Four of these cases had been significantly delayed in saying their first words (2 years or more) but then rapidly developed a good use of phrases before the age of three.

The greatest behavioural difficulty of the 46 children admitted to the ward consisted of lack of integration into the peer group. Over 90% were reported as having severe deficits in this area. For the great majority, these problems consisted of a combination of being 'out of the group', having no friends, being ignored, disliked or bullied by the others. It was not so much that they were not interested in their peers but rather that they approached them in an inappropriate way or that their unpredictable behaviour (i.e. aggressive outbursts) made them unpopular with the others. Three-quarters of the children were described as being clumsy during their stay on the ward (i.e. it was mentioned in their files that they showed impaired fine and gross motor skills, poor motor coordination or difficulty in participating in sports and games) although not all of them received a diagnosis of apraxia. Other frequently seen problems concerned the children's difficulty in finishing school work. They were reported as being too slow, too pedantic or too careless because they were preoccupied with other things (e.g. their special interests) or had major attention deficits. Asperger often regarded the children as being 'distracted from within/or by themselves'. Furthermore, half of the children displayed disciplinary problems, negativism, or conduct difficulties, particularly at school; they did not listen to what the teacher said or only followed their own 'spontaneous', idiosyncratic ideas. They were described as disrespectful towards authority, and could come across as impudent and blunt because they would speak out freely without thinking while being quite unaware of the situation or the status of the person to whom they were talking. Sometimes disciplinary problems went so far that s/he had to be expelled from school or excluded from PE lessons (20%).

Eighty-two percent were reported as having special, original and narrow interests and hobbies. Asperger and his team often described these interests as highly scientific and distinctive, while other interests were rather obscure or atypical for children that age (e.g. eye muscles, rubbish bins, earthworms, religious hymns, gangsters). Ninety-five percent of the admitted patients displayed some kind of language and communication deviancies that can be regarded as typical for AS. Asperger considered the 'autistic psychopath's' language peculiarities as one of the most dominant characteristics of the disorder. For many children, deviant prosody and quality of voice was reported (e.g. monotonous speech, singing, quality of voice, high pitched tone, over-precise articulation). The children were frequently regarded as ignorant of the social situation when speaking, and sometimes seemed to talk to themselves, commenting on their own actions or giving monologues without needing a listener. Facial expression was regarded as limited or different in 80% of the admitted children. More than one third of these children lacked emotional expression; 13% seemed tense; 17% had facial twitches/tics or an unnatural expression (e.g. permanent smile or grin); 17% appeared unusually serious and not child-like in their facial expression.

In order to determine whether Asperger's patients would fit the diagnostic criteria for Asperger's disorder today, 44 children with AP were analysed according to ICD-10 research criteria (World Health Organization 1993). The results show that 68% of the children would be diagnosed with AS according to current ICD-10 criteria. Twenty-five percent of the children (n=11) did not meet the requirement of normal development before the age of three. After systematically analysing 74 descriptions of 'autistic psychopaths' delineated by Asperger and his team from 1950 to 1986, we hope that a somewhat clearer picture of 'what Asperger meant' may arise. Only 5% of the analysed cases were females. Typically, the children were first referred in middle childhood (mean age 8 years). The children were described with several diagnostic labels, most commonly 'contact and instinct disorder', i.e. a combination of low social competence and a lack of instinctive knowledge about how to solve everyday problems or how to behave appropriately in a variety of situations. The most dominant behavioural difficulty of the children consisted of lack of integration into the peer group. The children seemed to others to be isolated and were often ignored, bullied or disliked by their classmates. The ability to concentrate on schoolwork was usually poor, and disciplinary problems and conduct disorder were seen in half of the children of the sample. Usually, typical pedagogical measures proved to have no effect on the child's behaviour, but rather made it worse. Over 80% of the children had special interests, most of which consisted of a fascination for certain animals and aspects of nature or were of a technical kind.

Although, in the present sample, early motor development was not found to be delayed very often, 59% had an additional diagnosis of motor apraxia, almost three-quarters showed motor clumsiness during their stay on the ward and another third displayed awkward or gauche body language and gait. Both language deviancies and motor clumsiness, however, seemed crucial for a diagnosis of AP in the present sample.

The authors would therefore agree with the point of view of Wing (2000) that AS cannot be clearly distinguished from autism but may still be clinically useful as a diagnostic category. In any case, current ICD-10 and DSM-IV criteria for AS do not quite capture the individuals originally described by Asperger and his team. They appear to differentiate AS from autism solely based on the onset criteria, regardless of the patient's social impairment later in life. In particular, motor and social clumsiness as well as speech and communication deviancies should be taken into consideration in further discussion of diagnostic criteria for AS.