Regardless of the time and rapidity of onset, the autistic child exhibits a disregard for other persons; this is typically quite striking but can be subtle in milder cases. Little or no eye contact is made, and the child is no more interested in another person than in an article of furniture. Proffered toys may be manipulated cleverly, placed in lines, or rejected. Insistence on constancy of environment may reach a point where the patient becomes distraught if even a single one of his possessions has been moved from its original place and remains distressed until it is replaced. If speech develops at all, it is automatic (echolalic) and not used effectively to communicate. A repertoire of elaborate stereotyped movements—such as whirling of the body, manipulating an object, toe-walking, and particularly hand-flapping—are characteristics. It is important to point out, that in any sizable group of autistic children there is a wide range of deficits in sociability, drive, affect, and communicative (verbal and gestural behavior) ability, ranging from an averbal, completely isolated state to considerable language skill and some capacity for attachment to certain people as well as for scholastic achievement. However, the IQ of the majority is below 70 and in 20 percent it is below 35; 1 percent, however, have normal or superior intelligence. In this higher-functioning group, taken to typify the Asperger syndrome, the child may be unusually adept or even supernormal in reading, calculating, drawing, or memorizing (“idiot savant”) while still having difficulty in adjusting socially and emotionally to others and in interpreting the actions of others. Many are clumsy and inept in athletic activities. The least degree of deficit allows success in a professional field but with handicap in the social sphere.
We take the current emphasis on the term autistic spectrum disorders to reflect a concept that each of the core elements of autism (in social, language, cognitive, and behavioral domains) may occur in widely varying degrees of severity. This view expands the diagnosis to many children who are highly functional except for a tendency to gaze aversion and other “soft signs,” together called “pervasive developmental disorder” (Filipek). There is also crossover with a number of namable developmental delays as noted below.
Rapin, who drew on a large clinical experience, has carefully documented the linguistic, cognitive, and behavioral features of the syndrome. She uses the term semantic-pragmatic disorder to designate the characteristic problem with language and behavior and to distinguish it from other forms of developmental disorders and developmental delay. There is a striking ability to understand isolated facts but not to comprehend concepts or conceptual groupings; consequently, these children and adults seem to have difficulty generalizing from an idea. Temple Grandin, a patient with a high-functioning Asperger type of autism who has written of her experiences and has been described by Sacks, indicates that she thinks in pictures rather than in semantic language. She reports a curious comfort from being tightly swaddled and has a highly developed emotional sensibility to the experiences of cattle, which has allowed her success in reforming and designing abattoirs. According to Eisenberg, who reviewed many of Kanner’s original cases and followed many other cases into adult life, one-third never spoke and remained social isolates, one-third acquired a rudimentary language devoid of communicative value, and the remainder were functional to various degrees, possessing an affected, stilted, colorless speech. It is in the latter group, representing the mildest degrees of autism, that one finds eccentrics, the mirthless, flat personalities, unable to adapt socially and habitually avoiding eye contact but sometimes possessing certain unusual aptitudes in memory, mathematics, factual knowledge, history, and science. Rutter, who has written extensively on the subject, says that the degree of language impairment and lowered intelligence predicts outcome; those who do not speak by 5 years of age will never learn to speak well.