Autism has become a deeply contested diagnosis. Whereas family advocacy organizations have long characterized the condition as a disorder in need of effective treatments, a growing number of adults who think of themselves as having high-functioning autism (or Asperger syndrome) insist that autism is an identity deserving of acceptance. The latter use the term “neurodiversity” to contend that autism should be regarded as a profoundly interwoven combination of intellectual gifts and social differences. Some even question the motivations underlying basic scientific research, arguing that genetic markers will be used in prenatal diagnosis to eliminate rather than improve the lives of people with autism.1
The debate over whether to consider autism a disability or identity is surely complicated by its expansion into a spectrum that encompasses a wide range of individuals and functioning. But this controversy is also rooted in a fundamental tension within the core definitions of autism as formulated in the 1940s by the 2 physicians credited for first describing the syndrome. Drs Leo Kanner and Hans Asperger both highlighted the presence of intellectual gifts in many of their patients, alongside social deficits and characteristic behaviors. This emphasis is best understood as a strategy to draw a sharp line dividing autism from mental retardation, reacting to a historical moment when the latter had become the target of a powerful eugenics movement.
“Eugenics” is a slippery term to define, but in the context of the early 20th century, it can be thought of as a social movement dedicated to improving the quality of the human race through the science of heredity. From roughly the time of the Great War (1914–1919) through the Second World War (1939–1945), it attracted a wide following in many countries, including the United States, Great Britain, and (most notoriously) Nazi Germany.2 Its appeal was fed by widespread anxiety regarding what was often called the “menace of the feebleminded,” the fear that the intellectually inferior classes were reproducing at a far higher rate than that of their more socially responsible superiors. The number of children consigned to residential institutions soared in this period. Cognitively impaired children could be institutionalized with only minimal formal evaluation, and it is highly plausible that many would be diagnosed today as having autism.3 The economic and social burden associated with the rise of institutionalization led to cries for more definitive solutions in the form of sterilization in the United States, and ultimately, the systematic elimination of “lives not worth living” in wartime Nazi Germany through forcible euthanasia.
In his book NeuroTribes, Steve Silberman4 has portrayed Hans Asperger as a pioneer of neurodiversity who resisted eugenic ideology by promoting a positive and benign view of autism. The Austrian pediatrician gave his first public lecture on “autistic psychopathy” in October 1938, just months after the incorporation of Austria into the Third Reich. That lecture (later to become the basis of his more widely cited 1944 thesis) described 4 patients whose striking combination of intellectual gifts and social interaction deficits Asperger likened to that of “little professors.” All had been seen in an innovative special education unit, the Heilpädagogik Station, characterized by an optimistic therapeutic philosophy contrasted with the fatalism so often associated with institutions. Interestingly, Asperger commented that he had specifically chosen “not too severe and thus more promising cases,” suggesting to Silberman that he was aware that they represented part of a broader continuum of autism. He thus emphasized the continuity of the syndrome with intellectuality rather than mental retardation. “Who among us does not recognize the autistic scientist,” Asperger asked, “whose clumsiness and lack of instincts have made him a familiar caricature, but who is capable of extraordinary accomplishments in a highly specialized field?”4
It has been less noticed that Asperger was not the only pioneer of early autism who sought to distinguish autism from the “unfit.” Kanner, the Johns Hopkins psychiatrist whose 1943 article is widely regarded as the first American description of autism, made a rather similar diagnostic move. Kanner’s vivid case series of 11 patients described many of the classic behaviors that continue to define autism today, but it differed in one important respect. None of the children, he asserted, had mental deficiency. He based his belief on the presence in his patients of striking capacities for memorization and complex interaction with objects. His first patient, Donald T., could recite 25 questions and answers of the Presbyterian catechism.5
Just as striking was Kanner’s characterization of his patients’ parents: “They all come of highly intelligent families.” Most of the fathers had advanced professional degrees, and all but 3 of their extended families were well represented in compendia such as American Men of Science.5 The autism pedigree was effectively the opposite of the counterpart for “feeble-mindedness” so vividly summarized by Justice Oliver Wendell Holmes’ famous opinion in the ruling justifying eugenic sterilization in Buck v. Bell, “Three generations of imbeciles is enough.”6
The focus on special “intellectual abilities,” so prominent in the thinking of both Kanner and Asperger, can be best understood as a strategy to distance their patients from the stigma of mental retardation in the eugenics era. Neither was simply describing what they saw; both were aware of children with autistic symptoms who had no such evidence of precocious intelligence. As already noted, Asperger presented only his “more promising cases.” Kanner appears to have disqualified patients with congenital syndromes associated with intellectual disability (such as tuberous sclerosis) from an autism diagnosis.7
The practical consequences of this distinction between autism and mental retardation for Kanner’s and Asperger’s patients is debatable. Most of Kanner’s original 11 patients were placed in state institutions and eventually lost their earlier intellectual abilities.8 The main exceptions, in fact, were the 3 who evaded residential placement, most notably his index case, Donald T., whose intellectual gifts became something of a sensation in his home town of Forest, Mississippi.9
In Asperger’s case, the Heilpädagogik Station where he had studied his “little professors” stayed in operation only to be destroyed in a bombing by Allied forces at the end of the war. Nor is there any evidence that, if Asperger did anticipate an autism spectrum, this recognition led him to protect patients functioning at lower cognitive levels. After the annexation of Austria into Nazi Germany, this potentially meant euthanasia. Documents unearthed by Austrian historian Herwig Czech (recently publicized in the English-speaking world by journalists John Donvan and Caren Zucker) have indicated that, in common with many of his peers under the Nazi regime, Asperger referred children with severe mental retardation to hospitals that were known euthanasia centers.9 Historians have already shown that physicians cooperated with the Nazi regime for a variety of reasons, including personal gain and professional survival.10 The revelation that “St Asperger” was among them remains poignant, a reminder of the moral vulnerability of even the most sympathetic and forward-thinking physicians of the time.
Nonetheless, Kanner and Asperger’s construction of autism as an entity combining both special abilities and social deficits has left an important legacy. Although autism has formally been defined in terms of deficits and pathologies, the public image of autism, particularly since the 1988 movie Rain Man, has often emphasized the theme of giftedness.
For some, this dimension of autism is framed as a hidden self, awaiting discovery and liberation through curative treatment. For neurodiversity advocates, such special abilities are part of the core identity of the person with autism. But either way, we need to understand the often highly charged debate over the meaning of autism in the context of the legacies of the eugenics movement and the long history of stigmatization of mental disability.
- Accepted May 22, 2017.
- Address correspondence to Jeffrey P. Baker, MD, PhD, Pediatrics, Trent Center for Bioethics, Humanities, and History of Medicine, Duke University School of Medicine, PO Box 3040, Durham, NC 27710. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Solomon A
- Kevles DJ
- Eyal G,
- Hart B,
- Onculer E,
- Oren N,
- Rossi N
- Silberman S
- Kanner L
- Lombardo P
- Frankl G
- Donvan J,
- Zucker C
- Proctor RN
- Copyright © 2017 by the American Academy of Pediatrics