THE LANCET
Seminar
The autistic spectrum
Lorna Wing
The autistic spectrum consists of a group of disorders of
development with life-long effects and that have in
common a triad of impairments in: social interaction,
communication, imagination, and behaviour (narrow,
and repetitive pattern of behaviour).1,2 The spectrum
includes, but is wider than, the syndromes originally
described by Leo Kanner3 and Hans Asperger.4
The triad can occur on its own but is often
accompanied by other features. It can be found together
with any level of ability, from profound general learning
disability to average or even superior cognitive skill in
areas not directly affected by the basic impairments. It
can occur with any other physical, psychological, or
psychiatric condition.
Clinical pictures
Each element of the triad has a range of manifestations.
The clinical picture is also affected by the individual’s
level of ability, and the number and type of additional
features or other disorders. Age, sex, personality, and
temperament, the social and physical environment, and
educational, psychological, and medical interventions all
influence behaviour.
The spectrum overlaps with but covers a wider range
than the category of pervasive developmental disorders
in the tenth edition of the International Classification
of Diseases (ICD-10).5 In ICD-10, pervasive
developmental disorders are divided into several sub-
groups (panel 1). The fourth edition of the American
Psychiatric Association’s Diagnostic and Statistical
Manual (DSM IV) has definitions of pervasive
developmental disorders and sub-groups that are almost
the same as those in ICD-10.6
Current attempts to identify specific syndromes
within the autistic spectrum, including those used in
ICD-10 and DSM IV, are unsatisfactory. The criteria
for distinguishing subgroups tend to be arbitrary, and
are difficult to apply and unhelpful in clinical practice.
The clinical picture can change with increasing age and
in different environments. The ICD-10 classification
system aims to increase reliability by defining Asperger’s
syndrome with the same criteria for social impairment
and repetitive routines as for autism but with no delay
in development of speech, self help, adaptive skills, and
curiosity up to the age of 3 years. However, this has
moved away from Asperger’s account of his syndrome.
His clinical descriptions closely resemble the group with
active but odd social interactions (see below), in
contrast to the aloofness and indifference of typical
autism. He noted that there were difficulties in learning
Lancet 1997; 350: 1761–66
The Centre for Social and Communication Disorders, Elliot House,
113 Masons Hill, Bromley, Kent, BR2 9HT, UK
(Lorna Wing FRCPsych)
Vol 350 • December 13, 1997
Panel 1: ICD-10 classification into subgroups
F84 Pervasive developmental disorders
F84·0 Childhood autism
F84·1 Atypical autism
F84·2 Rett’s syndrome
F84·3 Other childhood disintegrative disorder
F84·4 Overactive disorder associated with mental
retardation and stereotyped movements
F84·5 Asperger’s syndrome
F84·8 Other pervasive developmental disorders
F84·9 Pervasive developmental disorder, unspecified
simple practical skills and social adaptation from early
childhood and that abnormalities were recognisable
from the second year of life. Many clinicians diagnose
on their interpretation of Asperger’s clinical
descriptions, rather than insisting on normal
development before 3 years in the areas mentioned.7
In this article, a simple system of subgrouping based
solely on a description of the type of social impairment
will be used,1,8–10 which avoids the confusion inherent in
trying to identify the named syndromes. This simple
subgrouping has proved helpful in clinical practice even
though the groups are no more sharply differentiated
and permanent than in any other existing method of
classification in the specialty.2
Aloof group
The most easily recognised variant of the spectrum is
seen in children who appear aloof and indifferent to
others, especially their age peers, though they may
accept physical affection from familiar people. Some
individuals with autism are profoundly disabled and
have little or no speech and no skills in any area apart
from gross motor function, though there are some who
are not mobile. Their repetitive behaviour usually
consists of odd movements of limbs and body, known as
motor stereotypies, and fascination with simple sensory
stimuli, such as bright lights. In some, self-injury is a
major problem.
The aloof children who fit most closely into the
popular picture of autism and the ICD-10 definition of
childhood autism tend to have moderate or mild
learning disabilities, with higher levels of skill in specific
areas, especially visuospatial tasks or rote memory.
Some autistic children fit Kanner’s syndrome of early
infantile autism, narrowly defined as social aloofness
and resistance to change in their elaborate repetitive
routines. A few of these children have cognitive ability
in the normal or even the superior range. They may
have no speech but, more typically, speech is delayed in
onset and shows characteristic abnormalities including
immediate echolalia (parrot-like copying of other
people’s utterances) or delayed echolalia (repetition of
words or phrases in a stereotyped way). This type of
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speech may be meaningless or may be used as a request.
One child, for example, always said “Go for ride to
shops in Daddy’s green car”, to request any kind of
outing, even when the father bought a new blue car. The
tendency to echo often leads to reversal of pronouns; a
child may say, for example, “Do you want juice” when
they mean, “I want juice” because they echo the words
they hear when juice is offered. Some autistic children
develop large vocabularies but do not use their speech
for reciprocal conversation. They do not use non-verbal
body language to accompany or substitute for spoken
speech. Gestures tend to be confined to pulling people
along to use them as tools to obtain some desired object.
Eye contact is inappropriate for the social situation. Play
is absent or limited to a repetitive sequence of actions.
The pattern of activities is dominated by repetitive
routines, such as putting objects into long straight lines
or patterns, insisting on following the same routes for
journeys, and demanding a lengthy, unchanging bedtime
routine. These routines can come to dominate family life
because the child has terrifying temper tantrums if any
change is introduced.
In addition to the triad, other features include:
unusual responses to sensory stimuli, especially over
sensitivity to some sounds; disturbance of sleep pattern;
refusal to eat all but a few items of food; odd posture;
odd gait, such as tiptoe walking; motor stereotypies,
such as hand and arm flapping or twisting; poor
attention span in general but with the ability to attend
intensely to one or a few activities.
Passive group
A somewhat different picture is seen in children whose
social impairment presents as passivity. On ICD-10
criteria, some might be classified as childhood autism or
atypical autism, while others fit Asperger’s syndrome.
Such children do not socially interact spontaneously but
passively accept approaches from others. They have the
impairments of communication and imagination and
additional features similar to the aloof group, but
usually in less florid form. They tend to be more
amenable in behaviour and less obviously upset at
interference with their repetitive routines. Some have
ability in the average or high range and manage to
survive mainstream school, at least in the primary years.
The diagnosis may be missed until problems with
learning and with social interaction with age peers begin
to emerge in secondary school.
Active but odd group
A third type of social impairment is seen in children who
make active social approaches that are naive, odd,
inappropriate, and one-sided. They tend to fit
Asperger’s clinical descriptions of his syndrome. Their
speech is often fluent with good grammar and
vocabulary but repetitive and not used for reciprocal
conversation. In a small minority, there is no history of
delay in speech development or adaptive skills and they
could be classified as Asperger’s syndrome on the ICD-
10 criteria. These children may have quite complicated
play but observation shows that it is concerned only with
one or a few themes and usually not shared with other
children. Some like to watch particular videos and act
out the same scenes over and over again.
The repetitive routines take the form of fascination
with and talking about particular topics, such as
1762
tractors, train timetables, mathematical calculations,
dinosaurs, lamp posts, or species of birds. Some become
intensely interested in a particular person, real or
fictional. Any topic can become a special interest and
the focus may change from time to time. A small
proportion tend to fantasise about their special interests,
telling muddled stories about events that never
occurred. They seem to have difficulty distinguishing
these inventions from reality.
Poor gross motor coordination, most noticeable when
attempting to play team games, is particularly common
in the active but odd group. Odd responses to sensory
stimuli and motor stereotypies are less common, but can
occur. Behaviour difficulties, including temper tantrums
and physical and verbal aggression, arise from the
egocentricity and stubborn resistance to doing anything
other than their own preferred activities. The child’s
repetitive talking on a favourite theme and the constant
asking of the same questions regardless of any replies are
very wearing for parents. The range of cognitive ability
in this group is wide but levels tend to be higher than for
the aloof children, and a larger proportion have average
or superior intelligence as measured on standardised
tests.
Loners
The most subtle form of the triad, described by Sula
Wolff,11 is found in people of average, high, or
outstanding ability, including fluent speech, who tend to
prefer to be alone, lack empathy, and be concerned with
their own interests regardless of peer-group pressures.
Their schooldays are often stressful and difficult because
they will not conform to the demands of teachers or of
fellow pupils. Most are happier as adults and may follow
successful careers, sometimes of high academic
distinction. Some learn the rules of social interaction by
rote, while others remain solitary by choice. Some
marry, but partners may feel the lack of emotional
rapport. A minority develop psychiatric illnesses or
break the law in pursuit of their special interests. The
additional features often associated with the triad are
negligible or absent in this group, which overlaps with
Asperger’s descriptions of his syndrome.
High-functioning people with autistic disorders have
been able to describe their experiences of the world as a
confusing and frightening place.12
Aetiology
As yet, autism spectrum disorders can be defined on
behavioural criteria only. There is a wide range of
conditions that can be associated with autistic disorders,
though, in the present state of knowledge, a specific
aetiology can be found in only a minority of cases. Even
when a cause can be identified, this does not map onto
the behaviourally defined subgroup, whatever
classification system is used.
In the majority of cases, parents recognise that their
child has been different from birth or the first few
months of life. However, some report a set-back, usually
in the second or third year of life, though occasionally
later, after a period of apparently normal development.13
The regression, or failure to progress, affects language,
play, and social interaction and occasionally other skills.
In such cases, skilled, specific questioning about social
behaviour before the set-back often reveals
Vol 350 • December 13, 1997

A pupil and teacher from a school run by the National Autistic Society
abnormalities that the parents did not recognise, but
there are some children whose early development seems
to have been entirely normal before the gradual or
sudden change.
Early theories that autism was due to being reared by
cold and distant parents have been disproved.14 There is
strong evidence for a genetic cause in many, perhaps
most, cases of typical autism.15 Available evidence
suggests that genetic factors may be involved in any of
the spectrum disorders.16 However, it is also clear that
conditions affecting brain function—eg, tuberous
sclerosis17 or maternal rubella1—can be associated with
the autism triad.18 Epilepsy or an epileptiform
electroencephalogram (EEG) have been noted in a
significant minority of children with a reported set-back
in development as described above, and in a smaller
minority of those without such a history.13 By the time of
adult life, about a third of individuals with autistic
disorders have had at least one epileptic seizure. These
are most likely to occur among children and adults with
severe learning disabilities and motor deficits as well as
an autistic disorder. Immunisation against whooping
cough and, more recently, the triple vaccine for mumps,
measles, and rubella have been suggested as causes, but
scientific evidence either for or against has not, to my
knowledge, been published. Serious work in this field
must be based on sound epidemiological principles, not
on anecdotes.
Various specific developmental syndromes can be
associated with some or all of the features found in
autistic disorders. For example, children with Rett’s
syndrome often go through an autistic phase in the early
years but may become more sociable later.19 The typical
behaviour pattern in the fragile-X syndrome includes
delayed echolalia, hand flapping, repetitive speech, and
gaze avoidance, but not the social and symbolic
impairments of autistic disorders. However, the full
picture of autism can occur in this condition.20 The
similarities to and differences from autistic-spectrum
disorders may eventually provide clues to the
neuropathology. Neurobiological studies of individuals
with autism suggest abnormalities at the cellular level,
but not in gross brain structure.21 Necropsy studies have
shown unusually large brain size in some individuals.22
Biochemical studies are as yet inconclusive.23
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THE LANCET
Diagnosis
There are no physical tests for autistic
disorders. A patchy profile on cognitive
testing, tests showing absence or
impairment of theory of mind, and those
showing poor ability to comprehend or use
body language, can indicate the presence of
an autistic disorder, though good
performance on such measures in the
artificial situation of a formal test does not
exclude the diagnosis.24 Some children with
autistic disorders seen in a structured, one-
to-one situation, such as a school, clinic, or
during psychological testing, may behave
very well, smile, and look at the examiner
and show none of the overt features of
Steve Hickey
autism. If the same children are observed in
unstructured real-life settings, especially in
a group of age peers, the autistic behaviour
becomes apparent.
Diagnosis is made by obtaining a detailed
developmental history (from infancy), from parents or
other informants, with particular emphasis on the
elements of the autism triad and repetitive behaviour.
Semistructured interview schedules have been designed
for this purpose but specific training and experience is
needed.25,26
When the information has been collected, if it is to be
used for research, the ICD-10 research criteria27 can be
applied to assess whether a pervasive developmental
disorder is present and to which subgroup the individual
belongs. However, clinically, the most important point
to establish is whether the triad of impairments is
present. For this purpose, clinical experience is a surer
guide than the rigid application of a set of rules that are,
in any case, open to different interpretations.
Differential diagnosis includes generalised learning
disabilities and specific disorders affecting language,
reading, number work, motor coordination, hearing, or
vision. Any of these conditions can occur alone but also
in association with an autistic-spectrum disorder. When
any aspect of development is delayed or deviant, it is
appropriate to consider whether the autistic triad of
impairments is also present.28 An autistic disorder can
be missed because attention is given to only one aspect
of development. So-called semantic-pragmatic disorder,
in which a child has fluent speech, that is used for
repetitive talking about the child’s own concerns and
not for reciprocal conversation, is a particular problem.
Many workers believe that this does not occur on its
own but is always part of an autistic-spectrum
disorder.29 Attention deficit and hyperactivity,
Tourette’s syndrome, and obsessive-compulsive
disorder affect movement and behaviour. They also can
occur alone or together with the triad of impairments.28
In adolescents and adults autistic disorders, especially
in higher-functioning individuals, can be misdiagnosed
as any kind of psychiatric condition, or they can be
missed if a psychiatric condition is superimposed on the
developmental disorder. The history and detailed
assessment of the pattern of skills, disabilities, and
behaviour are required for correct diagnosis.28
When making a diagnosis, it is also necessary to
consider whether there are any physical abnormalities,
including epilepsy and other specific syndromes.
A common mistake made by those lacking relevant
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Panel 2: Sources of information and help
UK: The National Autistic Society (393 City Road, London,
EC1V 1NE, UK; tel +44 (0)171 903 3599; fax +44(0)171
833 9666) is a voluntary body with parent and professional
membership. It provides a wide range of services and
information on diagnostic centres, schools, residential
homes for adults, publications in the field, and many other
matters of interest to professionals, families, and to people
with autistic disorders. The National Society also has details
of all local autistic societies and other relevant
organisations.
Europe: The International Association Autism Europe, Rue E
Van Becelaere 26B, Bte 21, B-1170 Bruxelles, Belgium; tel
+32 (0)2 675 7505; fax +32 (0)2 675 7270.
USA: Autism Society of America, 7910 Woodmont Avenue,
Suite 650, Bethesda, Maryland 20814, USA; tel +1 301 657
0881.
experience is to assume that the child’s behaviour is due
solely to parental mishandling, especially since the
children often have an alert and attractive appearance.
For accurate diagnosis it is essential to ask the right
questions systematically, listen to the parents with great
care, and treat them and their information with respect.
Autistic-spectrum disorders merge into what can be
called eccentric normality and there is no clear cut-off
point. In clinical practice, a diagnosis of an autistic
disorder is considered only if help is sought by parents
or by individuals themselves for difficulties with
everyday life. In these circumstances, it is appropriate to
investigate whether, among other possibilities, the
difficulties are due to the types of impairments in
psychological function that underlie autistic disorders. A
diagnosis in those who are managing well and are happy
with their lives is of purely academic interest.
Education, management, and treatment
There is as yet no curative treatment for autistic
disorders. Many therapies have been promulgated on
anecdotal grounds but scientific evidence for their
efficacy is lacking. Controlled studies of auditory
integration training and facilitated communication have
been published and these have not substantiated the
claims made.30
The most effective way of helping the children to
maximise their abilities and minimise behaviour
disturbance is through structured education designed to
take account of their impairments and special skills.31
Some cope with support in mainstream schools or
schools for a mixture of disabilities but many need
specialised education in schools for autistic disorders.
Parents require information and guidance in order to
provide an organised, predictable environment at home
(panel 2). After school age the adults who do not
become independent need accommodation, occupation,
and leisure activities tailored to their special needs. The
basic principles underlying education and management
are the same for the whole autistic spectrum, though
details differ depending on levels of ability and the type
of social impairment.
The medical role is limited but important and most
effective when the doctor is part of a team with other
relevant professions. The first priority is diagnosis of the
autistic-spectrum disorder so that the available sources
of help can be contacted as early in the child’s life as
possible. Doctors who have no particular interest in this
1764
area can refer to specialists or one of the small number
of special centres so that a full diagnosis and assessment
can be done.
Examinations for possible causes and for additional
physical or psychological disorders should be
undertaken if there are clinical indications, such as a
clear history of regression in development. Clinical
practices vary but, in some clinics, EEG and
chromosomal investigations, including investigations for
fragile X, are done routinely. Epileptic activity is most
likely to be seen in a prolonged sleep EEG.13
The other part of the medical role is the treatment of
any associated conditions, including epilepsy, visual or
hearing impairments, and intercurrent illnesses.
The sudden onset of disturbed behaviour may be due
to physical factors, including epilepsy. Discomfort or
pain due to a physical condition may affect behaviour.
One young adult, for example, began to bite people
though he had no previous history of aggression. This
continued until a dental abscess was diagnosed and
treated. The possibility of a physical cause for a change
in behaviour should always be considered.
Disturbed behaviour that is due to psychological
rather than physical causes often responds to
appropriate environmental and behavioural
management, which is the treatment of choice.28 If
psychotropic medication is needed—eg, to reduce the
level of physical aggression—this should be given in
addition to environmental and behavioural treatment
and for as short a time as possible. The effects should be
carefully monitored because there is great variation in
individual response.
Superimposed psychiatric conditions may respond to
removal of adverse factors in the environment but may
also require the relevant type of drug treatment.
Prevalence
A review of 16 epidemiological studies using various
definitions of typical autism gave rates ranging from 3·3
to 16·0 per 10 000.32 Those adopting the original narrow
definition of Kanner found prevalences of around five
per 10 000. Two further studies investigated the rates
for children with other autistic-spectrum disorders
combined with learning disabilities and found
approximately 15 per 10 000.1,33 There is only one
published study of children in mainstream schools, done
in Sweden, which suggests a rate of 36 in 10 000 for the
picture described by Asperger and 35 in 10 000 for
other high functioning spectrum disorders.34 More
studies are needed to evaluate the accuracy of these
estimates. One difficulty in interpreting the published
rates is the fact that the most intensive studies have
been done on small populations and the confidence
limits are very wide, so there may be more overlap than
is often appreciated.
Boys and men are affected perhaps three or four times
more often than girls and women. Among those with
severe or profound disabilities, the male excess is less
pronounced than for those of higher ability.
There is currently an impression that the incidence of
autistic-spectrum disorders is rising. This may be due to
wider diagnostic criteria, greater awareness of these
disorders, or a genuine change in incidence.35 It would
be a lengthy and expensive task to do a study that could
provide the answers.
Vol 350 • December 13, 1997

Prognosis
Disturbed behaviour is often evident from age 2 to 5
years, tends to improve from 6 to 10 years, but may re-
appear in adolescents and young adults, eventually
calming down in middle and later life. At any age, the
problems can be diminished by appropriate education
and behavioural and environmental management.
As noted above, psychiatric illnesses can occur in
adolescents and adults.36 Depression is particularly
common in response to awareness of problems in social
interaction and there is a risk of suicide. Catatonic states
of varying degrees of severity develop in a small
proportion of cases for unknown reasons.26 A very small
minority of more able individuals break the law in
pursuit of their special interests or because of paranoid
feelings arising from social rejection, whether apparent
or real.36,37
The outcome for independence in adult life is closely
linked to overall level of ability.38 Individuals with severe
learning disabilities will remain dependent all their lives,
requiring total support and supervision in living
accommodation, occupation, and leisure activities.
Those with mild learning disabilities may achieve some
degree of independence in living or working but most
are likely to need some support to help them cope with
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the pressures of daily life. Most of those with average or
high ability will become independent as adults but a
minority will remain dependent to some extent, needing
support in daily living, or work, or both.
To my knowledge, there are no published studies of
longevity in autistic-spectrum disorders. Life expectancy
would be affected by the presence of other conditions
with implications for physical health, such as epilepsy or
tuberous sclerosis.
Autistic-spectrum disorders have profound effects on
the lives of the individuals who are affected and their
families. Their difficulties are often intensified by lack of
recognition, even denial that autism exists, among some
medical and other professional workers. The problems
are made worse by the hostility of some lay people when
observing autistic behaviour. Even the autistic
individuals with high levels of ability suffer because their
struggle to comprehend social rules is so often
misunderstood. Appropriate advice and support for
families, specialised education, occupation, leisure and,
when required, residential provision can reduce distress
and help the affected individuals develop potential skills
and lead more contented lives. The essential first step to
obtaining these services is early recognition of the
presence of the autistic triad of impairments.
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38 Rutter M. Autistic children: infancy to adulthood. Semin Psychiatry
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Further reading
Clinical pictures
Bartak L, Rutter M. Differences between mentally retarded and
normally intelligent autistic children. J Autism Childhood
Schizophren 1976; 6: 109–20.
DeMyer M. Motor, perceptual-motor and intellectual disabilities of
autistic children. In: Wing L, ed. Early childhood autism. Oxford:
Pergamon, 1976: 169–96.
Grandin T. Scariano MM. Emergence—labelled autistic. Tunbridge
Wells: Costello, 1986.
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Vol 350 • December 13, 1997