The Biology of the Autistic Syndromes. (3rd ed.). Christopher Gillberg and Mary Coleman. United Kingdom: Lavenham Press, 2000.
I have been a long-time admirer of Christopher Gillberg's work, having read in the early 1990s his poignant, respectful, and delightful description of a boy with Asperger syndrome whom he encountered as a patient in his office. This account was published in Autism and Asperger Syndrome by Uta Frith (1991). He described the boy coming into his office, chatting with his secretary about how many words per minute he could type, then reading a pamphlet about Asperger syndrome and exclaiming triumphantly that he believed he had it, and, after a few moments, that he believed his father had it too! Gillberg describes how the boy then commented that now he could explain to his teachers why he paced about the playground at recess rather than playing with the other children. I was struck by how Gillberg was able to, in a few sentences, capture, so respectfully, the essence of the unique social style of children with Asperger syndrome. I have since followed his voluminous research career.
This book with Coleman, however, is neither research nor clinical description, but, rather, a summary of what is known today about the biology of autism, with an emphasis on etiology. Unfortunately, as the authors readily acknowledge in the introduction, what is known today about this subject, despite decades of research, is still relatively little:
Although a great deal more is known now than at the time of the writing of the second edition of this book, this third edition has few final answers. There are a series of fascinating theories about the changes in the developing brain that cause autism . . . from the biochemical . . . to the neurostructural. . . . Many patients with an autistic syndrome do not yet have a true diagnosis of a well-defined disease entity; the majority do not have adequate medical therapies available. Important strides have been made regarding educational intervention . . . and every child with autism needs, at a minimum, an individualized program tailored to the child's particular profile. (p. 3)
The authors begin with a discussion of the conceptualization of autism as a phenotypic presentation that is the final common pathway for many different biological etiologies. This is reflected in the title of the book. Much of the volume is dedicated to the summary of the research regarding the many specific known etiologies that unfortunately explain the presence of autism in only a small minority of children who have this diagnosis. That is, although many co-morbidities exist, the cause of autism in most children is still unknown, and this is, of course, a frustration for researchers, clinicians, and families as well as a potential source of frustration for readers hoping to find the “answer.”
The initial discussion of diagnostic criteria and systems will be very useful to clinicians and researchers engaged in the diagnostic process. Each of the most commonly used diagnostic systems are discussed and compared in detail. The authors stress that even with various specific diagnostic systems in existence, because of the difficulty in objectively quantifying the nature of autism, determining the diagnosis requires the “ ‘gestalt acumen’ of the experienced clinician” (p. 31). The authors make the important point that the validity of any research study depends on this key factor, as, of course, does clinical work. The authors' clinical familiarity with children who have autism is apparent throughout even this heavily biological text and, to me as a psychologist, gives it a strong sense of credibility.
The discussion of the epidemiology of autism is thorough and extremely useful. The many complexities of evaluating whether the incidence has increased include the following: differing diagnostic criteria both over time and across studies, difficulties in many countries—including the United States—in conducting population-based research, and the possibility of increased awareness altering participation and, hence, identification. However, after a detailed discussion of these and other challenges to addressing this question, and a thorough review and summary of all of the epidemiological research, the authors conclude that autism is, in fact, more common than was previously thought and occurs at least at a rate of 4 to 5 children per 1,000—at least 10 times the often previously cited incidence of 2 to 5 in 10,000. Some provocative hypotheses are offered as to why there may be a real increase, although the authors caution that it is not certain whether these numbers reflect an actual increase or rather simply a more accurate count than previously. Regardless, the they point out that it is important in terms of research, health care, and education that the new numbers be used because autism can no longer be considered a rare disorder.
The overlap between the autistic syndromes and mental health/psychiatric disorders is touched on in several places and will perhaps be given more press in the next edition of the book, as increasing new research is emerging in this area (e.g., the work of Jean Frazier and her colleagues at McLean Hospital in Boston). The complex intrafamiliar and co-morbid relationships between autism/Asperger syndrome and bipolar disorder are discussed briefly. This is a promising new conceptualization because treatment of the bipolar component in individuals with autism spectrum disorders can enormously alleviate troublesome symptoms. In the chapter on Asperger's disorder, the authors suggest one of the SSRIs may help individuals with depressive and/or obsessive symptoms; however, they then indicate that psychopharmacology for adults should be avoided. In our clinical experience, psychiatric symptoms as they emerge in individuals with Asperger's disorder (e.g., anxiety; mood disorders, thought disorders) are often very responsive to the appropriate pharmacological treatment in addition to therapeutic and educational approaches. The authors add that there is little to no research regarding this issue. This may have been their justification in providing limited psychopharmacologic recommendations in spite of common current clinical practice.
There is relatively brief coverage of educational intervention. Clearly, this is not the theme or purpose of this book. However, perhaps instead of providing a limited overview, which does not include many commonly used treatment approaches for children with autism or Asperger disorder (e.g., floor time, Greenspan, 1998; social stories gray; individual play therapy), it could be more useful in future volumes to simply point out that intensive and early therapies are usually beneficial and then direct readers to some of the many other sources of information.
There are six chapters (about half of the book) devoted to associations between autism other medical disorders, especially including the known causes of autism in a small minority of people with this disorder. Because most individuals with autism do not have these specific other disorders/known etiologies, from a clinician's perspective, for the majority of patients seen this will not be helpful. However, as a cataloguing of what is known about etiology, these chapters are extremely useful, especially, perhaps, for geneticists and for pediatricians deciding whether to refer a child for a genetics work-up. As a nonmedical professional, I am not in a position to evaluate the validity of the research presented; however, it is certainly to the authors' credit that these chapters are highly readable to nonmedical professionals who wish to develop a basic understanding of co-morbidity in autism.
The book jacket summary states that the book “is designed for use by physicians who diagnose and treat people with an autistic spectrum disorder.” In my opinion the book will also be particularly useful as a reference resource for the following circumstances:
Medical clinicians, perhaps especially geneticists will find useful the cataloguing of co-morbid syndromes and conditions associated with autism.
Medical clinicians and researchers will find it useful as a guide at the beginning stages of evaluating the validity of claims of new discoveries of specific etiologies or biological treatments.
Clinicians, including doctors and psychologists in the business of diagnosing children, as well as researchers, will find the initial discussions of the complexities of diagnostic systems informative in determining what techniques to use in their work.
Although this book may be of interest to some educators and parents who wish to gain an overview of the state of knowledge from a biological perspective, in part because of the lack of answers and because of the authors efforts to essentially ‘catalogue’ the many known and hypothesized mechanisms and etiologies, it will not be particularly useful in terms of developing further understanding of an individual child or group of children. The authors do not, for example, summarize the research regarding understanding the cognitive, language, or social development or the mental processing of children with autism. This is clearly not the authors' intent, but I mention it rather as a point of information for potential readers.