In Practice
A practicing doctor's views on psychiatry and contemporary culture.
by Dr. Peter Kramer

Dear Abby: Is autism a mental Iillness?
Published on July 31, 2008 by Peter D. Kramer in In Practice

psychologytoday.com

While we are on the question of disease labels I see that “ Dear Abby” has been “corrected” by many readers who find her “way off base” for misclassifying autism. In a prior column, she had called it a “mental-health disorder.” Now she accepts that she was mistaken. Because autism is “genetically predetermined — biologically based” or “neurologically based,” it is not a mental health disorder.

Jeanne Phillips, writing under the pen name Abigail van Buren, quotes a Mayo Clinic doctor to the effect that autism “affects behavior, cognitive ability and social skills” and notes that the syndrome appears as a diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. That list would seem to argue for the label Dear Abby had applied initially, mental health disorder.

No, Phillips now says. Autism is a “neurodevelopmental disorder.” But aren’t many mental illnesses neurodevelopmental disorders? Conditions that first appear in childhood are especially likely to fit that description. Think of pervasive developmental disorder or early-onset schizophrenia. Those conditions stand at the core of child psychiatry — and they are likely to require the services that, within medicine, the mental health professions provide.

The same is true for autism. The primary treatments are behavioral and psychological; where medications play a role, they tend to be the ones that psychiatrists prescribe. Much of the finest research on autism was performed by psychiatrists, such as my beloved teacher, the late Donald J. Cohen. His work serves as a model of integration, using the research methods of genetics and neuroscience and the therapeutic techniques of psychopharmacology, behaviorism, teacher training, and, yes, psychoanalysis, in a wiser mode.

Some of the impetus for the reclassifying autism is to spare affected families shame, that is, the shame of having raised a child with mental illness. This reaction is understandable, given the history of autism in psychiatry, and particularly in psychoanalysis where the condition was once attributed to bad parenting. Autism can be heartbreaking for parents; certainly it is a neurodevelopmental disorder, and if that's what families prefer to call it, we should probably all join in. But then, the question arises, what is autism being distanced from? What do we make of families whose children suffer obsessive-compulsive disorder, Tourette syndrome, and the rest? We might note that autism overlaps substantially with those very diseases.

So, yes, it is easy to see why families whose members are afflicted by autism might hope to recategorize the condition. But, Dear Abby, might you have replied that today an alternative and arguably yet more humane response would consist in embracing the “mental illness” label — and insisting that that isn’t shameful?