Ordinary people in general, and health practitioners in particular, have a picture of normal development. They draw attention to anything deemed “not normal”. Medical science has the task of describing and measuring the abnormality and seeking an explanation, as a prelude for treatment and prevention. It is a never-ending process. A developmental disorder that has attracted a great deal of attention is autism.
This note is prompted by a newspaper article by Ariana Eunjung Cha, first published in the Washington Post, reprinted in the Age on 30 December 2025, page 16, titled “A brain wired differently: New science points to four distinct types of autism.”
The article was of great interest to me because of a fifty-year involvement in the field, rewarded by election as an Honorary Life Member of ‘Autism Victoria’ (now renamed ‘Amaze’), consequent upon my role as the principal advisor on child mental health to the Victorian Government Health Department for a couple of decades.
The syndrome of autism was first described in western scientific literature in 1943 by Professor Leo Kanner. His clinical annotations led to intense speculation about possible social causation by “refrigerator mothers” that took some time to dispel. Family research soon identified genetic predisposition in twin studies, inheritance and the disproportionate prevalence in males. These, and other epidemiological studies showing strong associations with other brain disorders, shifted the focus strongly to the biological underpinnings. Attempts at measuring prevalence were bedevilled by the question of what were the necessary and sufficient criteria for inclusion in the syndromal cohort.
Lorna Wing’s landmark community survey of children in the Borough of Camberwell in London in the early 1970s gave a prevalence of 2-4 per ten thousand children, using the triad of impaired social interaction, impaired communication and restricted (often repetitive) behavioural patterns, combined with intellectual disability. The variety of presentations gave rise to the term ‘autism spectrum’, which perpetuated these criteria into the writing of the DSM [Diagnostic and Statistical Manual of Psychiatric Disorders] of the American Psychiatric Association, and the ICD {International Classification of Diseases} of the UN World Psychiatric Association.
Subsequent editions of these manuals have greatly broadened the criteria and their operational inclusions, significantly changing the prevalence estimates. Today, the estimated prevalence of children in the autism spectrum approaches 2%, nearly 100 times greater than Lorna Wing’s estimate. No, we don’t have 100 times more children with a disorder called ‘autism’, we just have 100 times more children whose developmental needs are being acknowledged.
However, these changes do matter. The recent blowout in the costs of the NDIS is largely attributed to an increased enrolment of children with autism. The proposed introduction of a ‘Thriving Kids’ program is an attempt to cater for lesser degrees of disability without all children with autism being under the NDIS umbrella. MHYFVic has pointed out, in several bulletins and in submission to the Thriving Kids Consultative Committee, that the fundamental mistake is approving eligibility for support on the basis of diagnostic label rather that assessment of disability support needs.
This is why Ariana Cha’s article is so important. In it she reports, “For decades, autism has been described as a spectrum – an elastic term that stretches from non-verbal children to adults with doctorates. Beneath that vast range lies a shared pattern of social communication and behavioural differences, long resistant to neat explanations. Now, advances in brain imaging, genetics and computational science are revealing discrete biological subtypes.”
Natalie Sauerwald, one of the quoted lead authors, compared earlier autism research to assembling a jigsaw puzzle, only to find that the pieces didn’t quite fit – not because the image was unclear but because “the box had always contained several puzzles, shuffled together”. There isn’t just one autism, Sauerwald said: “There are many autisms.”
There is a usefulness in referring to the autism spectrum, just as there is a usefulness in referring to intellectual disability. However, the usefulness must avoid thinking that all children with that label are ‘the same’, just as we avoid thinking that all children with intellectual disability are ‘the same’. Future research will reveal the different biological pathways resulting in the autism syndrome, with the potential for preventing or treating some of those pathways. In the meantime, every individual deserves to be supported according to need.
Allan Mawdsley