Intended for healthcare professionals

Clinical Review

Diagnosis of autism

BMJ 2003; 327 doi: (Published 28 August 2003) Cite this as: BMJ 2003;327:488

There is a social context to the current epidemic

It is with more than a little trepidation that I write this responce,
so powerful has the Autism lobby (like the ADHD one) become. But I feel I
must challenge the wisdom behind this article and link this isssue to
wider socio-cultural factors that sadly have never enterred the debate.

The article shows its colours by completely ignoring context. It
focuses on a within-child explanation for the rapid rise in rates of
diagnosis, suggesting that the only cultural factor affecting this has
been poor levels of recognition in the past. Its this sort of tunnel
vision that has led to the ADHD epidemic and now the autism and asperger
one. Theoretically the arguments presented limp along years behind other
branches of science, through a lack of engagement with other disciplines
and lack of knowledge concerning other perspectives. Whilst the immaturity
of children may be a fact of biology, what meaning we give to this
immaturity is a fact of culture. By lacking any tangible evidence of
organic pathology and any biological tests to substantiate our hypothesis
of a neurological dysfunction, the diagnosis becomes vulnerable to what I
call the 'elastic band syndrome' whereby the boundaries of the disorder
can endlessly expand and is dependent on the subjective opinion of the
diagnoser (Timimi, 2002).

It is with horror that I hear this call for early diagnosis of autism.
Instead of building on strengths, understanding context and using our
clinical skills to help script stories of competence and mastery, we are
writing into a child's life from early on a life-story centred around
disability and deficit. This is a serious and unecessary form of
'developmental terrorism'. We must recognise that our notions of child
development are culture bound and too often create a blueprint of age-
dependent expectations which us ordinary parents fear our children can't
live up to, rather than a set of required behaviours that our children
must master if they are to be considerred fully human. And why the over-
representation of boys? What is going on in our conceptualisation of
childhood that is leading to us diagnosing boys as suffering from all
these 'neurodevelopmental disorders' in ever-increasing numbers?
In my clinical practice I often come across children and adolescents
laballed autistic. Focussing on their abilities, its common for me to find
much about them that doesn't fit the autistic discourse. Once I re-open
the question of diagnosis I am happy to say that many adolescents ask me
to officially 'undiagnose' them, something which their parents are usually
very pleased about.

We can and should do better than this relentless medicalisation of
children. The cost children and families are paying is already too high.
Children should not becoming the scapegoats helping us avoid complex socio
-cultural issues. We must become more competent at integrating medical
theory with other perspectives, otherwise we will soon have a grown up
generation of children (mainly boys) who have become unecessarily
convinced that they are somehow deficient and incapable.

Timimi, S. (2002) Pathalogical Child Psychiatry and the
Medicalization of Childhood. Hove: Brunner-Routledge.

Competing interests:  
None declared

Competing interests: No competing interests

01 September 2003
Sami Timimi
Consultant Child and Adolescent Psychiatrist
Ash Villa, Sleaford, NG34