Mental Retardation

The relationship between autism and mental retardation has been enduring. Even as the language of mental retardation changed—evolving from feeblemindedness early in the twentieth century to mental deficiency and retardation and finally to developmental disability—clinicians and researchers remained perplexed about how their schemes of classification and diagnosis might accommodate the overlap between different disorders. Were autism and mental retardation correlated in some meaningful way, or was it coincidental when they co-occurred in the same child? When and how should significant linguistic or social delays be contrasted with cognitive delays? Did it even make sense to draw bright lines between the development of communication, interaction, and thought?

In recent years, autism and intellectual impairment have frequently been defined as virtual opposites, making it more difficult to perceive their combination. After Asperger syndrome entered the DSM in 1994, for example, teens and young adults with the diagnosis embraced the term “Aspies” and proudly celebrated their nerdiness. No matter how socially awkward, children with Asperger’s were extremely bright. Children with mental retardation were not.

Yet for much of autism’s history, mental defect has been considered central to autism as well as to childhood psychosis and childhood schizophrenia. In his classic 1943 description of autism, Leo Kanner differentiated autism from mental retardation precisely because he thought the link between them was common but erroneous. His point was that the social and linguistic disabilities presented by many children with autism did not necessarily diminish their potential for normal intellectual or creative growth. Children with autism might even be unusually precocious, and several of Kanner’s cases were, but he described all of them as intelligent. Children with mental retardation, on the other hand, offered clear evidence of intellectual subnormality. They could never perform the complex feats of memory, math, or music that came easily to some autistic children, even as they easily navigated social interactions that baffled their autistic counterparts.

Autism has overlapped with cognitive impairment, sometimes in paradoxical ways, combining elements of stark cognitive disability with unusual, even extraordinary talent. Hans Asperger, who wrote about autism in the early 1940s, concluded that it was possible “to consider such individuals both as child prodigies and as imbeciles with ample justification.” Even on the back wards of state mental hospitals, in which residents with multiple disabilities exhibited self-abusive and sometimes violent behavior, neurologist and author Oliver Sacks remembered that he saw flashes of ability “shining through the devastation.” Raymond Babbitt, the fictional character played by Dustin Hoffman in the 1988 film, “Rain Man,” was a famous example of someone with savant-like mathematical skills who lacked the ability to care for his own basic needs.

From the 1930s through the 1960s, hundreds of children with autistic behaviors were seen and treated by psychiatrist Lauretta Bender at New York’s Bellevue Hospital and Creedmoor State Hospital. She followed them over many years and concluded that “the most variable factor is the organicity.” What Bender meant was that some cases of autism were predominantly hereditary in origin, whereas others were likely precipitated by birth trauma or linked to physiological conditions such as gastrointestinal disorders or “chronic brain syndrome.” In approximately 20% of cases, she found no organic factors were ever apparent. By the 1960s, Bender suspected that cognitive deficit, at least measured by intelligence tests, was the rule for individuals with autism rather than the exception. The biological logic of virtually all developmental disabilities was obvious to her, even if the causes of autism remained puzzling in their diversity.

Advocates who pursued deinstitutionalization and normalization in order to improve the lives of Americans with mental retardation understood that these children and adults had long been feared and stigmatized as well as subjected to draconian policies, such as compulsory eugenic sterilization. In spite of some progress, people with “MR” in the post-1945 decades remained on the margins. They were embarrassing family secrets—as Rosemary Kennedy was for Joseph and Rose Kennedy—when they were not entirely invisible. Confined to residential institutions or cared for by families with little public assistance, individuals with mental retardation were a living rebuke to the independence and competition prized by the meritocratic society around them. What value was there in educating them, including them in communities, or advancing their rights if they were destined to remain lifelong children, permanently dependent? In research and service fields related to mental retardation, professionals felt equally devalued, as if the work they did was contaminated by the inferiority of the people they studied and served.

One strategy for change was to transform children with mental retardation from social menaces into paragons of religious virtue. Depicting children with mental retardation as embodiments of childhood innocence and moral rectitude was a caricature, of course, but its appeal was undeniable. Dale Evans Rogers, entertainer and wife of Roy Rogers, took exactly this approach in the short book she wrote about her “mongoloid” daughter. Robin was born with Down syndrome in 1950 and died in 1952 of a heart condition. In Angel Unaware, Robin narrated her own story, after death, from a secure and happy perch in heaven. Her message was that she—and other “handicapped” babies—were angelic messengers of  Christian love sent to deliver God’s plan to parents and spread God’s glory on earth. Royalties from this successful book helped to fund the National Association for Retarded Children during its early years.

Making mental retardation sentimental did not eliminate all the incentives for obscuring its connection to autism. It should not be surprising that parents and professionals often maligned mental retardation in hopes of lessening the stigma of autism. The League for Emotionally Disturbed Children, founded in 1950 by parents determined to improve the lives of children with severe emotional and behavioral disorders, complained that the “MR” designation was a confusing catch-all in need of refinement. What the organization really objected to was the use of the label at all. Children with autism were not “run of the mill retardates,” insisted Bernard Rimland in 1968. As a leading researcher and parent of an affected child, he aimed to elevate the unique characteristics and special needs of autistic children over those of ordinary children who faced serious intellectual challenges.

Separating autism from cognitive disability for the purpose of developing specialized clinical and educational interventions ironically resulted in diagnosis-shifting. That increased the number of children diagnosed with autism, a syndrome that had formerly been considered exceedingly rare. Beginning in the 1960s, children moved out of mental retardation and into autism, in part because the shame and secrecy associated with autism had started to subside and the educational services had started to multiply. By the turn of the twenty-first century, there was a flood of questions about why the incidence of autism was rising and whether it had reached epidemic levels. Evidence from the 1960s also suggests that mental retardation was utilized to resegregate schools racially, with African-American children becoming overrepresented in special education. Even the term retardation, originally welcomed as a progressive alternative to feeblemindedness and mental defect, became derogatory—as in the slur, “retard.” Autism consequently became ever more identified with whiteness and affluence. Seeing autism in African-American children, poor children, or any children with obvious intellectual disabilities got harder.

The history of autism is inseparable from the history of mental retardation. Ideas about both, and the children and adults who occupied these categories, profoundly influenced their experiences, constrained their opportunities, and shaped their reputations. The United States did not have federal legislation guaranteeing free public education to all children with disabilities until 1975. Fears attached to intellectual deficit and difference were surely important historical reasons why Americans with developmental disabilities were relative latecomers to equal rights and social respect.