Wing L. e Gould J. (1979) - Deficiências Graves de Interação Social e Anormalidades Associadas em Crianças Epidemiologia e Classificação.

Journal of Autism and Developmental Disorders, Vol. 9, No.
1, 1979
Severe Impairments of Social Interaction and

Associated Abnormalities in Children:
Epidemiology and Classification
Lorna Wing and Judith Gould

Medical Research Council, Social Psychiatry Unit, London
The prevalence, in children aged under 15, of severe impairments of social

interaction, language abnormalities, and repetitive stereotyped behaviors
was investigated in an area of London. A "socially impaired" group (more
than half of whom were severely retarded) and a comparison group of
"sociable severely mentally retarded" children were identified. Mutism or
echolalia, and repetitive stereotyped behaviors were found in almost all the
socially impaired children, but to a less marked extent in a minority of the
sociable severely retarded. Certain organic conditions were found more
often in the socially impaired group. A subgroup with a history of Kanner's
early childhood autism could be identified reliably but shared many ab-
normalities with other socially impaired children. The relationships
between mental retardation, typical autism, and other conditions involving
social impairment were discussed, and a system of classification based on
quality of social interaction was considered.
INTRODUCTION
Children with severe impairments of social interaction, abnormalities

of language development involving both speech and gesture, and a behav -
ioral repertoire consisting mainly of repetitive, stereotyped activities begin-
ning from birth or within the first few years of life have been described by a
number of writers. This pattern of impairments and behavior problems has
been variously (and unfortunately) termed childhood psychosis, childhood
autism, or childhood schizophrenia.
Some workers have attempted to identify subgroups among these
children, suggesting that certain varieties of these behaviors cluster together
11
0162-3257/79/0300-0011$03.00/0 © 1979 Plenum Publishing Corporation
12 Wing and Gould
often enough to form specific syndromes. Examples are the "dementia pre-
cocissima" and "dementia precosissima catatonica" of De Sanctis (1906,
1908), Earl's (1934) "primitive catatonic psychosis of idiocy," the
"dementia" occurring between 3 and 5 years of age described by both
Heller and Weygandt (see Hulse, 1954), Mahler's (1952) "symbiotic psy-
chosis," the "autistic psychopathy" of Asperger (1944; Van Krevelen,
1971), and Kanner's (1943) "early infantile autism." These "syndromes,"
although thought by their proponents to be specific, have many features in
common. Individual children may show mixtures of items from more than
one syndrome, making diagnosis difficult. When discussing this subject,
Anthony (1958a) wrote, "The cult of names added chaos to an already con-
fused situation, since there did not seem to be a sufficiency of symptoms to
share out among the various prospectors, without a good deal of overlap."
Some attempts have been made to subclassify the whole range of the
clinical phenomenon being described here, rather than to select particular
subgroups and ignore the rest. Anthony (1958a,b, 1962), Kolvin (1971), and
Rutter (1972) divided on age of onset, suggesting that if the abnormal
behavior began before age 3, the cause, course, and prognosis were differ ent
from those associated with onset between 3 and 5 years. They also made the
important point that the conditions being discussed here should not be
classified as forms of schizophrenia. An illness resembling adult schizo-
phrenia can be seen rarely in childhood, but never before age 5 years.
Despite this work, classification remains in a most unsatisfactory
state. There are problems not only in subdividing within the group as a
whole but in relating it to other handicapping conditions of childhood. In
particular, abnormalities of social interaction and language development,
and stereotyped behavior can be found in some children administratively
categorized as mentally retarded (Haracopos & Kelstrup, 1978), especially
those with intelligence quotients below 50 (defined in the United Kingdom
as in the severely retarded range). Conversely, the majority of children who
show the abnormalities being considered perform as mildly or severely men-
tally retarded even on tests not involving language (DeMyer, 1976; Kolvin,
Humphrey, & McNay, 1971; Lotter, 1967; Rutter & Lockyer, 1967; Rutter,
Shaffer, & Sturge, 1975; Wing, Yeates, Brierley, & Gould, 1976), though
there are some with normal intelligence on nonverbal or even verbal tests
(Bartak & Rutter, 1976).
In order to investigate these problems of classification, the present
authors decided to carry out an epidemiological survey, within a defined
geographical area, of all children in a specified age range who showed one
or more of the impairments and abnormal behaviors discussed above,
whether or not there were associated organic conditions or additional
handicaps, such as deafness or blindness, and regardless of level of intel-
ligence or age of onset.
Impairments of Social Interaction 13
The aims of the study were to find (a) the prevalence and distribution
of the three types of abnormalities, and whether they tended to occur
together, (b) how the clinical pictures of which they formed a part could be
subgrouped, and (c) how they were related to mental retardation.
No prior assumptions were made as to the specificity of any of the
previously proposed syndromes that include these abnormalities.
METHOD
Selection of Subjects
The subjects were selected from children aged under 15 years on the
chosen census day, December 31, 1970, who had parents living in the
former southeast London borough of Camberwell. This mainly working-
class area had a total population of 155,000, of whom 35,000 were under 15
years old.
All children, whether at home or in residential care, who were known
to the local health, education, or social services for reasons of physical or
mental handicap or behavior disturbance were identified through the
Camberwell cumulative psychiatric and mental retardation register (Wing &
Halley, 1972) and the records kept by the local services. These 914 children
were then screened, as described in Wing et al. (1976) and 132 of them were
selected on one or both of the following criteria.
The first criterion was the presence of at least one of the following
items, regardless of level of intelligence: (a) absence or impairment of social
interaction, especially with peers; (b) absence or impairment of develop -
ment of verbal and nonverbal language; (c) repetitive, stereotyped activities
of any kind. (These are defined below, under "Behavioral Variables.")
The second criterion was a level of function on formal tests or on
educational achievement in the severely retarded range, regardless of the
pattern of behavior and impairments. The only exceptions were nonmobile
children, 28 in all, who were excluded because their inability to walk un-
aided limited the possibility of their showing abnormal behavior.
At the time of assessment, 108 of the 132 children selected were
known to the preschool or school-age services for children with severe re-
tardation, 10 were in schools for children with mild educational subnor -
mality and 6 in schools or classes for autistic children, 3 were attending
schools for the deaf or partially hearing, 2 were in units for deaf/blind
children, 1 was in a school for the partially sighted, 1 was at a school for
delicate children, and 1 was in a day nursery. None was in a school for nor-
mal children, though 1 autistic child was later transferred to such a school.
14 Wing and Gould
The final step in the study was the intensive investigation of the
children identified from the preliminary screening procedures. Their
patterns of handicaps, behavior, and skills were examined in detail. Psycho-
logical and medical data were collected in order to provide independent
criteria for evaluating possible methods of clinical classification.
At the time of the detailed interviews with parents and teachers, the
ages of the children ranged from 2 years 2 months to 18 years. The inves-
tigators have remained in touch with the children since the interviews and
tests were completed.
Examination of the Children

Behavioral Variables
Professional workers such as teachers, nurses, or child care staff, and,

for children who lived at home, a parent (usually the mother) were inter -
viewed by one of the present authors, using the MRC Children's Handi-
caps, Behaviour and Skills (HBS) structured schedule (Wing & Gould,
1978). The authors also observed the children in the classroom, nursery, or
residential unit, or at home, and made their own ratings on selected parts of
the same schedule.
The HBS schedule is used to structure an interview in order sys-
tematically to obtain clinical information concerning a child's level of
development in different areas of function, practical or schoolwork skills
required, and abnormalities of behavior present during the preceding
month.
When there was disagreement between raters, the authors repeated
their observations until they could establish the reasons for the variations,
and make the final judgment of the score to be used in the analysis of
results. If no reason for the discrepancy could be found—a rare occur-
rence—the authors' rating was used.
Although the whole schedule was completed for each child and the
results were available for the classification exercise, only certain aspects
relevant to the aims of the paper will be reported on in detail. The problems
were rated as present if they were a marked feature of the child's behavior.
Quality of Social Interaction. Behavior rated in this section was
grouped under 4 headings:
1. "Social aloofness" covered very severe impairment of social inter-
action. Some of the children with this behavior were aloof and indifferent in
all situations. Others would make approaches to obtain things they wanted,
but returned to aloofness once the need was gratified. Some liked simple
Impairments of Social Interaction 15
physical contact with adults, such as cuddling, tickling, or games of

chasing, but had no interest in the purely social aspects of the contact. The
social indifference was especially marked toward other children, as com -
pared with adults.
2. "Passive interaction" described the behavior of children
who did not make social contact spontaneously but who amiably
accepted approaches and did not resist if other children dragged
them into their games. Some of these children were liked by their
classmates because they could be used as babies in a game of
mothers and fathers or as patients for doctors and nurses. They
would remain in their allotted role as long as the other children were
playing, but they would wander off at the end of the game unless
redirected by their peers.
3. "Active, but odd interaction" included children who did
make spontaneous social approaches, mostly to adults but also to
other children. Their behavior was inappropriate because it was
undertaken mainly to indulge some repetitive, idiosyncratic
preoccupation. They had no interest in and no feeling for the needs
and ideas of others. They did not modify their speech or behavior
to adapt to others but continued to pursue their own topics or
favorite activities even in the face of active discouragement. They
tended to pester other people and were sometimes rejected by their
peers because of their peculiar behavior. For this reason they were
less socially acceptable than the "passive" group.
4. "Appropriate interaction" covered those whose social
interactions were appropriate for their mental age. They enjoyed
social contact for its own sake with adults and with other children.
There were a few children in the study with this behavior whose
mental ages were very low, in some cases under 12 months, although
most children of this kind were nonmobile. They showed the
same kind of pleasure in, and response to, social approaches as
a normal baby (Schaffer, 1974; Trevarthen, 1974). They used eye
contact, facial expression, and gesture to indicate interest and to try
to join in conversation as best they could. Such children contrasted
markedly with the aloof and indifferent group in that they paid
attention when someone entered the room, and anticipated a
social approach before one was actually made.
Abnormalities of Use of Speech. Four types of abnormalities
(described in Ricks & Wing, 1975) were rated: (a) absence of speech; (b)
echolalia, immediate or delayed; (c) reversal of pronouns; and (d) idiosyn-
cratic uses of words or phrases.
Because Kanner (1946) emphasized the diagnostic importance of the
last two items, these were rated if there was evidence from case notes or in-
formants' accounts that they had occurred in the past, as well as at the time
of interview.

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Journal of Autism and Developmental Disorders, Vol. 9, No.

Severe Impairments of Social Interaction and

Lorna Wing and Judith Gould

The prevalence, in children aged under 15, of severe impairments of social

Children with severe impairments of social interaction, abnormalities

Examination of the Children

Professional workers such as teachers, nurses, or child care staff, and,

physical contact with adults, such as cuddling, tickling, or games of

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