Over recent years there has been an expanding number of books and research papers devoted to autism. Indeed, the current awareness of autism could be argued to be higher than at any point in its history. However, very few of these publications acknowledge the pioneering work of Lorna Wing. Wing, who died in 2014, was a British psychiatrist and parent of an autistic child who not only played a pivotal role in the development of the National Autistic Society and Elliot House, one of the first autism diagnostic centres in the UK, but also shaped our current understanding of autism by helping to define its key characteristics and what is useful in terms of support.
Although descriptions and terminology have changed over the years, such as the shift away from referring to high-functioning autism and the now somewhat controversial label of Asperger syndrome to the broader term of autism spectrum disorder, the underlying issues remain the same. Wing played a significant role in the awareness and description of Asperger syndrome (Wing Reference Wing1981) and the subsequent development of the Diagnostic Interview for Social and Communication Disorders. Of particular influence was her book The Autism Spectrum: A Guide for Parents and Professionals, first published in 1996. Offering a guide to the recognition of autism and problems experienced by autistic individuals from birth into adulthood, this book remains relevant today. Wing was the first clinician to view autism as a spectrum, with all autistic people presenting as non-heterogeneous individuals showing variations of characteristic difficulties and features, and as a condition overlapping with other neurodevelopmental conditions.
Autism as a spectrum
Among the observations made by Wing was that, although there have been attempts to delineate specific subgroups of autism spectrum disorder, they are confounded by the considerable overlap among the suggested syndromes:
‘The clinical picture of every type of autistic disorder is made up of a large number of features. In clinical practice the more you see of these conditions, the more it appears that any combination of the features is possible. Some combinations are more likely than others but there are no absolute rules. The boundaries are always difficult to define’ (Wing Reference Wing1996: p. 31).
Although slow to occur, it is also significant that the move to a spectrum view of autism was eventually adopted by the key diagnostic systems – DSM-5 (American Psychiatric Association 2013) and ICD-11 (World Health Organization 2021). It is interesting to note that although Asperger syndrome has been removed as a diagnosis, it remains meaningful for many, and that some studies suggest that there is a difference between those with Asperger syndrome and those with high-functioning autism in clinical profiles (de Giambattista et al., Reference de Giambattista, Ventura and Trerotoli2019).
The triad of impairments
While acknowledging that every individual with autism is different, along with the psychologist Judith Gould in the ground-breaking Camberwell Study (Wing and Gould Reference Wing and Gould1979), Wing outlined that all individuals display varying degrees of difficulties and features across three key areas of functioning: social interaction, social communication (verbal and non-verbal) and imagination – the so-called ‘triad of impairments’.Footnote a The study also noted a number of other features, such as repetitive stereotyped activities (including routines), oddities with movement, sensory issues, anxieties and attentional differences. With respect to social interactions, an interesting but largely forgotten observation made by Wing (Reference Wing1996) was the suggestion that individuals appear to fall into one of four possible types (although there is no clear cut-off between each): ‘aloof’, ‘passive’, ‘active but odd’ and ‘over-formal stilted’. Each of these types was described as reflecting different styles of social interaction and how they relate to others. It is interesting to note that, although the triad remains a key diagnostic feature of autism, it has subsequently been revised in DSM-5 and ICD-11 to a dyad, where persistent social and communication difficulties have been combined, and imagination remains as restricted, repetitive patterns of behaviour, interests or activities.
Autism in forensic settings
Wing also developed an interest in autistic individuals who became involved with the criminal justice system, including those detained in high secure psychiatric care. It is likely that her experiences with such patients shaped her views of autistic individuals who became involved with forensic psychiatric services. The Autistic Spectrum includes a short section on ‘delinquent and criminal behaviour’ among some autistic individuals, and Wing went on to write an insightful paper entitled ‘Asperger’s syndrome: management requires diagnosis’ published in the Journal of Forensic Psychiatry (Wing Reference Wing1997). Despite being almost 30 years old, this largely forgotten paper offers thoughts that remain highly relevant today regarding how autistic individuals who find themselves in secure services should be managed and the importance of autism awareness among staff. It also perhaps highlights that we have known for many years that autistic individuals are present in forensic settings and that they present with different problems and needs compared with many other offender groups, but progress in developing more autism-informed services has been slow.
In the paper, Wing noted that although many individuals achieve independence as adults, there are some who will break the law and who will require care and supervision adapted to their special needs. Furthermore, some autistic individuals will require long-term care and supervision, including in a secure environment. However, she emphasised that ‘in the right kind of environment, the individual may behave in an exemplary way but, if he or she is moved to a setting that does not provide the right type of programme, the criminal behaviour may very well recur’ (Wing Reference Wing1997). Pre-dating the idea of making ‘reasonable adjustments’ and the recent suggestion of a ‘neurodiversity-informed’ model of care (Criminal Justice Joint Inspection 2021). Wing outlined several recommendations, suggesting that ‘whilst there is no cure, it is possible to alleviate some of the problems and that the crucial elements for appropriate care lie in carefully structuring the environment and the daily programmes, and in training staff in the psychological strategies to be used’ (Wing Reference Wing1997). Long before others, Wing also highlighted that psychological strategies should be adapted and used in the same way by all staff (i.e. a consistent approach to care). However, with regard to putting recommendations into action, she suggested a need for high levels of staff training, skill and experience. When applied consistently, she believed that the recommendations improved the quality of life for the individual and reduced the likelihood of inappropriate behaviour. It is interesting to note that such recommendations are very much in line with the SPELL framework (Structure, Positive (approaches and expectations), Empathy, Low arousal, Links) for supporting autistic individuals (Beadle-Brown and Mills Reference Beadle-Brown and Mills2018).
Although there have been and continue to be significant developments in awareness of autistic individuals across the criminal justice system, it is right to acknowledge the contribution of Wing. The suggestion of a neurodiversity-informed model of care is not new and we have known for some time that there are autistic individuals in secure units who have specific needs, and that making reasonable adjustments and improving staff awareness are crucial. It is also important to highlight that Wing’s recommendations are very much in line with England’s national autism strategy (HM Government 2021) and its proposal that by 2026 improvements will be made to autistic peoples’ experiences of coming into contact with the criminal and youth justice systems, by ensuring that all staff understand autism and how to support autistic people.
In conclusion, although the number of books and publications devoted to autism continues to expand, Wing’s The Autistic Spectrum (1996) remains relevant reading for all who work with autistic individuals, and its postscript is as important today as it was in 1996:
‘Those of us who live and/or work with children and adults with autistic disorders have to try to enter their world, since they cannot find their way into ours. We need to learn to comprehend and empathize with autistic experiences in order to find ways to help each individual cope with a system of social rules that is alien to them. The reward for the effort involved is a deeper understanding of human social interaction and an appreciation of the wonder of child development. The key to autism is the key to the nature of human life’ (Wing Reference Wing1996: p. 225).
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