Book Review

Unstrange Minds: Remapping the World of Autism

N Engl J Med 2007; 357:310-311July 19, 2007

Article

Unstrange Minds: Remapping the World of Autism
By Roy Richard Grinker. 340 pp. New York, Basic Books, 2007. $26.95. ISBN: 978-0-465-02763-7

Perhaps nowhere in medicine is it more apparent than in the world of psychiatry that illness cannot exist outside culture. How a person perceives a symptom and how a society defines a disorder determine whether a physician ever makes a diagnosis and attempts a treatment.

It is this premise that Roy Richard Grinker, an anthropologist and the father of an autistic child, uses as a starting point to illuminate the history and current state of autism, a genetic and developmental disorder, in Unstrange Minds. He leads the reader across cultures and continents but observes that even when the diagnostic definitions of autism vary, the challenges and devastation for patients and their families are often the same.

Grinker begins by walking the reader through his daughter Isabel's early symptoms and life in Washington, D.C. Like so many parents, Grinker and his wife realized that Isabel was different only when they had another child. Her inability to communicate or make friends, her use of repetitive speech, and her unusual preoccupations all added up to the diagnosis of autism in 1994. The Grinkers then faced the struggles and stigma familiar to any family of a child with a psychiatric or developmental disorder.

Autism is now reported in 60 of 10,000 live births. Psychiatrists in the United States can refer to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, for the clear criteria, which have been continually broadened, for the autism spectrum syndrome. But there is still no specific laboratory test or radiographic evidence for this psychological paradox, first identified in 1943 by Leo Kanner, that causes children to crave repetition, to appear unable to interact with others, and to be overly sensitive to sights, sounds, and smells. Clinically, symptoms can vary, and the disorder resists consistent recognition even within cultures. According to Grinker, some cultures do not identify autism as a pathology. Autistic children in Senegal, for example, are referred to as “marvelous children.” The Navajo Indians regard children with autistic symptoms as “perpetual children.” In South Korea, a child with classic symptoms of autism is thought to be “more pure than others and closer to God,” and beliefs about autism differ substantially between peoples in Africa and India.

Ultimately, it is through a historical account of psychiatry that the author illuminates the origins of autism and attempts to explain how it changed from an invisible illness to what many now consider an epidemic. Autism increased in prevalence from 1 in every 3000 births in the mid-1990s to as high as 1 in every 150 births today. But is there an autism epidemic? Grinker and others think not. The rise in diagnoses may be due mostly to the broadening of the diagnostic criteria, increased awareness among parents and the media, skilled teachers and astute physicians, aggressive epidemiologic methods, and the mere fact that autism is a relatively new disorder. Better methods of diagnosis and of counting those who are affected have swollen the numbers but do not represent a true rise in incidence. Grinker also posits other factors that contribute to an increase in diagnoses of autism — namely, insurance incentives and research dollars.

Fortunately, these marvelous children — once labeled idiots, imbeciles, and feebleminded — are benefiting from early diagnosis as well as from progressive parents, practitioners, and educational methods and interventions that offer assistance. In his book, Grinker reveals that his daughter, now a teenager, has become a cellist, an artist, and a loving sister.

This book was written for professionals who want to appreciate the history and epidemiology of autism and learn why we should continue to look for environmental links to the disorder, although the author believes we are unlikely to find any. It is also written for parents of autistic children who want to learn from personal, cross-cultural stories and gain insight into valuable information about interventions and educational settings, as well as for the curious person who wants to reflect on cultural influences on the disease and understand the growing phenomenon of autism. All these people will be enlightened after reading this book, which was thoughtfully written by a father and scientist trying to understand his daughter and illuminate her disorder.

Teresa L. Schraeder, M.D.
Mount Auburn Hospital, Cambridge, MA 02138