Medscape Pediatrics.  2007; (c)2007 Medscape

Posted 02/07/2007

Review of Unstrange Minds

By Howard Markel, MD, PhD, George E. Wantz Professor of the History of
Medicine, Professor of Pediatrics and Communicable Diseases, Director of the
Center for the History of Medicine, University of Michigan, Ann Arbor;
author of When Germs Travel: Six Major Epidemics and the Fears They Have
Unleashed (Pantheon Books)

The term "epidemic" has been with us for much of recorded history. Over the
past few decades, however, the definition of the term has expanded to
include a description of rapidly rising dilemmas that were formerly
considered in the exclusive realm of chronic diseases, social problems, and
even behaviors. Witness, for example, the public health clarions about the
epidemic of lung cancer, associated with the rise of cigarette smoking, or
the epidemics of obesity, handgun violence, and substance abuse.

When it comes to developing public health campaigns against specific health
problems, the status of epidemic is definitely worth seeking, because
governmental policies and research programs are typically developed to
respond to epidemic health threats.

And hopefully, something gets done to ameliorate such burgeoning problems,
which brings me to the topic of autism and its rise in incidence over the
past 15 years. One would have to live under a rock not to notice the growing
concern over a potential epidemic of autism.

Autism: The Epidemic?
Indeed, the numbers are compelling. In 1990, autism was diagnosed in about
4.7 out of every 10,000 American children. By the end of 2006, that number
had risen to approximately 60 out of every 10,000, which translates to 1 out
of every 166 American kids.

A recently published book, "Unstrange Minds: Remapping the World of Autism,"
by George Washington University anthropologist Roy Richard Grinker,
critically questions whether there truly is an autism epidemic or, perhaps,
whether it is simply better recognition of an issue that has long been with
us but not widely noticed. Could the decided rise in autism cases that
parents, schoolteachers, and child health professionals are seeing in recent
years be the unintended consequence of changing clinical definitions, policy
changes, and heightened awareness among those who spend significant time
with children?

Using the tools of an anthropologist, Grinker explores autism and the role
it plays in cultures around the world, and endeavors to make sense of the
increase in autism cases being reported in Africa, East Asia, India, and the
United States. Along the way, he makes a number of fascinating points about
how doctors and health professionals understand issues pertaining to mental
health and how cultural shifts can influence such understanding.

A Change in the Cultural Tide
Four major sea changes in the social and cultural responses to autism,
according to Grinker, include the following:

        1.. Doctors have developed more broadly interpreted definitions of
autism over the past few decades. If one were to consult the successive
editions of the Diagnostic and Statistical Manual of Mental Disorders, one
cannot help but notice that each description is written to include more and
more people.

        2.. The milder condition of Asperger's syndrome and "pervasive
developmental disorder, not otherwise specified" (PDD-NOS) were added to the
DSM diagnosis of autism in 1994 and 1987, respectively. These additions may
have contributed to 50% to 75% of the increase in the diagnoses of autism

        3.. American schools have long been required to report information
about the numbers of students requiring special educational services. But
autism was not added to this list until the 1991-1992 academic calendar. In
1995, 22,445 US students were receiving special services related to autism;
in 2004, that number jumped to 140,254.

        4.. In some states, there is an increasing array of financial
incentives to having a diagnosis of autism, such as one's potential
eligibility for Medicaid. By contrast, there has been a decided lack of
incentives, state insurance, and availability of affordable health programs
for the more mundane diagnosis of mental retardation over the same time

Keeping an Open Mind
As more people learn about autism, Grinker argues, there has been less
stigma associated with this brain-based disorder, and more people are now
willing to be open about the condition. He also argues that doctors and
other health professionals today might be more willing to label a child
autistic -- as opposed to mentally retarded -- if they believe such a label
might get that child the educational services he or she needs.

Grinker has a 15-year-old daughter with autism. In part, this book was his
search for the truth about the condition that struck his child and an
attempt at making sense of its greater implications. He hoped he would find
a distinct culprit, an enemy that could be combatted and defeated.

He concludes that autism is a disorder of "multiple causes, shifting
definitions, and a scientific reality we are only just beginning to

After reading this impassioned and thoughtful tome, readers will conclude
that whether one classifies autism as an epidemic or simply a major mental
disorder, there is much more to be learned about this complex and puzzling

        1.. Grinker RR. Unstrange Minds: Remapping the World of Autism. New
York, NY: Basic Books; 2007.

©2006 Roy Richard Grinker