Kanner's first case, Donald, has long served as a prototype for diagnosis. It had been evident early in life that the boy was different from other children. At two years of age, he could hum and sing tunes accurately from memory. Soon he learned to count to 100 and to recite both the alphabet and the 25 questions and answers of the Presbyterian catechism. Yet he had a mania for making toys and other objects spin. Instead of playing like other toddlers, he arranged beads and other things in groups of different colors or threw them on the floor, delighting in the sounds they made. Words for him had a literal, inflexible meaning. Donald was first seen by Kanner at age five. Kanner observed that the boy paid no attention to people around him. When someone interfered with his solitary activities, he was never angry with the interfering person but impatiently removed the hand that was in his way. His mother was the only person with whom he had any significant contact, and that seemed attributable mainly to the great effort she made to share activities with him. By the time Donald was about eight years old, his conversation consisted largely of repetitive questions. His relation to people remained limited to his immediate wants and needs, and his attempts at contact stopped as soon as he was told or given what he had asked for. Some of the other children Kanner described were mute, and he found that even those who spoke did not really communicate but used language in a very odd way. For example, Paul, who was five, would parrot speech verbatim. He would say "You want candy" when he meant "I want candy." He was in the habit of repeating, almost every day, "Don't throw the dog off the balcony," an utterance his mother traced to an earlier incident with a toy dog. Twenty years after he had first seen them, Kanner reassessed the members of his original group of children. Some of them seemed to have adapted socially much better than others, although their failure to communicate and to form relationships remained, as did their pedantry and single-mindedness. Two prerequisites for better adjustment, though no guarantees of it, were the presence of speech before age five and relatively high intellectual ability. The brightest autistic individuals had, in their teens, become uneasily aware of their peculiarities and had made conscious efforts to conform. Nevertheless, even the best adapted were rarely able to be self-reliant or to form friendships. The one circumstance that seemed to be helpful in all the cases was an extremely structured environment. As soon as the work of the pioneers became known, every major clinic began to identify autistic children. It was found that such children in addition to their social impairments have substantial intellectual handicaps. Although many of them perform relatively well on certain tests, such as copying mosaic patterns with blocks, even the most able tend to do badly on test questions that can be answered only by the application of common sense. Autism is rare. According to the strict criteria applied by Kanner, it appears in four of every 10,000 births. With the somewhat wider criteria used in current diagnostic practice, the incidence is much higher: one or two in 1,000 births, about the same as Down's syndrome. Two to four times as many boys as girls are affected. For many years, autism was thought to be a purely psychological disorder without an organic basis. At first, no obvious neurological problems were found. The autistic children did not necessarily have low intellectual ability, and they often looked physically normal. For these reasons, psychogenic theories were proposed and taken seriously for many years. They focused on the idea that a child could become autistic because of some existentially threatening experience. A lack of maternal bonding or a disastrous experience of rejection, so the theory went, might drive an infant to withdraw into an inner world of fantasy that the outside world never penetrates.

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