Your Kids Aren't Sick

[READER’S NOTE:  To follow is an easier way to read Kanner’s important follow-up study from 1971.  I simply copied and converted the text so it could be placed in a MS Word format.  I made no changes, including grammar or obscure references, or anything else for that matter.  I wouldn’t dare.  I did alter the format a bit for the reader.  When there were direct quotes from parents or professionals, and they were descriptive of the types of behaviors being discussed, I put them in italics.  Also, if there were long descriptions, from a parent for example, I put their words into a separate paragraph.  For those trained in temperament theory, these very detailed behavioral descriptions provide important clues to understanding these unique children.  [You can also find a PDF copy of the original paper here.]

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PATHOLOGY

To understand and measure emotional qualities is very difficult.  Psychologists and educators have been struggling with that problem for years but we are still unable to measure emotional and personality traits with the exactness with which we can measure intelligence.  -Rose Zeligs in Glimpses into Child Life*

AUTISTIC DISTURBANCES OF AFFECTIVE CONTACT
BY LEO KANNER – 1943

Since 1938, there have come to our attention a number of children whose condition differs so markedly and uniquely from anything reported so far, that each case merits – and, I hope, will eventually receive a detailed consideration of its fascinating peculiarities.  In this place, the limitations necessarily imposed by space call for a condensed presentation of the case material.  For the same reason, photographs have also been omitted.  Since none of the children of this group has as yet attained an age beyond 11 years, this must be considered a preliminary report, to be enlarged upon as the patients grow older and further observation of their development is made.

Case 1.
Donald T. was first seen in October, 1938, at the age of 5 years, 1 month.  Before the family’s arrival from their home town, the father sent a thirty-three-page typewritten history that, though filled with much obsessive detail, gave an excellent account of Donald’s background.  Donald was born at full term on September 8, 1933.  He weighed nearly 7 pounds at birth.  He was breast fed, with supplementary feeding, until the end of the eighth month; there were frequent changes of formulas.  “Eating,” the report said, “has always been a problem with him. He has never shown a normal appetite.  Seeing children eating candy and ice cream has never been a temptation to him.”  Dentition proceeded satisfactorily. He walked at 13 months.

At the age of 1 year “he could hum and sing many tunes accurately.”  Before he was 2 years old, he had “an unusual memory for faces and names, knew the names of a great number of houses” in his home town.”  He was encouraged by the family in learning and reciting short poems, and even learned the Twenty­ third Psalm and twenty-five questions and answers of the Presbyterian Catechism.”  The parents observed that “he was not learning to ask questions or to answer questions unless they pertained to rhymes or things of that nature, and often then he would ask no question except in single words.”  His enunciation was clear. He became interested in pictures and very soon knew an inordinate number of the pictures in a set of Compton’s Encyclopedia.”  He knew the pictures of the presidents “and knew most of the pictures of his ancestors and kinfolks on both sides of the house.”  He quickly learned the whole alphabet “backward as well as forward” and to count to 100.

It was observed at an early time that he was happiest when left alone, almost never cried to go with his mother, did not seem to notice his father’s home­comings, and was indifferent to visiting relatives.  The father made a special point of mentioning that Donald even failed to pay the slightest attention to Santa Claus in full regalia:

“He seems to be self-satisfied.  He has no apparent affection when petted.  He does not observe the  fact that anyone comes or goes, and never seems glad to see father or mother or any playmate.  He seems almost to draw into his shell and live within himself.  We once secured a most attractive little boy of the same age from an orphanage and brought him home to spend the summer with Donald, but Donald has never asked him a question nor answered a question and has never romped with him in play.  He seldom comes to anyone when called but has to be picked up and carried or led wherever he ought to go.”

In his second year, he “developed a mania for spinning blocks and pans and other round objects.”  At the same time, he had:

“A dislike for self-propelling vehicles, such as Taylor-tots, tricycles, and swings.  He is still fearful of tricycles and seems to have almost a horror of them when he is forced to ride, at which time he will try to. hold onto. the person assisting him.  This summer (1937] we bought him a playground slide and on the  first afternoon when other children were  sliding on it he would not get about it, and when we put him up to slide down it he seemed horror­ struck.  The next morning when nobody was present, however, he walked out, .climbed the ladder, and slid down, and he has slid on it frequently since, but slides only when no other child is present to join him in sliding. He was always constantly happy and busy entertaining himself, but resented being urged to play with certain things.”

When interfered with, he had temper tantrums, during which he was destructive.  He was “dreadfully fearful of being spanked or switched” but “could not associate his misconduct with his punishment.”

In August, 1937, Donald was placed in a tuberculosis preventorium in order to provide for him “a change of environment.”  While there, he had a “disinclination to play with children and do things children his age usually take an interesting.” He gained weight but developed the habit of  shaking his head from side  to side. He continued spinning objects and jumped up and down in ecstasy as he watched them spin. He displayed:

“An abstraction of mind which made him perfectly oblivious to everything about him.  He appears to be always thinking and thinking, and to get his attention almost requires one to break down a mental barrier between his inner consciousness and the outside world.”

The father, whom Donald resembles physically, is a successful, meticulous, hard-working lawyer who has had two “breakdowns” under strain of  work.  He always took every ailment seriously, taking to his bed and following doctors’ orders punctiliously even for the slightest cold.  “When he walks down the street, he is so absorbed in thinking that he sees nothing and nobody and cannot member anything about the walk.”  The mother, a college graduate, is a calm, capable woman, to whom her husband feels vastly superior.  A second child, a boy, was born to them on May 22, 1938.

Donald, when examined at the Harriet Lane Home in October, 1938, was found to be in good physical condition.  During the initial observation and in a two-week study by Drs. Eugenia S. Cameron and George Frankl at the Child Study Home of Maryland, the following picture was obtained:

There was a marked limitation of spontaneous activity.  He wandered about smiling, making stereotyped movements with his fingers, crossing them about in the air.  He shook his head from side to side, whispering or humming the same three-note tune.  He spun with great pleasure anything he could seize upon to spin.  He kept throwing things on the floor, seeming to delight in the sounds they made.  He arranged beads, sticks, or blocks in groups of different series of colors. Whenever he finished one of these performances, he squealed and jumped up and down. Beyond this he showed no initiative, requiring constant instruction (from his mother) in any form of activity other than the limited ones in which he was absorbed.

Most of his actions were repetitions carried out in exactly the same way in which they had been performed originally. If he spun a block, he must always start with the same face uppermost.  When he threaded buttons, he arranged them in a certain sequence that had no pattern to it but happened to be the order used by the father when he first had shown them to Donald.

There were also innumerable verbal rituals recurring all day long. When he desired to get down after his nap, he said, “Boo (his word for his mother], say ‘Don, do you want to  get down?’ ” 

His mother would comply, and Don would say: “Now say ‘All right.'”

The mother did, and Don got down. At mealtime, repeating something that had obviously been said to him often, he said to his mother, “Say ‘Eat it or I won’t give you tomatoes, but if you don’t eat it I will give you tomatoes,’ ” or “Say ‘If you drink to there, I’ll laugh and I’ll smile.’ “

And his mother had to conform or else he squealed, cried, and strained every muscle in his neck in tension. This happened all day long about one thing or another. He seemed to have much pleasure in ejaculating words or phrases, such as “Chrysanthemum”; “Dahlia, dahlia, dahlia”; “Business”; “Trumpet vine”; “The right one is on, the left one is off”; “Through the dark clouds shining:” Irrelevant utterances such as these were his ordinary mode of speech. He always seemed to be parroting what he had heard said to him at one time or another.  He used the personal pronouns for the persons he was quoting, even imitating the intonation. When he wanted his mother to pull his shoe off, he said: “Pull off your shoe.”  When he wanted a bath, he said: “Do you want a bath?”

Words to him had a specifically literal, inflexible meaning. He seemed unable to generalize, to transfer an expression to another similar object or situation.  If he did so occasionally, it was a substitution, which then “stood” definitely for the original meaning.  Thus he christened each of his water color bottles by the  name of one of the Dionne quintuplets – Annette for blue, Cecile for red, etc.  Then, going through a series of color mixtures, he proceeded in this manner: “Annette and Cecile make purple.”

The colloquial request to “put that down” meant to him that he was to put the thing on the floor.  He had a “milk glass” and a “water glass.”  When he spit some milk into the “water glass,” the milk thereby became “white water.”

The word “yes” for a long time meant that he wanted his father to put him up on his shoulder. This had a definite origin. His father, trying to teach him  to say “yes” and “no,” once asked him, “Do you want me to put you on my shoulder?”

Don expressed his agreement by repeating the question literally, echolalia­like.  His father said, “If you want me to, say ‘Yes’; if you don’t want me to, say ‘No.'”

Don said “yes” when asked. But thereafter ”yes” came to mean that he desired to be put up on his father’s shoulder.

He paid no attention to persons around him.  When taken into a room, he completely disregarded the people and instantly went for objects, preferably those that could be spun. Commands or actions that could not possibly be disregarded were resented as unwelcome intrusions.  But he was never angry at the interfering person.  He angrily shoved away the hand that was in his way or the foot that stepped on one of his blocks, at one time referring to the foot on the block as “umbrella.”  Once the obstacle was removed, he forgot the whole affair.  He gave no heed to the presence of other children but went about his favorite pastimes, walking off from the children if they were so bold as to join him.  If a child took  a toy from him, he passively permitted it.  He scrawled lines on the picture books the other children were coloring, retreating or putting his hands over his ears  if they threatened him in anger.  His mother was the only person with whom he had any contact at all, and even she spent all of her time developing ways of keeping him at play with her.

After his return home, the mother sent periodic reports about his development.  He quickly learned to read fluently and to play simple tunes on the piano.  He began, whenever his attention could be obtained, to respond to questions “which require yes or no for an answer.” Though he occasionally began to speak of himself as “I” and of the person addressed as “you,” he continued for quite some time the pattern of pronominal reversals.  When, for instance, in February 1939, he stumbled and nearly fell, he said of himself, “You did not fall down.”  He expressed puzzlement about the inconsistencies of spelling: “bite” should  be spelled “bight” to correspond to the spelling of “light.”  He could spend hours writing on the blackboard. His play became more imaginative and varied, though still quite ritualistic.

He was brought back for a check-up in May, 1939. His attention and concentration were improved. He was in better contact with his environment, and there were some direct reactions to people and situations.  He showed disappointment when thwarted, demanded bribes promised him, gave evidence of pleasure when praised.  It was possible, at the Child Study Home, to obtain with constant insistence some conformity to daily routine and some degree of proper handling of objects. But he still went on writing letters with his fingers in the air, ejaculating words – “Semicolon”; “Capital”; “Twelve, twelve”; “Slain, slain”; “I could put a little comma or semicolon” – chewing on paper, putting food on his hair, throwing books into the toilet, putting a key down the water drain, climbing onto the table and bureau, having temper tantrums, giggling and whispering artistically.  He got hold of an encyclopedia and learned about fifteen words in the index and kept repeating them over and over again.  His mother was helped in trying to develop his interest and participation in ordinary life situations.

The following are abstracts from letters sent subsequently by Donald’s mother:

September, 1939. He continues to eat and to wash and dress himself only at my insistence and with my help. He is becoming resourceful, builds things with his blocks, dramatizes stories, attempts to wash the car, waters the flowers with the hose, plays store with the grocery supply, tries to cut out pictures with the scissors.  Numbers still have a great attraction for him.  While his play is definitely improving, he has never asked questions about  people and shows no interest in our conversation . . .

October, 1939 [a school principal friend of the mother’s had agreed to try Donald in the first grade of her school).  The first day was very trying for them but  each succeeding day  has improved very much. Don is much more independent, wants to do many things for himself.  He marches in line nicely, answers when called upon, and is more biddable and obedient. He never voluntarily relates any of  his experiences  at  school and never objects to going . . .

November, 1939.  I visited his room this morning and was amazed to see how nicely he cooperated and responded.  He was very quiet and calm and listened to what the teacher was saying about half the time.  He does not squeal or run around but takes his place like the other children.  The teacher began writing on the board.  That immediately attracted his attention.  She wrote:

BETTY MAY FEED A FISH

DON MAY FEED  A  FISH

JERRY MAY FEED A FISH

In his turn he walked up and drew a circle around his name.  Then he fed a goldfish. Next, each child was given his weekly reader, and he turned to the proper page as the teacher directed and read when called upon. He also answered a question about one of the pictures. Several times, when pleased, he jumped up and down and shook his head once while answering . . .

March, 1940.  The greatest improvement I notice is his awareness of things about him.  He talks very much more and asks a good many questions. Not often does he voluntarily  tell me of happenings at school, but if I ask leading questions, he answers them correctly. He really enters into the games with other children. One day he enlisted the family in one game  he had just learned, telling each of us just exactly what to do. He feeds himself some better and is better able to do things for himself . . .

March, 1941. He has improved greatly, but  the basic difficulties are still evident . .

Donald was brought for another check-up in April, 1941.  An invitation to enter the office was disregarded, but he had himself led willingly.  Once inside, he did not even glance at the three physicians present (two of whom he well remembered from his previous visits) but immediately made for the desk and handled papers and books.  Questions at first were met with the stereotyped reply, “I don’t know.”  He then helped himself  to pencil and paper and  wrote and drew pages and pages full of letters of the alphabet and a few simple designs.  He arranged the letters in two or three lines, reading them in vertical rather than horizontal succession, and was very much pleased with the result. Occasionally he volunteered a statement or question: “I am going to stay for two days at the Child Study Home.”  Later he said, “Where is my mother?”

“Why do you want her?” he was asked.  “I want to hug her around the neck.”

He used pronouns adequately and his sentences were grammatically correct.

The major part of his “conversation” consisted of questions of an obsessive nature.  He was inexhaustible in bringing up variations: “How many days in a week, years in a century, hours in a day, hours in half a day, weeks in a century, centuries in half a millennium,” etc., etc.; “How many  pints in a gallon, how many gallons to fill four gallons?” Sometimes he asked, “How many hours in a minute, how many days in an hour?” etc.  He looked thoughtful and always wanted an answer. At times he temporarily compromised by responding quickly to some other question or request but promptly returned to the same type of behavior.  Many of his replies were metaphorical or otherwise peculiar.  When asked to subtract 4 from 10, he answered: “I’ll draw a hexagon.”

He was still extremely autistic.  His relation to  people had developed only in so far as he addressed them when he needed or wanted to know something.  He never looked at the person while talking and did not use communicative gestures.  Even this type of contact ceased the moment he was told or given what he had asked for.

A letter from the mother stated in October, 1942:

Don is still indifferent to much that is around him.  His interests change often, but always he is absorbed in some kind of silly, unrelated subject.  His literal-mindedness is still very marked, he wants to spell words as they sound and to pronounce letters consistently.   Recently I have been able to have Don do a few chores around the place to earn picture show money.  He really enjoys the movies now but not with any idea of a connected story.  He remembers them in the order in which he sees them.  Another of his recent hobbies is with old issues of Time magazine.  He found a copy of the first issue of March 3, 1923, and has attempted to make a list of the dates of publication of each issue since that time. So far he has gotten to April, 1934.  He has figured the number of issues in a volume and similar nonsense.

Case 2
Frederick W. was referred on May 27, 1942, at the age of 6 years, with the physician’s complaint that his “adaptive behavior in a social setting is characterized by attacking as well as withdrawing behavior.”  His mother stated:

The child has always been self-sufficient.  I could leave him alone and he’d entertain himself very happily, walking around, singing, I have never known him to cry in demanding attention.  He was never interested in hide-and-seek, but he’d roll a  ball back and forth, watch his father shave, hold the razor box and put the razor back in, put the lid on the soap box.  He never was very good with cooperative play.  He doesn’t care to play with the ordinary things that other children play with, anything with wheels on.  He is afraid of mechanical things; he runs from them.  He used to be afraid of my egg beater, is perfectly petrified of  my vacuum cleaner.  Elevators are simply a  terrifying experience to him.  He is afraid of spinning tops.

Until the last year, he mostly ignored other people.  When we had guests, he just wouldn’t pay any attention. He looked curiously at  small children and then would go off all  alone. He acted as if people weren’t there at all, even with his grandparents.  About a year ago, he began showing more interest in observing them, would even go up to them.  But usually  people are an interference.  He’ll push people away from him.  If people come too close to him, he’ll push them away.  He doesn’t want me to touch him or put my arm around him, but he’ll come and touch me.

To a certain extent, he likes to stick to the same thing. On one of the bookshelves we  had three pieces in a certain arrangement.  Whenever this was changed, he always rearranged it in the old pattern.  He won’t try new things, apparently.  After watching for a long time,  he does it all of a sudden. He wants to be sure he does it right.

He had said at least two words  [“Daddy “and “Dora,” the mother’s first name] before he was 2 years old.  From then on, between 2 and 3 years, he would say words that seemed to come as a surprise to himself.  He’d say them once and never repeat them. One of the first words he said was “overalls.” [The parents never expected him to answer any of their questions, were once surprised when he did give an answer “Yes”].  At about 2½ years, he began to sing.  He sang about twenty or thirty songs, including a little French lullaby.  In his fourth year, I tried to make him ask for things before he’d get them.  He was stronger willed than I was and held out longer, and he would not get it but he never gave in about it.  Now he can count up to into the hundreds and can read numbers, but  he is  not  interested in numbers as they apply to objects.  He has great difficulty in learning the proper use of personal pronouns.  When receiving a gift, he would say of himself: “You say ‘Thank you.’ “

He bowls, and when he sees the pins go down, he’ll jump up and down in great glee.

Frederick was born May 23, 1936, in breech presentation.  The mother had “some kidney trouble” and an elective cesarean section was performed about two weeks before term.  He was well after birth; feeding presented no problem.  The mother recalled that he was never observed to assume an anticipatory posture when she prepared to pick him up.  He sat up at 7 months, walked at about 18 months.  He had occasional colds but no other illness.  Attempts to have him attend nursery school were unsuccessful: “he would either  be  retiring  and  hide in a corner or would push himself into the middle of a group and be very aggressive.”

The boy is an only child. The father, aged 44, a university graduate and a plant pathologist, has traveled a great deal in connection with his work. He is a patient, even-tempered man, mildly obsessive; as a child he did not  talk “until late” and was delicate, supposedly “from lack of vitamin in diet allowed in Africa.”  The mother, aged 40, a college graduate, successively a secretary to physicians, a purchasing agent, director of secretarial studies in a girls’ school, and at one time a teacher of history, is described as healthy and even-tempered.

The paternal grandfather organized medical missions in Africa, studied tropical medicine in England, became an authority on manganese mining in Brazil, was at the same time dean of a medical school and director of an art  museum in an American city, and is listed in Who’s Who under two different names.  He disappeared in 1911, his whereabouts remaining obscure for twenty-five years.  It was then learned that he had gone to Europe and married a novelist, without obtaining a divorce from his first wife. The family considers him “a very strong character of the genius type, who wanted to do as much good as he could.”

The paternal grandmother is described as “a dyed-in-the-wool missionary if ever there was one, quite dominating and hard to get along with, at present pioneering in the South at a college for mountaineers.”

The father is the second of five children. The oldest is a well known newspaper man and author of a best-seller.  A married sister, “high-strung and quite precocious,” is a singer.  Next comes a brother who writes for adventure magazines.  The youngest, a painter, writer, and radio commentator, “did not talk until he was about 6 years old,” and the first words he is reported to have spoken were, “When a lion can’t talk he can whistle.”

The mother said of her own relatives, “Mine are very ordinary people.”  Her family is settled in a Wisconsin town, where her father is a banker; her mother is “mildly interested” in church work, and her three sisters, all younger than herself, are average middle-class matrons.

Frederick was admitted to the Harriet Lane Home on May 27, 1942.  He appeared to be well nourished. The circumference of his head was 21 inches, of his chest 22 inches, of his abdomen 21 inches. His occiput and frontal region were markedly prominent.  There was a supernumerary nipple in the left axilla.  Reflexes were sluggish but present.  All other findings, including laboratory examinations and X ray of his skull, were normal, except for large and ragged tonsils.

He was led into the psychiatrist’s office by a nurse, who left the room immediately afterward.  His facial expression was tense, somewhat apprehensive, and gave the impression of intelligence.  He wandered aimlessly about for a few moments, showing no sign of awareness of the three adults present.  He then sat down on the couch, ejaculating unintelligible sounds, and then abruptly lay down, wearing throughout a dreamy-like smile. When he responded to questions or commands at all, he did so by repeating them echolalia fashion.  The most striking feature in his behavior was the difference in his reactions to objects and to people.  Objects absorbed him easily and he showed good attention and perseverance in playing with them. He seemed to regard people as unwelcome intruders to whom he paid as little attention as they would permit.  When forced to respond, he did so briefly and returned to his absorption in things.  When a hand was held out before him so that he could not possibly ignore it, he played with it briefly as if it were a detached object.  He blew out a match with an expression of satisfaction with the achievement, but did not look up to the person who had lit the match. When a fourth person entered the room, he retreated for a minute or two behind the bookcase, saying, “I don’t want you,” and waving him away, then resumed his play, paying no further attention to him or anyone else.

Test results (Grace Arthur performance scale) were difficult to evaluate because of his lack of cooperation.  He did best with the Seguin form board (shortest time, 58 seconds). In the mare and foal completion test he seemed to be guided by form entirely, to the extent that it made no difference whether the pieces were right side up or not.  He completed the triangle but not the rectangle.  With all the form boards he showed good perseverance and concentration, working at them spontaneously and interestedly.  Between tests, he wandered about the room examining various objects or fishing in the wastebasket without regard for the persons present. He made frequent sucking noises and occasionally kissed the dorsal surface of his hand. He became fascinated with the circle from the form board, rolling it on the desk and attempting, with occasional success, to catch it just before it rolled off.

Frederick was enrolled at the Devereux Schools on September 26, 1942.

Case 3
Richard M. was referred to the Johns Hopkins Hospital on February 5, 1941, at 3 years, 3 months of age, with the complaint of deafness because he did not talk and did not respond to questions.  Following his admission, the interne made this observation:

The child seems quite intelligent, playing with the toys in his bed and being adequately curious about instruments used in the examination.  He seems quite self-sufficient in his play.  It is difficult to tell definitely whether he hears, but  it seems that he does.  He will obey commands, such as “Sit up” or “Lie down,” even when he does not see the speaker. He does not pay attention to conversation going on around him, and although he does make noises, he says no recognizable words.

His mother brought with her copious notes that indicated obsessive preoccupation with details and a tendency to read all sorts of peculiar interpretations into the child’s performances.  She watched (and recorded) every gesture and every “look,” trying to find their specific significance and finally deciding on a particular, sometimes very farfetched explanation.  She thus accumulated an account that, though very elaborate and richly illustrated, on the whole revealed more of her own version of what had happened in each instance than it told of what had actually occurred.

Richard’s father is a professor of forestry in a southern university.  He is very much immersed in his work, almost entirely to the exclusion of social contacts.  The mother is a college graduate. The maternal grandfather is physician, and the rest of the family, in both branches, consists of intelligent professional people. Richard’s brother, thirty-one months his junior, is described as a normal, well developed child.

Richard was born on November 17, 1937.  Pregnancy and birth were normal.  He sat  up at 8 months and walked at  1 year.  His mother began to “train” him at the age of 3 weeks, giving him a suppository every morning “so his bowels would move by the clock.”  The mother, in comparing her two children, recalled that while her younger child showed an active anticipatory reaction to being picked up, Richard had not shown any physiognomic or postural sign of preparedness and had failed to adjust his body to being held by her or the nurse.  Nutrition and physical growth proceeded satisfactorily.  Following smallpox vaccination at 12 months, he had an attack of diarrhea and fever, from which he recovered in somewhat less than a week.

In September, 1940, the mother, in commenting on Richard’s failure to talk, remarked in her notes:

I can’t be sure just when he stopped the imitation of word sounds. It seems that he has he did not disclose what was in his head, that it was there all right. Now that he is making so many sounds, it is disconcerting because it is-now evident that he can’t talk. Before, I thought he could if he only would.  He gave the impression of silent wisdom to me . . . One puzzling and discouraging thing is the great difficulty one has in getting his attention.

On physical examination, Richard was found to be healthy except for large tonsils and adenoids, which were removed on February 8, 1941. His head circumference was 54½ cm. His electroencephalogram was normal.

He had himself led willingly to the psychiatrist’s office and engaged at once in active play with the toys, paying no attention to the persons in the room.  Occasionally, he looked up at the walls, smiled and uttered short staccato forceful sounds – “Eel! Ee! Ee!”  He complied with a  spoken and gestural command of his mother to take off his slippers.  When the command was changed to another, this time without gestures, he repeated the original request and again took off his slippers (which had been put on again).  He performed well with the unrotated form board but not with the rotated form board.

Richard was again seen at the age of 4 years, 4 months.  He had grown considerably and gained weight.  When started for the examination room, he screamed and made a great fuss, but once he yielded he went along willingly.  He immediately proceeded to turn the lights on and off. He showed no interest in the examiner or any other person but was attracted to a small box that he threw as if it were a ball.

At 4 years, 11 months, his first move in entering the office (or any other room) was to turn the lights on and off.  He climbed on a chair, and from the chair to the desk in order to reach the switch of the wall lamp.  He did not communicate his wishes but went into a rage until his mother guessed and procured what he wanted.  He had no contact with people, whom he definitely regarded as an interference when they talked to him or otherwise tried to gain his attention.

The mother felt that she was no longer capable of handling him, and he was placed in a foster home near Annapolis with a woman who had shown a remarkable talent for dealing with difficult children. Recently, this woman heard him say clearly his first intelligible words. They were, “Good night.”

Case 4
Paul G. was referred in March, 1941, at the age of 5 years, for psychometric assessment of what was thought to be a severe intellectual defect.  He had attended a private nursery school, where his incoherent speech, inability to conform, and reaction with temper outbursts to any interference created the impression of feeblemindedness.

Paul, an only child, had come to this country from England with his mother at nearly 2 years of age. The father, a mining engineer, believed to be in Australia now, had left his wife shortly before that time after several years of an unhappy marriage.  The mother, supposedly a college graduate, a restless, unstable, excitable woman, gave a vague and blatantly conflicting history of the family background and the child’s development.  She spent much time emphasizing and illustrating her efforts to make Paul clever by teaching him to memorize poems and songs.  At 3 years, he knew the words of not less than thirty-seven songs and various and sundry nursery rhymes.

He was born normally. He vomited a great deal during his first year, and feeding formulas were changed frequently with little success.  He ceased vomiting when he was started on solid food.  He cut his teeth, held up his head, sat up, walked, and established bowel and bladder control at the usual age.  He had measles, chickenpox, and pertussis without complications.  His tonsils were removed when he was 3 years old.  On physical examination, phimosis was found to be the only deviation from otherwise good health.

The following features emerged from observation on his visits to the clinic, during five weeks’  residence in a boarding  home, and  during a few days’ stay in the hospital.

Paul was a slender, well built, attractive child, whose face looked  intelligent and animated.  He had good manual dexterity.  He rarely responded to any form of address, even to the calling of his name.  At one time he picked up a block from the floor on request.  Once he copied a circle immediately after it had been drawn before him.  Sometimes an energetic “Don’t!” caused him  to interrupt his activity of  the  moment.  But usually, when spoken to, he went on with whatever he was doing as if nothing had been said.  Yet one never had the feeling that he was willingly disobedient or contrary.  He was obviously so remote that the remarks did not reach him.  He was always vivaciously occupied with something and seemed to be highly satisfied, unless someone made a persistent attempt to interfere with his self-chosen actions.  Then he first tried impatiently to get out of the way and, when this met with no success, screamed and kicked in a full-fledged tantrum.

There was a marked contrast between his relations to people and to objects.  Upon entering the room, he instantly went after objects and used them correctly.  He was not destructive and treated the objects with care and even affection.  He picked up a pencil and scribbled on paper that he found on the  table.  He opened a box, took out a toy telephone, singing again and again:  “He wants the telephone,” and went around the room with the mouthpiece and receiver in proper position.  He got hold of a  pair of scissors and patiently and skillfully cut a sheet of paper into small bits, singing the  phrase “Cutting paper,” many times.  He helped himself to a toy engine, ran around the room holding it up high and singing over and over again, “The engine is flying.”  While these utterances, made always with the saine inflection, were clearly connected with his actions, he ejaculated others that could not be linked up with immediate situations.  These are a few examples:  “The people in the hotel”; “Did you hurt your leg?” “Candy is all gone, candy is empty”; “You’ll fall off the bicycle and bump your head.”  However, some of those exclamations could be definitely traced to previous experiences. He was in the  habit of saying almost every day, “Don’t  throw the dog off the balcony.”  His mother recalled that she had said those words to him about a toy dog while they were still in England.  At the sight of a saucepan he would invariably exclaim, “Peten-eater.”  The mother remembered that this particular association had begun when he was 2 years old and she happened  to drop a saucepan while reciting to him the nursery rhyme about “Peter, Peter, pumpkin eater.”  Reproductions of warnings of bodily injury constituted a major portion of his utterances.

None of these remarks was meant to have communicative value.  There was, on his side, no affective tie to people.  He behaved as if people as such did not matter or even exist.  It made no difference whether one spoke to him in a friendly or a harsh way.  He never looked up at people’s faces.  When he had any dealings with persons at all, he treated them, or rather parts of them, as if they were objects.  He would use a hand to lead him.  He would, in playing, butt his head against his mother as at other times he did against a pillow.  He allowed his boarding mother’s hands to dress him, paying not the slightest attention to her.  When with other children, he ignored them and went after their toys.

His enunciation was clear and he had a good vocabulary.  His sentence construction was satisfactory, with one significant exception.  He never used the pronoun of the first person, nor did he refer to himself as Paul.  All statements pertaining to himself were made in the second person, as literal repetitions of things that had been said to him before.  He would express his desire for candy by saying, “You want candy.”  He would pull his hand away from a hot radiator and say “You get hurt.”  Occasionally there were parrot-like repetitions of things said to him.

Formal testing could not be carried out, but he certainly could not be regarded as feeble minded in the ordinary sense.  After hearing his boarding mother say grace three times, he repeated it without a flaw and has retained it since then.  He could count and name colors.  He learned quickly to identify his favorite victrola records from a large stack and knew how to mount and play them.  His boarding mother reported a number of observations that indicated compulsive behavior.  He often masturbated with complete abandon.  He ran around in circles emitting phrases in an ecstatic-like fashion. He took a small blanket and kept shaking it, delightedly shouting, “Ee! Ee!”  He could continue in this manner for a long time and showed great actitation when he was interfered with.  All these and many other things were not only repetitions but recurred day after day with almost photographic sameness.

Case 5.
Barbara K. was referred in February, 1942, at 8 years, 3 months of age. Her father’s written note stated:

First child, born normally October 30, 1933.  She nursed very poorly and was put on bottle after about a week.  She quit taking any kind of nourishment at 3 months.  She was tube-fed five times daily up to 1 year of age.  She began to eat then, though there was much difficulty until she was about 18 months old.  Since then she has been a good eater, likes to experiment. with food, tasting, and now fond of cooking.

Ordinary vocabulary at 2 years, but always slow at putting words into sentences. Phenomenal ability to spell, read, and a good writer, but still has difficulty with verbal expression.  Written language has helped the verbal.  Can’t get arithmetic except as a memory feat.

Repetitious as a baby, and obsessive now: holds things in hands, takes things to bed with her, repeats phrases, gets stuck on an idea, game, etc., and rides it hard, then goes to something else.  She used to talk using “you” for herself and “I” for her mother or me, as if she were saying things as we would in talking to her.

Very timid, fearful of  various and changing things, wind, large animals, etc.  Mostly

than any member in the class about something, she would give no hint of it, just keep quiet, maybe not even listen. 

In camp last summer she was well liked, learned to swim, is graceful in water (had always appeared awkward in her motility before), overcame fear of ponies, played best with children of 5 years of age.  At camp she slid into avitaminosis and malnutrition but offered almost no verbal complaints.

Barbara’s father is a prominent psychiatrist.  Her mother is a well educated, kindly woman.  A younger brother, born in 1937, is healthy, alert, and well developed.

Barbara “shook hands” upon request (offering the left upon coming, the right upon leaving) by merely raising a limp hand in the approximate direction of the examiner’s proffered hand; the motion definitely lacked the implication of greeting.  During the entire interview there was no indication of any kind of affective contact.  A pin prick resulted in withdrawal of her arm, a fearful glance at the pin (not the examiner), and utterance of the word “Hurt!” not addressed to anyone in particular.

She showed no interest in test performances. The concept of test, of sharing an experience or situation, seemed foreign to her.  She protruded her tongue and played with her hand as one would with a toy.  Attracted by a pen on the desk stand, she said: “Pen like yours at home.” Then, seeing a pencil, she inquired: “May I take this home?”

When told that she might, she made no move to take it. The pencil was given to her, but she shoved it away, saying, “It’s not my pencil.”

She did the same thing repeatedly in regard to other objects.  Several times she said, “Let’s see Mother” (who was in the waiting room).

She read excellently, finishing the 10-year Binet fire story in thirty-three seconds and with no errors, but was unable to reproduce from memory anything she had read.  In the Binet pictures, she saw (or at least reported) no action or relatedness between the single items, which she had no difficulty enumerating. Her handwriting was legible. Her drawing (man, house, cat sitting on six legs, pumpkin, engine) was unimaginative and stereotyped.  She used her right hand for writing, her left for everything else; she was left-footed and right-eyed.

She knew the days of the week. She began to name them: “Saturday, Sunday, Monday,” then said, “You go to school” (meaning, “on Monday”), then stopped as if the performance were completed.

Throughout all these procedures, in which – often after several repetitions of the question or command – she complied almost automatically, she scribbled words spontaneously: “oranges”; “lemons”; “bananas”; “grapes”; “cherries”; “apples”; “apricots”; “tangerine”; “grapefruits”; “watermelon  juice”;  the words sometimes ran into each other and were obviously not meant for others to read.

She frequently interrupted whatever “conversation” there was with references to “motor transports” and “piggy-back,” both of which – according to her father – had preoccupied her for quite some  time. She said, for instance,  “I saw motor transports”; “I saw piggy-back when I went to school.”

Her  mother remarked,  “Appendages  fascinate  her, like a smoke stack or a pendulum.”  Her father had previously stated:  “Recent  interest  in  sexual matters, hanging about when we take a bath, and obsessive interest in toilets.”  Barbara was placed at the Devereux Schools, where she is making some progress in learning to relate herself to people.

Case 6                      
Virginia S., born September 13, 1931, has resided at a state training school for the feebleminded since 1936, with the exception of one month in 1938, when she was paroled to a school for the deaf “for educational  opportunity.”  Dr. Esther L. Richards, who saw her several times, clearly recognized that she was neither deaf nor feebleminded and wrote in May, 1941:

Virginia stands out from other children [at the training school] because she is absolutely different from any of the others.  She is neat and tidy, does not play with other children, and does not seem to be deaf from gross tests, but does not talk.  The child will amuse herself by the hour putting picture puzzles together, sticking to them until they are done.  I have seen her with a box filled with the parts of two puzzles gradually work out the pieces for each.  All findings seem to be in the nature of a congenital abnormality which looks as if it were more of a personality abnormality than an organic defect.

Virginia, the younger of two siblings, was the daughter of a psychiatrist, who said of himself (in December, 1941): “I have never liked children, probably a reaction on my part to the restraint from movement (travel), the minor interruptions and commotions.”

Of Virginia’s mother, her husband said: “She is not by any means the mother type. Her attitude [toward a child] is more like toward a doll or pet than anythingelse.”

Virginia’s brother, Philip, five years her senior, when referred to us because of severe stuttering at 15 years of age, burst out in tears when asked how things were at home and he sobbed: “The only’ time my father has ever had anything to do with me was when he scolded me for doing something wrong.”

His mother did not contribute even that much.  He felt that all his life he had lived in “a frosty atmosphere” with two inapproachable strangers.

In August, 1938, the psychologist at the training school observed that Virginia could respond to sounds, the calling of her name, and the command, “Look!”

She pays no attention to what is said to her but quickly comprehends whatever is expected.  Her performance reflects discrimination, care, and precision.

With the nonlanguage items of the Binet and Merrill-Palmer tests, she achieved an I.Q. of 94.

“Without a doubt,” commented the psychologist,

Her intelligence is superior to this.  She is quiet, solemn, composed.  Not once have I

seen her smile.  She retires within herself, segregating herself from others. She seems to be in a world of her own, oblivious to all but the center of interest in the presiding situation.  She is mostly self-sufficient and independent. When others encroach upon her integrity, she tolerates them with indifference.  There was no manifestation of friendliness or interest in persons. On the other hand, she finds pleasure in dealing with things, about which she shows imagination and initiative.  Typically, there is no display of affection.

Psychologist’s note, October, 1939.  Today Virginia was much more at home in the office.  She remembered (after more than a year) where the toys were kept and helped herself.  She could not be persuaded to participate in test procedures, would not wait for demonstrations when they were required.  Quick, skilled moves.  Trial and error plus insight.  Very few futile moves.  Immediate retesting reduced the time and error by more than half.  There are times, more often than not, in which she is completely oblivious to all but her immediate focus of attention . . .

January, 1940. Mostly she is quiet, as she has always worked and played alone.  She has not resisted authority or caused any special trouble.  During group activities, she soon becomes restless, squirms, and wants to leave to satisfy her curiosity about something elsewhere.  She does make some vocal sounds, crying out if repressed or opposed too much by another child.  She hums to herself, and in December I heard her hum the perfect tune of a Christmas hymn while she was pasting paper chains.

June, 1940.  The school girls have said that Virginia says some words when at the cottage.  They remember that she loves candy so much and says “Chocolate,” “Marshmallow,” also “Mama” and “Baby.”

When seen on October 11, 1942, Virginia was a tall, slender, very neatly dressed 11-year-old girl.  She responded when called by getting up and coming nearer without ever looking up to the person who called her.  She just stood listlessly, looking into space.  Occasionally, in answer to questions, she muttered, ”Mamma, baby.”  When a group was formed around the piano, one child playing and the others singing, Virginia sat among the children, seemingly not even noticing what went on, and gave the impression of being self-absorbed.  She did not seem to notice when the children stopped singing.  When the group dispersed she did not change her position and appeared not to be aware of the change of scene.  She had an intelligent physiognomy, though her eyes had a blank expression.

Case 7
Herbert B. was referred on February 5, 1941, at 3 years, 2 months of age.  He was thought to be seriously retarded in intellectual development.  There were no physical abnormalities except for undescended testicles. His electroencephalogram was normal.

Herbert was born November 16, 1937, two weeks before term by elective cesarean section; his birth weight was 6¼ pounds.  He vomited all food from birth through the third month.  Then vomiting ceased almost abruptly and, except for occasional regurgitation, feeding proceeded satisfactorily.  According to his mother, he was “always slow and quiet.”  For a time he was believed to be deaf because “he did not register any change of expression when spoken to or when in the presence of other people; also, he made no attempt to speak or to form words.”  He held up his head at 4 months and sat at 8 months, but did not try to walk until 2 years old, when suddenly “he began to walk without any preliminary crawling or assistance by chairs.” He persistently refused to take fluid in any but an all-glass container.  Once, while at a hospital, he went three days without fluid because it was offered in tin cups.  He was “tremendously frightened by running water, gas burners, and many other things.”  He became upset by any change of an accustomed pattern: “if he notices change, he is very fussy and cries.”  But he himself liked to pull blinds up and down, to tear cardboard boxes into small pieces and play with them for hours, and to close and open the wings of doors.

Herbert’s parents separated shortly after his birth.  The father, a psychiatrist, is described as “a man of unusual intelligence, sensitive, restless, introspective, taking himself very seriously, not interested in people, mostly living within him­ self, at times alcoholic.”  The mother, a physician, speaks of herself as “energetic and outgoing, fond of people and children but havinglittle insight into their problems, finding it a great deal easier to accept people rather than try to understand them.”  Herbert is the youngest of three children. The second is a normal, healthy boy.  The oldest, Dorothy, born in June, 1934, after thirty-six hours of hard labor, seemed alert and responsive as an infant and said many words at 18 months, but toward the end of the second year she “did not show much progression in her play relationships or in contacts with other people.”  She wanted to be left alone, danced about in circles, made queer noises with her mouth, and ignored persons completely except for her mother, to whom she clung “in panic and general agitation.” (Her father hated her ostensibly.)  “Her speech was very meager and expression of ideas completely lacking.  She had difficulties with her pronouns and would repeat ‘you’ and ‘I’ instead of using them for the proper persons.”  She was first declared to be feebleminded, then schizophrenic, but after the parents separated (the children remaining with their mother), she “blossomed out.”  She now attends school, where she makes good progress; she talks well, has an I.Q. of 108, and – though sensitive and moderately apprehensive – is interested in people and gets along reasonably well with them.

Herbert, when examined on his first visit, showed a remarkably intelligent physiognomy and good motor coordination.  Within certain limits, he displayed astounding purposefulness in the pursuit of self-selected goals.  Among a group of blocks, he instantly recognized those that were glued to a board and those that were detachable.  He could build a tower of blocks as skillfully and as high as any child of his age or even older.  He could not be diverted from his self chosen occupations.  He was annoyed by any interference, shoving intruders away (without ever looking at them), or screaming when the shoving had no effect.

He was again seen at 4 years, 7 months, and again at 5 years, 2 months of age.  He still did not speak.  Both times he entered the office without paying the slightest attention to the people present.  He went after the Seguin form board and instantly busied himself putting the figures into their proper spaces and taking them out again adroitly and quickly.  When interfered with he whined impatiently.  When one figure was stealthily removed, he immediately noticed its absence, became disturbed, but promptly forgot all about it when it was put back.  At times, after he had finally quieted down following the upset caused by the removal of the form board, he jumped up and down on the couch with an ecstatic expression on his face.  He did not respond to being called or to any other words addressed to him.  He was completely absorbed in whatever he did.  He never smiled.  He sometimes uttered inarticulate sounds in a monotonous singsong manner.  At one time he gently stroked his mother’s leg and touched it with his lips.  He very frequently brought blocks and other objects to his lips.  There was an almost photographic likeness of his behavior during the two visits, with the main exception that at 4 years he showed apprehension and shrank back when a match was lighted, while at 5 years he reacted by jumping up and down ecstatically.

Case 8
Alfred L. was brought by his mother in November, 1935, at 3½ years of age with this complaint:

He has gradually shown a marked tendency toward developing one special interest which will completely dominate his day’s activities. He talks of little else while the interest exists, he frets when he is not able to indulge in it (by seeing it, coming in contact with it, drawing pictures of it, and it is difficult to get his attention because of his preoccupation . . . There has also been the problem of an overattachment to the world of objects and failure to develop the usual amount of social awareness.

Alfred was born in May, 1932, three weeks before term.  For the first two months, “the feeding formula caused considerable concern but then he gained rapidly and became an unusually large and vigorous baby.”  He sat up at 5 months and walked at 14.

Language developed slowly; he seemed to have no interest in it.  He seldom tells experience.  He still confuses pronouns.  He never asks questions in the form of questions (with the appropriate inflection).  Since he talked, there has been a tendency to repeat over and over one word or statement.  He almost never says a sentence without repeating it.  Yesterday, when looking at a picture, he said many times, “Some cows standing in the water.”  We counted fifty repetitions, then he stopped after several more and then began over and over.

He had a good deal of “worrying”:

He frets when the bread is put in the oven to be made into toast, and is afraid it will get burned and be hurt.  He is upset when the sun sets.  He is upset because the moon does not always appear in the sky at night.  He prefers to play alone; he will get down from a piece of apparatus as soon as another child approaches.  He likes to work out some project with large boxes (make a trolley, for instance) and does not want anyone to get on it or interfere.

When infantile thumb sucking was prevented by mechanical devices, he gave it up and instead put various objects into his mouth.  On several occasions pebbles were found in his stools.  Shortly before his second birthday, he swallowed cotton from an Easter rabbit, aspirating some of the cotton, so that tracheotomy became necessary.  A few months later, he swallowed some kerosene “with no ill effects.”

Alfred was an only child.  His father, 30 years old at the time of his birth, “does not get along well with people, is suspicious, easily hurt, easily roused to anger, has to be dragged out to visit friends, spends his spare time reading, gardening, and fishing.”  He is a chemist and a law school graduate.  The mother, of the same age, is a “clinical psychologist,” very obsessive and excitable.  The paternal grandparents died early; the father was adopted by a minister.  The maternal grandfather, a psychologist, was severely obsessive, had numerous tics, was given to “repeated hand washing, protracted thinking along one line, fear of being alone, cardiac fears.” The grandmother, “an excitable, explosive person, has done public speaking, published several books, is an incessant solitaire player, greatly worried over money matters.”  A maternal uncle frequently ran away from home and school, joined the marines, and later “made a splendid adjustment in commercial life.”

The mother left her husband two months after Alfred’s birth. The child has lived with his mother and maternal grandparent.  “In the home is a nursery school and kindergarten (run by the mother), which creates some confusion for the child.”  Alfred did not see his father until he was 3 years, 4 months old, when the mother decided that “he should know his father” and “took steps to have the father come to the home to see the child.”

Alfred, upon entering the office, paid no attention to the examiner. He immediately spotted a train in the toy cabinet, took it out, and connected and disconnected the cars in a slow, monotonous manner.  He kept saying many times, “More train – more train – more train.”  He repeatedly “counted” the car windows: “One, two windows – one, two windows – one, two windows – four window, eight window, eight windows.”  He could not in any way be distracted from the trains.  A Binet test was attempted in a room in which there were no trains.  It was possible with much difficulty to pierce from time to time through his preoccupations. He finally complied in most instances in a manner that clearly indicated that he wanted to get through with the particular intrusion; this was repeated with each individual item of the task.  In the end he achieved an I.Q. of 140.

The mother did not bring him back after this first visit because of “his continued distress  when  confronted with a member of the medical profession.”  In August, 1938, she sent upon request written report of his development. From this report, the following passages are quoted:

He is called a lone wolf.  He prefers to play alone and avoids groups of children at play. He does not pay much attention to adults except when demanding stories.  He avoids competition.  He reads simple stories to himself.  He is very fearful of being hurt, talks a great deal about the use of the electric chair.  He is thrown into a panic when anyone accidentally covers his face.

Alfred was again referred in June, 1941.  His parents had decided to live together.  Prior to that the boy had been in eleven different schools.  He had been kept in bed often because of colds, bronchitis, chickenpox, streptococcus infection, impetigo, and a vaguely described condition which the mother – the assurances of various pediatricians to the contrary notwithstanding – insisted was “rheumatic fever.”  While in the hospital, he is said to have behaved “like a manic patient.”  (The mother liked to call herself a psychiatrist and to make “psychiatric” diagnoses of the child.)  From the mother’s report, which combined obsessive enumeration of detailed instances with “explanations” trying ‘to prove Alfred’s “normalcy,” the following information was gathered.

He had begun to play with children younger than himself, “using them as puppets-that’s all.”  He had been stuffed with music, dramatics, and recitals, and had an excellent rote memory.  He still was “terribly engrossed” in his play, didn’t want people around, just couldn’t relax:

He had many fears, almost always connected with mechanical noise (meat grinders, vacuum cleaners, street cars, trains, etc.).  Usually he winds up with an obsessed interest in the things he was afraid of.  Now he is afraid of the shrillness of a dog’s barking.

Alfred was extremely tense during the entire interview, and very serious minded, to such an extent that had it not been for his juvenile voice, he might have given the impression of a worried and preoccupied little old man.  At the same time, he was very restless and showed considerable pressure of talk, which had nothing personal in it but consisted of obsessive questions about windows, shades, dark rooms, especially the X-ray room.  He never smiled.  No change of topic could get him away from the topic of light and darkness.  But in between he answered the examiner’s questions, which often had to be repeated several times, and to which he sometimes responded as the result of a bargain – “You answer my question, and I’ll answer yours.”  He was painstakingly specific in his definitions.  A balloon “is made out of lined rubber and has air in it and some have gas and sometimes they go up in the air and sometimes they can hold up – and when they got a hole in it they’ll bust up; if  people squeeze they’ll bust.  Isn’t it right?”  A tiger “is a thing, animal, striped, like a cat, can scratch, eats people up, wild, lives in the jungle sometimes and in the forests, mostly in the jungle. Isn’t it right?”  This question “Isn’t it right?” was definitely meant to be answered; there was a serious desire to be assured that the definition was sufficiently complete.

He was often confused about the meaning of words.  When shown a picture and asked, “What is this picture about?” he replied, “People  are moving about.”

He once stopped and asked, very much perplexed, why there was “The Johns Hopkins Hospital” printed on the history sheets:  “Why do they have to say it?”  This, to him, was a real problem of major importance, calling for a great deal of thought and discussion.  Since the histories were taken at the hospital, why should it be necessary to have the name on every sheet, though the person writing on it knew where he was writing?  The examiner, whom he remembered very well from his visit six years previously, was to him nothing more nor less than a person who was expected to answer his obsessive questions about darkness and light.

Case 9
Charles N. was brought by his mother on February 2, 1943, at 4½ years of age, with the chief complaint, “The thing that upsets me most is that I can’t reach my baby.”  She introduced her report by saying: “I am trying hard not to govern my remarks by professional knowledge which has intruded in my own way of thinking by now.”

As a baby, the boy was inactive, “slow and phlegmatic.”  He would lie in the crib, just staring.  He would act almost as if hypnotized.  He seemed to concentrate on doing one thing at a time. Hypothyroidism was suspected, and he was given thyroid extract, without any change of the general condition.

His enjoyment and appreciation of music encouraged me to play records.  When he was I½ years old, he could discriminate between eighteen symphonies.  He recognized the composer as soon as the first movement started.  He would say “Beethoven.”  At about the same age, he began to spin toys and lids of bottles and jars by the hour.  He had a lot of manual dexterity in ability to spin cylinders.  He would watch it and get severely excited and jump up and down in ecstasy.  Now he is interested in reflecting light from mirrors and catching reflections.  When he is interested in a thing, you cannot change it. He would pay no attention to me and show no recognition of me if I enter the room . . .

The most impressive thing is his detachment and his inaccessibility.  He walks as if he is in a shadow, lives in a world of his own where he cannot be reached.  No sense of relationship to persons.  He went through a period of quoting another person; never offers anything himself.  His entire conversation is a replica of whatever has been said to him.  He used to speak of himself in the second person, now he uses the third person at times; he would say, “He wants” – never “I want.”  . . .

He is destructive; the furniture in his room looks like it has hunks out of it.  He will break a purple crayon into two parts and say, “You had a beautiful  purple crayon and now it’s two pieces. Look what you did.”

He developed an obsession about feces, would hide it anywhere (for instance, in drawers), would tease me if I walked into the room: “You soiled your pants, now you can’t have your crayons!”

As a result, he is still not toilet trained.  He never soils himself in the nursery school, always does it when he comes home.  The same is true of wetting.  He is proud of wetting, jumps up and down with ecstasy, says, “Look at the big puddle he made.”

When he is with other people, he doesn’t look up at them.  Last July, we had a group of people.  When Charles came in, it was just like a foal who’d been let out of an enclosure. He did not pay attention to them but  their presence was felt.  He will mimic a voice and he sings and some people would not notice any abnormality in the child.  At school, he never envelops himself in a group, he is detached from the rest of the children, except when he is in the assembly; if there is music, he will go to the front row and sing.

He has a wonderful memory for words. Vocabulary is good, except for pronouns. He never initiates conversation, and conversation is limited, extensive  only as far as objects go.

Charles was born normally, a planned and wanted child. He sat up at 6 months and walked at less than 15 months – “just stood up and walked one day-no preliminary creeping.”  He has had none of the usual children’s diseases.

Charles is the oldest of three children.  The father, a high-school graduate and a clothing merchant, is described as a “self-made, gentle, calm, and placid person.”  The mother has “a successful business record, theatrical booking office in New York, of remarkable equanimity.” The other two children were 28 and 14 months old at the time of Charles’ visit to the Clinic.  The maternal grandmother, “very dynamic, forceful, hyperactive, almost hypomanic,” has done some writing and composing.  A maternal aunt, “psychoneurotic, very brilliant, given to hysterics,” has written poems and songs.  Another aunt was referred to as “the amazon of the family.”  A maternal uncle, a psychiatrist, has considerable musical talent.  The paternal relatives are described as “ordinary simple people.”

Charles was a well developed, intelligent-looking ·boy, who was in good physical health.  He wore glasses. When he entered the office, he paid not the slightest attention to the people present (three physicians, his mother, and his uncle).  Without looking at anyone, he said, “Give me a pencil!” and took a piece of paper from the desk and wrote something resembling a figure 2 (a large desk calendar prominently displayed a figure 2; the day was February 2). He had brought with him a copy of Readers Digest and was fascinated by a picture of a baby.  He said, “Look at the funny baby,” innumerable times, occasionally adding, “Is he not funny? Is  he not sweet?”

When the book was taken away from him, he struggled with the hand that held it, without looking at the person who had taken the book.  When he was pricked with a pin, he said, “What’s this?” and answered his own question:  “It is a needle.”       

He looked timidly at the pin, shrank from further pricks, but at no time did he seem to connect the pricking with the person who held the pin.  When the Readers Digest was taken from him and thrown on the floor and a foot placed over it, he tried to remove the foot as if it were another detached and interfering object, again with no concern for the person to whom the foot belonged.  He once turned to his mother and excitedly said, “Give it to you!”

When confronted with the Seguin form board, he was mainly interested in the names of the forms, before putting them into their appropriate holes.  He often spun the forms around, jumping up and down excitedly while they were in motion. The whole performance was very repetitious.  He never used language as a means of communicating with people.  He remembered names, such as “octagon,” “diamond,” “oblong block,” but nevertheless kept asking, “What is this?”  

He did not respond to being called and did not look at his mother when she spoke to him.  When the blocks were removed, he screamed, stamped his feet, and cried, “I’ll give it to you!” (meaning “You give it to me”). He was very skillful in his movements.

Charles was placed at the Devereux Schools.

Case 10.   
John F. was first seen on February 13, 1940, at 2 years, 4 months of age.  The father said:

“The main thing that worries me is the difficulty in feeding.  That is the essential thing, and secondly his slowness in development. During the first days of life he did not take the breast satisfactorily.  After fifteen days he was changed from breast to bottle but did not take the bottle satisfactorily.  There is a long story of trying to get food down.  We have tried everything under the sun. He has been immature all along.  At 20 months he first started to walk.  He sucks his thumb and grinds his teeth quite frequently and rolls from side to side before sleeping.  If we don’t do what he wants, he will scream and yell.”

John was born September 19, 1937; his birth weight was 7½ pounds.  There were frequent hospitalizations because of the feeding problem.  No physical disorder was ever found, except that the anterior fontanelle did not close until he was 2½ years of age.  He suffered from repeated colds and otitis media, which necessitated bilateral myringotomy.

John was an only child until February, 1943.  The father, a psychiatrist, is “a very calm, placid, emotionally stable person, who is the soothing element in the family.”  The mother, a high school graduate, worked as secretary in a pathology laboratory before marriage – “a-hypomanic type of person; sees everything as a pathological specimen rather than well; throughout the pregnancy she was very apprehensive, afraid she would not live through the labor.”  The paternal grandmother is “obsessive about religion and washes her hands every few minutes.” The maternal grandfather was an accountant.

John was brought to the office by both parents.  He wandered about the room constantly and aimlessly.  Except for spontaneous scribbling, he never brought two objects into relation to each other.  He did not respond to the simplest commands, except that his parents with much difficulty elicited bye-bye, pat-a-cake, and peek-a-boo gestures, performed clumsily.  His typical attitude toward objects was to throw them on the floor.

Three months later, his vocabulary showed remarkable improvement, though his articulation was defective.  Mild obsessive trends were reported, such as pushing aside the first spoonful of every dish.  His excursions about the office were slightly more purposeful.

At the end of his fourth year, he was able to form a very limited kind of affective contact, and even that only with a very limited number of people.  Once such a relationship had been established, it had to continue in exactly the same channels.  He was capable of forming elaborate and grammatically correct sentences, but he used the pronoun of the second person when referring to himself.  He used language not as a means of communication but mainly as a repetition of things he had heard, without alteration of the personal pronoun. There was very marked obsessiveness.  Daily routine must be adhered to rigidly; any slightest change of the pattern called forth outbursts of panic.  There was endless repetition of sentences.  He had an excellent rote memory and could recite many prayers, nursery rhymes, and songs “in different languages”; the mother did a great deal of stuffing in this respect and was very proud of these “achievements”: “He can tell victrola records by their color and if one side of the record is identified, he remembers what is on the other side.”

At 4½ years, he began gradually to use pronouns adequately.  Even though his direct interest was in objects only, he took great pains in attracting the attention of the examiner (Dr. Hilde Bruch) and in gaining her praise.  However, he never addressed her directly and spontaneously.  He wanted to make sure of the sameness of the environment literally by keeping doors and windows closed.  When his mother opened the door “to pierce through his obsession,” he became violent in closing it again and finally, when again interfered with, burst helplessly into tears, utterly frustrated.

He was extremely upset upon seeing anything broken or incomplete.  He noticed two dolls to which he had paid no attention before.  He saw that one of them had no hat and became very much agitated, wandering about the room to look for the hat.  When the hat was retrieved from another room, he instantly lost all interest in the dolls.

At 5½ years, he had good mastery of the use of pronouns. He had begun to feed himself satisfactorily.  He saw a group photograph in the office and asked his father, “When are they coming out of the picture and coming in here?”

He was very serious about this. His father said something about the pictures they have at home on the wall. This disturbed John somewhat.  He corrected his father: “We have them near the  wall” (“on” apparently meaning to him “above” or “on top”).

When he saw a penny, he said, “Penny. That’s where you play tenpins.”  He had been given pennies when he knocked over tenpins while playing with his father at home.

He saw a dictionary and said to his father, “That’s where you left the money?”  Once his father had left some money in a dictionary and asked John to tell his mother about it.  His father whistled a tune and John instantly and correctly identified it as “Mendelssohn’s violin concerto.”  Though he could speak of things as big or pretty, he was utterly incapable of making comparisons (“Which is the bigger line? Prettier face?” etc.).

In December, 1942, and January, 1943, he had two series of predominantly right-sided convulsions, with conjugate deviation of the eyes to the right and transient paresis of the right arm.  Neurologic examination showed no abnormalities.  His eyegrounds were normal.  An electroencephalogram indicated “focal disturbance in the left occipital region,” but “a  good part of the  record could not be read because of the continuous marked artefacts due to the child’s lack of cooperation.”

Case 11.
Elaine C. was brought by her parents on April 12, 1939, at  the  age of 7 years, 2 months,  because of  “unusual development”:  “She doesn’t adjust.  She stops at all abstractions.  She doesn’t understand other children’s games, doesn’t retain interest in stories read to her, wanders off and walks by herself, is especially fond of animals of all kinds, occasionally mimics them by walking on all fours and making strange noises.”

Elaine was born on February 3, 1932, at term.  She appeared healthy, took feedings well, stood up at 7 months and walked at less than a year.  She could say four words at the end of her first year but made no progress in linguistic development for the following four years.  Deafness was suspected but ruled out.  Because of a febrile illness at 13 months, her increasing difficulties were interpreted as possible postencephalitic behavior disorder.  Others blamed the  mother, who was accused of inadequate handling of the child.  Feeblemindedness was another diagnosis. For eighteen months, she was given anterior pituitary and thyroid preparations. “Some doctors,” struck by Elaine’s intelligent physiognomy, “thought she was a normal child and said that she would outgrow this.”

At 2 years, she was sent to a nursery school, where “she independently went her way, not doing what the others did.  She, for instance, drank the water and ate the plant when they were being taught to handle flowers.”  She developed an early interest in pictures of animals.  Though generally restless, she could for hours concentrate on looking at such pictures, “especially engravings.”

When she began to speak at about 5 years, she started out with complete though simple sentences that were “mechanical phrases” not related to the situation of the moment or related to it in a peculiar metaphorical way.  She had an excellent vocabulary, knew especially the names and “classifications” of animals.

She did not use pronouns correctly, but used plurals and tenses well.  She “could not use negatives but recognized their meaning when others used them.”  There were many peculiarities in her relation to situations:

She can count by rote. She can set the table for numbers of people if the names are given her or enumerated in any way, but she cannot set the table “for three.”  If sent for a specific object in a certain place, she cannot bring it if it is somewhere else but still visible.

She was “frightened” by noises and anything moving toward her.  She was so afraid of the vacuum cleaner that she would not even go near the closet where it was kept, and when it was used, ran out into the garage, covering her ears with her hands.

Elaine was the older of two children.  Her father, aged 36, studied law and the liberal arts in three universities (including the Sorbonne), was an advertising copy writer, “one of those chronically thin persons, nervous energy readily expended.”  He was at one time editor of a magazine.  The mother, aged 32, a “self-controlled, placid, logical person,” had done editorial work for a magazine before marriage. The maternal grandfather was a newspaper editor, the grandmother was “emotionally unstable.”

Elaine had been examined by a Boston psychologist at  nearly 7 years of age.

The report stated among other things:

Her  attitude toward  the examiner  remained  vague and detached.  Even when annoyed by restraint, she might vigorously push aside a table or restraining hand with a scream, but she made no personal appeal for help or sympathy.  At favorable moments she was competent in handling her crayons or assembling pieces to form pictures of animals.  She could name a wide variety of pictures, including elephants, alligators, and dinosaurs.  She used language in simple sentence structure, but rarely answered a direct question.  As she plays, she repeats over and over phrases which are irrelevant to the immediate situation.

Physically the child was in good health.  Her electroencephalogram was normal.

When examined in April, 1939, she shook hands with the physician upon request, without looking at him, then ran to the window and looked out.  She automatically heeded the invitation to sit down. Her reaction to questions – after several repetitions – was an echolalia type reproduction of the whole question or, if it was too lengthy, of the end portion.  She had no real contact with the persons in the office.  Her expression was blank, though not unintelligent, and there were no communicative gestures.  At one time; without changing her physiognomy, she said suddenly: “Fishes don’t cry.”  After a time, she got up and left

the room without asking or showing fear.

She was placed at the Child Study Home of Maryland, where she remained for three weeks and was studied by Drs. Eugenia S. Cameron and George Frankl.  While there she soon learned the names of all the children, knew the color of their eyes, the bed in which each slept, and many other details about them, but never entered into any relationship with them.  When taken to the playgrounds, she was extremely upset and ran back to her room.  She was very restless but when allowed to look at pictures, play alone with blocks, draw, or string beads, she could entertain herself contentedly for hours.  Any noise, any interruption disturbed her.  Once, when on the toilet seat, she heard a knocking in the pipes; for several days thereafter, even when put on a chamber pot in her own room, she did not move her bowels, anxiously listening for the noise.  She frequently ejaculated stereotyped phrases, such as, “Dinosaurs don’t cry”; “Crayfish, sharks, fish, and rocks”; “Crayfish and forks live in children’s tummies”; “Butterflies live in children’s stomachs,, and in their panties, too”; “Fish have sharp teeth and bite little children”; “There is war in the sky”; “Rocks and crags,  I will kill” (grabbing her blanket and kicking it about the bed); “Gargoyles bite children and drink oil”; “I will crush old angle worm, he bites children” (gritting her teeth and spinning around in a circle, very excited); “Gargoyles have milk bags”; “Needle head. Pink wee-wee. Has a yellow leg. Cutting the dead deer. Poison deer. Poor Elaine. No tadpoles in the house. Men broke deer’s leg” (while cutting the picture of a deer from a book); “Tigers and cats”; “Seals and salamanders”; “Bears and foxes.”

A few excerpts from the observations follow:

Her language always has the same quality.  Her speech is never accompanied by facial expression or gestures.  She does not look into one’s face.  Her voice is peculiarly unmodulated, somewhat hoarse; she utters her words in an abrupt manner. 

Her utterances are impersonal. She never uses the personal pronouns of the first and second persons correctly.  She does not seem able to conceive the real meaning of these words.

Her grammar is inflexible.  She uses sentences just as she has heard them, without adapting them grammatically to the situation of  the  moment.  When she says, ”Want me to draw a spider,” she means, “I want you to draw spider.”

She affirms by repeating a question literally, and she negates by not complying.

Her speech rarely communicative.  She has no relation to children, has never talked to them, to be friendly with them, or to play with them.  She moves among them like a strange being, as one moves between the pieces of furniture of a room.

She insists on the repetition of the  same routine always.  Interruption of  the routine is one of the most frequent occasions for her outbursts.  Her own activities are simple and repetitious.  She is able to spend hours in some form of daydreaming and seems to be very happy with it.  She is inclined to rhythmical movements which always are masturbatory.  She masturbates more in periods of excitement than during calm happiness . . . Her movements are quick and skillful.

Elaine was placed in a private school in Pennsylvania. In a ·recent letter, the father reported “rather amazing changes”:

She is a tall, husky girl with clear eyes that have long since lost any trace of that animal wildness they periodically showed in the time you knew her.  She speaks well on almost any subject, though with something of  an odd intonation.  Her conversation is still rambling talk, frequently with an amusing point, and it is only occasional, deliberate, and announced. She reads very well, but she reads fast, jumbling words, not pronouncing clearly, and not making proper emphases.  Her range of information is really quite wide, and her memory almost infallible. It is obvious that Elaine is not “normal.”  Failure in anything leads to a feeling of defeat, of despair, and to a momentary fit of depression.

DISCUSSION

The eleven children (eight boys and three. girls) whose histories have been briefly presented offer, as is to be expected, individual differences in the degree of their disturbance, the manifestation of specific features, the family constellation, and the step-by-step development in the course of years.  But even a quick review of the material makes the emergence of a number of essential common characteristics appear inevitable.  These characteristics form a unique “syndrome,” not heretofore reported, which seems to be rare enough, yet is probably more frequent than is indicated by the paucity of observed cases.  It is quite possible that some such children have been viewed as feebleminded or schizophrenic.  In fact, several children of our group were introduced to us as idiots or imbeciles, one still resides in a state school for the feebleminded, and two had been previously considered as schizophrenic.

The outstanding, “pathognomonic,” fundamental disorder is the children’s inability to relate themselves in the ordinary way to people and situations from the beginning of life.  Their parents referred to them as having always been “self-sufficient”; “like in a shell”; “happiest when left alone”; “acting as if people weren’t there”; “perfectly oblivious to everything about him”; “giving the impression of silent wisdom”; “failing to develop the usual amount of social awareness”; “acting almost as if hypnotized.”  This is not, as in schizophrenic children or adults, a departure from an initially present relationship; it is not a “withdrawal” from formerly existing participation.  There is from the start an extreme autistic aloneness that, whenever possible, disregards, ignores, shuts out anything that comes to the child from the outside.  Direct physical contact or such motion or noise as threatens to disrupt the aloneness is either treated “as if it weren’t there” or, if this is no longer sufficient, resented painfully as distressing interference.

According to Gesell, the average child at 4 months of age makes an anticipatory motor adjustment by facial tension and shrugging attitude of the shoulders when lifted from a table or placed on a table, Gesell commented:

It is possible that a less definite evidence of such adjustment may be found as low down as the neonatal period.  Although a habit must be conditioned by experience, the opportunity for experience is almost universal and the response is sufficiently objective to merit further observation and record.

This universal experience is supplied by the frequency with which an infant is picked up by his mother and other persons.  It is therefore highly significant that almost all mothers of our patients recalled their astonishment at the children’s failure to assume at any time an anticipatory posture preparatory to being picked up.  One father recalled that his daughter (Barbara) did not for years change her physiognomy or position in the least when the parents, upon coming home after a few hours’ absence, approached her crib talking to her and making ready to pick her up.

The average infant learns during the first few months to adjust his body to the posture of the person who holds him.  Our children were not able to do so for two or three years.  We had an opportunity to observe 38-month-old Herbert in such a situation.  His mother informed him in appropriate terms that she was going to lift him up, extending her arms in his direction. There was no response.  She proceeded to take him up, and he allowed her to do so, remaining completely passive as if he were a sack of flour.  It was the mother who had to do all the ad­ jesting.  Herbert was at that time of capable of sitting, standing, and walking.

Eight of the eleven children acquired the ability to speak either at the usual age 1 or after some delay.  Three (Richard, Herbert, Virginia) have so far remained “mute.”  In none of the eight “speaking” children has language over a period of years served to convey meaning to others. They were, with the exception of John F., capable of clear articulation and phonation.  Naming of objects presented no difficulty; even long and unusual words were learned and retained with remarkable facility.  Almost all the parents reported, usually with much pride, that the children had learned at an early age to repeat an inordinate number of nursery rhymes, prayers, lists of animals, the roster of presidents, the alphabet forward and backward, even foreign-language (French) lullabies.  Aside from the recital of sentences contained in the ready-made poems or other remembered pieces, it took a long time before they began to put words together. Other than that, “language” consisted mainly of “naming,” of nouns identifying objects, adjectives indicating colors, and numbers indicating nothing specific.

Their excellent rote memory, coupled with the inability to use language in any other way, often led the parents to stuff them with more and more verses, zoologic and botanic names, titles and composers of victrola record pieces, and the like.  Thus, from the start, language – which the children did not use for the purpose of communication – was deflected in a considerable measure to a self-sufficient, semantically and conversationally valueless or grossly distorted memory exercise.  To a child 2 or 3 years old, all these words, numbers, and poems (“questions and answers of the Presbyterian  Catechism”;  “Mendelssohn’s violin concerto”; the Twenty-third Psalm”; a French lullaby; an encyclopedia index page) could hardly have more meaning than sets of nonsense syllables to adults.  It is difficult to know for certain whether the stuffing as such has contributed essentially to the course of the psychopathologic condition.  But it is also difficult to imagine that it did not cut deeply into the development of language as a tool for receiving and imparting meaningful messages.

As far as the communicative functions of speech are concerned, there is no fundamental difference between the eight speaking and the three mute children.  Richard was once overheard by his boarding mother to say distinctly, “Good night.”  Justified skepticism about this observation was later dispelled when this “mute” child was seen in the office shaping his mouth in silent repetition of words when asked to say certain things. “Mute” Virginia – so he . cottage mates insisted – was heard repeatedly to say, “Chocolate”; “Marshmallow”; “Mama”; “Baby.”

When sentences are finally formed, they are for a long time mostly parrot-like repetitions of heard word combinations.  They are sometimes echoed immediately, but they are just as often “stored” by the child and uttered at a later date.  One may, if one wishes, speak of delayed echolalia.  Affirmation is indicated by literal repetition of a question. “Yes” is a concept that it takes the children many years to acquire.  They are incapable of using it as a general symbol of assent.  Donald learned to say “Yes” when his father told him that he would put him on his shoulders if he said “Yes.” This word then came to “mean” only the desire to be put on his father’s shoulders.  It took many months before he could detach the word “yes” from this specific situation, and it took much longer before he was able to use it as a general term of affirmation.

The same type of literalness exists also with regard to prepositions.  Alfred, when asked, “What is this picture about?” replied: “People are moving about.”  John F. corrected his father’s statement about pictures on the wall; the pictures were “near the wall.”  Donald T., requested to put something down, promptly put in on the floor.  Apparently the meaning of a word becomes inflexible and cannot be used with any but the originally acquired connotation.

There is no difficulty with plurals and tenses.  But the absence of spontaneous sentence formation and the echolalia type reproduction has, in every one of the eight speaking children, given rise to a peculiar grammatical phenomenon.  Personal pronouns are repeated just as heard, with no change to suit the altered situation.  The child, once told by his mother, “Now I will give you your milk,” expresses the desire for milk in exactly the same words.  Consequently, he comes to speak of himself always as “you,” and of the person addressed as “I”.   Not only the words, but even the intonation is retained.  If the mother’s original remark has been made in form of a question, it is reproduced with the grammatical form and the inflection of a question. The repetition “Are you ready for your dessert?” means that the child is ready for his dessert. There is a set, not-to-be-changed phrase for every specific occasion.  The pronominal fixation remains until about the sixth year of life, when the child gradually learns to speak of himself in the first person, and of the individual addressed in the second person.  In the transitional period, he sometimes still reverts to the earlier form or at times refers to himself in the third person.

The fact that the children echo things heard does not signify that they “attend” when spoken to. It often takes numerous reiterations of a question or command before there is even so much as an echoed response.  Not less than seven of the children were therefore considered as deaf or hard of hearing.  There is an all-powerful need for being left undisturbed.  Everything that is brought to the child from the outside, everything that changes his external or even internal environment, represents a dreaded intrusion.

Food is the earliest intrusion that is brought to the child from the outside.  David Levy observed that affect-hungry children, when placed in foster homes where they are well treated, at first demand excessive quantities of food.  Hilde Bruch, in her studies of obese children, found that overeating often result d when affectionate offerings from the parents were lacking or considered unsatisfactory.  Our patients, reversely, anxious to keep the outside world away, indicated this by the refusal of food.  Donald, Paul (“vomited a great deal during the first year”), Barbara (“had to be tube-fed until 1 year of age”), Herbert, Alfred, and John presented severe feeding difficulty from the beginning of life.  Most of them, after an unsuccessful struggle, constantly interfered with, finally gave up the struggle and of a sudden began eating satisfactorily.

Another intrusion comes from loud noises and moving objects, which are therefore reacted to with horror.  Tricycles, swings, elevators, vacuum cleaners, running water, gas burners, mechanical toys, egg beaters, even the wind could on occasions bring about a major panic.  One of the children was even afraid to go near the closet in which the vacuum cleaner was kept.  Injections and examinations with stethoscope or otoscope created a grave emotional crisis.  Yet it is not the noise or motion itself that is dreaded.  The disturbance comes from the noise or motion that intrudes itself, or threatens to intrude itself, upon the child’s aloneness.  The child himself can happily make as great a noise as any that he dreads and move objects about to his heart’s desire.

But the child’s noises and motions and all of his performances are as monotonously repetitious as are his verbal utterances.  There is a marked limitation in the variety of his spontaneous activities.  The child’s behavior is governed by an anxiously obsessive desire for the maintenance of sameness that nobody but the child himself may disrupt on rare occasions.  Changes of routine, of furniture arrangement, of a pattern, of  the order in which every day acts are carried out, can drive him to despair.  When John’s parents got ready to move to a new home, the child was frantic when he saw the moving men roll up the rug in his room.  He was acutely upset until the moment when, in the new home, he saw his furniture arranged in the same manner as before.  He looked pleased, all anxiety was suddenly gone, and he went around affectionately patting each piece.  Once blocks, beads, sticks have been put together in a certain way, they are always regrouped in exactly the same way; even though there was no definite design.  The children’s memory was phenomenal in this respect.  After the lapse of several days, a multitude of blocks could be rearranged in precisely the same unorganized pattern, with the same color of each block turned up, with each picture or letter on the upper surface of each block facing in the same direction as before.  The absence of a block or the presence of a supernumerary block was noticed immediately, and there was an imperative demand for the restoration of the missing piece.  If someone removed a block, the child struggled to get it back, going into a panic tantrum until he regained it, and then promptly and with sudden calm after the storm returned to the design and replaced the block.

This insistence on sameness led several of the children to become greatly disturbed upon the sight of-anything broken or incomplete.  A great part of the day was spent in demanding not only the sameness of the wording of a request but also the sameness of the sequence of events.  Donald would not leave his bed after his nap until after he had said, “Boo, say ‘Don, do you want to get down?'” and the mother had complied.  But this was not all.  The act was still not considered completed.  Donald would continue, “Now say ‘All right.'”  Again the mother had to comply, or there was screaming until the performance was completed.  All of this ritual was an indispensable part of the act of getting up after a nap.  Every other activity hadto be completed from beginning to end in the manner in which it had been started originally.  It was impossible to return from a walk without having covered the same ground as had been covered before.  The sight of a broken crossbar on a garage door on his regular daily tour so upset Charles that he kept talking and asking about it for weeks on end, even while spending a few days in a distant city.  One of the children noticed a crack in the office ceiling and kept asking anxiously and repeatedly who had cracked the ceiling, not calmed by any answer given her.  Another child, seeing one doll with a hat and another without a hat, could not be placated until the other hat was found and put on the doll’s head.  He then immediately lost interest in the two dolls; sameness and completeness had been restored, and all was well again.

The dread of change and incompleteness seems to be a major factor in the explanation of the monotonous repetitiousness and the resulting limitation in the variety of spontaneous activity.  A situation, a performance, a sentence is not regarded as complete if it is not made up of exactly the same elements that were present at the time the child was first confronted with it.  If the slightest ingredient is altered or removed, the total situation is no longer the same and therefore is not accepted as such, or it is resented with impatience or even with a reaction of profound frustration.  The inability to experience wholes without full attention to the constituent parts is somewhat reminiscent of the plight of children with specific reading disability who do not respond to the modern system of configurational reading instruction but must be taught to build up words from their alphabetic elements.  This is perhaps one of the reasons why those children of our group who were old enough to be instructed in reading immediately became excessively preoccupied with the “spelling” of words, or why Donald, for example, was so disturbed over the fact that “light” and bite,” having the same phonetic quality, should be spelled differently.

Objects that do not change their appearance and position, that retain their sameness and never threaten to interfere with the child’s aloneness, are readily accepted by the autistic child.  He has a good relation to objects; he is interested in them, can play with them happily for hours. He can be very fond of them, or get angry at them if, for instance, he cannot fit them into a certain space.  When with them, he has a gratifying sense of undisputed power and control. Donald and Charles began in the second year of life to exercise this power by spinning everything that could be possibly spun and jumping up and down in ecstasy when they watched the objects whirl about.  Frederick “jumped up and down in great glee” when he bowled and saw the pins go down.  The children sensed and exercised the same power over their own bodies by rolling and other rhythmic movements.  These actions and the accompanying ecstatic fervor strongly indicate the presence of masturbatory orgiastic gratification.

The children’s relation to people is altogether different.  Every one of the children, upon entering the office, immediately went after blocks, toys, or other objects, without paying the least attention to the persons present.  It would be wrong to say that they were not aware of the presence of persons.  But the people, so long as they left the child alone, figured in about the same manner as did the desk, the bookshelf, or the filing cabinet.  When the child was addressed, he was not bothered.  He had the choice between not responding at all or, if a question was repeated too insistently, “getting it over with” and continuing with whatever he had been doing.  Comings and goings, even of the mother, did not seem to register. Conversation going on in the room elicited no interest.  If the adults did not try to enter the child’s domain, he would at times, while moving between them, gently touch a hand or a knee as on other occasions he patted the desk or the couch.  But he never looked into anyone’s face.  If an adult forcibly intruded himself by taking a block away or stepping on an object that the child needed, the child struggled and became angry with the hand or the foot, which was dealt with per se and not as a part of a person.  He never addressed a word or a look to the owner of the hand or foot.  When the object was retrieved, the child’s mood changed abruptly to one of placidity.  When pricked, he showed fear of the pin but not of the person who pricked him.  ·

The relation to the members of the household or to other children did not differ from that to the people at the office.  Profound aloneness dominates all behavior.  The father or mother or both may have been away for an hour or a month; at their homecoming, there is no indication that the child has been even aware of their absence.  After many outbursts of frustration, he gradually and reluctantly learns to compromise when he finds no way out, obeys certain orders, complies in matters of daily routine, but always strictly insists on the observance of his rituals.  When there is company, he moves among the people “like a stranger” or, as one mother put it, “like a foal who had been let out of an enclosure.”  When with other children, he does not play with them.  He plays alone while they are around, maintaining no bodily, physiognomic, or verbal contact with them.  He does not take part in competitive games.  He just is there, and if sometimes he happens to stroll as far as the periphery of a group, he soon removes himself and remains alone.  At the same time, he quickly becomes familiar with the names of all the children of the group, may know the color of each child’s hair, and other details about each child.

There is a far better relationship with pictures of people than with people themselves. Pictures, after all, cannot interfere.  Charles was affectionately interested in the picture of a child in a magazine advertisement.  He remarked repeatedly about the child’s sweetness and beauty.  Elaine was fascinated by pictures of animals but would not go near a live animal.  John made no distinction between real and depicted people.  When he saw a group photograph, he asked seriously when the people would step out of the picture and come into the room.

Even though most of these children were at one time or another looked upon as feebleminded, they are all unquestionably endowed with good cognitive potentialities.  They all have strikingly intelligent physiognomies. Their faces at the same time give the impression of serious-mindedness and, in the presence of others, an anxious tenseness, probably because of the uneasy anticipation of possible interference.  When alone with objects, there is often a placid smile and an expression of beatitude, sometimes accompanied by happy though monotonous humming and singing.  The astounding vocabulary of the speaking children, the excellent memory for events of several years before, the phenomenal rote memory for poems and names, and the precise recollection of complex patterns and sequences, bespeak good intelligence in the sense in which this word is commonly used. Binet or similar testing could not  be carried out because of limited accessibility.  But all the children did well with the Seguin form board.

Physically, the children were essentially normal.  Five had relatively large heads.  Several of the children were somewhat clumsy in gait and gross motor performances, but all were very skillful in terms of finer muscle coordination.  Electroencephalograms were normal in the case of all but John, whose anterior fontanelle did not close until he was 2½ years old, and who at 5¼ years had two series of predominantly right-sided convulsions.  Frederick had a super­numerary nipple in the left axilla; there were no other instances of congenital anomalies.

There is one other very interesting common denominator in the backgrounds of these children. They all come of highly intelligent families.  Four fathers are psychiatrists, one is a brilliant lawyer, one a chemist and law school graduate employed bythe government Patent Office, one a plant pathologist, one a professor of forestry, one an advertising copy writer who has a degree in law and has studied in three universities, one is a mining engineer, and one a successful business man.  Nine of the eleven mothers are college graduates.  Of the two who have only high school education, one was secretary in a pathology laboratory, and the other ran a theatrical booking office in New York City before marriage.  Among the others, there was a free-lance writer, a physician, a psychologist, a graduate nurse, and Frederick’s mother was successively a purchasing agent, the director of secretarial studies in a girls’ school, and a teacher of history.  Among the grandparents and collaterals there are many physicians, scientists, writers, journalists, and students of art.  All but three of the families are represented either in Who’s Who in America or in American Men of Science, or in both.

Two of the children are Jewish, the others are all of Anglo-Saxon descent.  Three are “only” children, five are the first-born of two children in their respective families, one is the oldest of three children, one is the younger of two, and one the youngest of three.

COMMENT

The combination of extreme autism, obsessiveness, stereotypy, and echolalia brings the total picture into relationship with some of the basic schizophrenic phenomena.  Some of the children have indeed been diagnosed as of this type at one time or another.  But in spite of the remarkable similarities, the condition differs in many respects from all other known instances of childhood schizophrenia.

First of all, even in cases with the earliest recorded onset of schizophrenia, including those of De Sanctus dementia praecocissima and of Heller’s dementia infantilis, the first observable manifestations were preceded by at least two years of essentially average development; the histories specifically emphasize a more or less gradual change in the patients’ behavior.  The children of our group have all shown their extreme aloneness from the very beginning of life, not responding to anything that comes to them from the outside world.  This is most characteristically expressed in the recurrent report of failure of the child to assume an anticipatory posture upon being picked up, and of failure to adjust the body to that of the person holding him.

Second, our children are able to establish and maintain an excellent, purposeful, and “intelligent” relation to objects that do not threaten to interfere with their aloneness, but are from the start anxiously and tensely impervious to people, with whom for a long time they do not have any kind of direct affective contact.  If dealing with another person becomes inevitable, then a temporary relationship is formed with the person’s hand or foot as a definitely detached object, but not with the person himself.

All of the children’s activities and utterances are governed rigidly and consistently by the powerful desire for aloneness and sameness.  Their world must seem to them to be made up of elements that, once they have been experienced in a certain setting or sequence, cannot be tolerated in any other setting or sequence; nor can the setting or sequence be tolerated without all the original ingredients in the identical spatial or chronologic order.  Hence the obsessive repetitiousness.  Hence the reproduction of sentences without altering the pronouns to suit the occasion.  Hence, perhaps, also the development of a truly phenomenal memory that enables the child to recall and reproduce complex “nonsense” patterns, no matter how unorganized they are, in exactly the same form as originally construed.

Five of our children have by now reached ages between 9 and 11 years.  Except for Vivian S., who has been dumped in a school for the feebleminded, they show a very interesting course.  The basic desire for aloneness and sameness has remained essentially unchanged, but there has been a varying degree of emergence from solitude, an acceptance of at least some people as being within the child’s sphere of consideration, and a sufficient increase in the number of experienced patterns to refute the earlier impression of extreme limitation of the child’s ideational content.  One might perhaps put it this way:  While the schizophrenic tries to solve his problem by stepping out of a world of which he has been a part and with which he has been in touch, our children gradually compromise by extending cautious feelers into a world in which they have been total strangers from the beginning.  Between the ages of 5 and 6 years, they gradually abandon the echolalia and learn spontaneously to use personal pronouns with adequate reference.  Language becomes more communicative, at first in the sense of a question-and-answer exercise, and then in the sense of greater spontaneity of sentence formation.  Food is accepted without difficulty.  Noises and motions are tolerated more than previously.  The panic tantrums subside.  The repetitiousness assumes the form of obsessive preoccupations.  Contact with a limited number of people is established in a twofold way: people are included in the child’s world to the extent to which they satisfy his needs, answer his obsessive questions, teach him how to read and to do things.  Second, though people are still regarded as nuisances, their questions are answered and their commands are obeyed reluctantly, with the implication that it would be best to get these interferences over with, the sooner to be able to return to the still much desired aloneness.  Between the ages of 6 and 8 years, the children begin to play in a group, still never with the other members of the play .group, but at least on the periphery alongside the group.  Reading skill is acquired quickly, but the children read monotonously, and a story or a moving picture is experienced in unrelated portions rather than in its coherent totality.  All of this makes the family feel that, in spite of recognized “difference” from other children, there is progress and improvement.

It is not easy to evaluate the fact that all of ourpatients have come of highly intelligent parents. This much is certain, that there is a great deal of obsessiveness in the family background.  The very detailed diaries and reports and the frequent remembrance, after several years, that the children had learned to recite twenty-five questions and answers of the Presbyterian Catechism, to sing thirty-seven nursery songs, or to discriminate between eighteen symphonies, furnish a telling illustration of parental obsessiveness.

One other fact stands out prominently. In the whole group, there are very few really warmhearted fathers and mothers.  For the most part, the parents, grandparents, and collaterals are persons strongly preoccupied with abstractions of a scientific, literary, or artistic nature, and limited in genuine interest in people.  Even some of the happiest marriages are rather cold and formal affairs.  Three of the marriages were dismal failures.  The question arises whether or to what extent this fact has contributed to the condition of the children.  The children’s aloneness from the beginning of life makes it difficult to attribute the whole picture exclusively to the type of the early parental relations with our patients.

We must, then, assume that these children have come into the world with innate inability to form the usual, biologically provided affective contact with people, just as other children come into the world with innate physical or intellectual handicaps.  If this assumption is correct, a further study of our children may help to furnish concrete criteria regarding the still diffuse notions about the constitutional components of emotional reactivity.  For here we seem to have pure-culture examples of inborn autistic disturbances of affective contact.*

* Since the completion of this paper, 2 more cases of inborn autistic disturbance of affective contact have come under our observation.

MASTER’S THESIS

AUTISM AND  SELF-DEFILING PHENOMENA

by R. L. Cima

Cal State Fullerton – Counseling 536 – Department:  Counseling/Psychology.

Submitted:  December 1982

DEFINITION
The term autism comes from the Greek autos, meaning oneself, and ismos, meaning characteristic of.  It has been translated as morbid concentration.  A Swiss psychiatrist, Paul Eugen Bleuler, was the first to use the word autistic as an adjective to describe his patients’ “psychotic image of their being.” (Ritvo, 1976, pg. 8).  At the time this phenomenon was called Childhood Schizophrenia, Symbiotic Psychosis, and Atypical Ego Development.

The algolagnic (hurt luster) presents a rather unique set of symptoms and is perhaps why Keirsey refers to the ISFP as “the most misunderstood of all types.”  In no other set of symptoms are the subjective interpretations of others so critical to determine pathology.  The idea of someone doing something harmful to their own well-being assumes the observer knows and understands what the well-being is for the person observed.

Reviewing the investigated literature, the over-riding concern is to understand symptomology using the various familiar models and theories.  The attempt here is to report phenomenological behavior and to search for the commonality of behaviors in autism, vagrancy, fetishism and masochism.  As the literature was somewhat sketchy as to etiology, except for autism, it will become obvious this writer’s ideas have filled in the gaps. These ideas will be noted.

In Dr. Leo Kanner’s book, Autistic Disturbances of Affective Contact (1943), he first used the word as a noun, referring to this phenomenon as Early Infantile Autism.  From that beginning, when autism was first described as a medical disturbance, all literature has taken its lead.  Based on eleven observed cases he summarized: “The outstanding pathognomonic, fundamental disorder is the children’s inability to relate themselves in the ordinary way to people and situations from the beginning of life” (Kanner, 1943, pg. 5). There is, he would note, from the beginning, an extreme autistic aloneness.

To begin to describe the symptoms of autism, it was noticed in virtually every publication investigated these symptoms were termed “bizarre.”  Doubleday Dictionary (l975) defines bizarre as “exceedingly odd,” with synonyms that include “fantastic,” “outlandish,” “grotesque,” and “freakish.”  Indeed, as seen by an objective observer, these overt behaviors, or lack of proper overt behaviors, could be viewed as strange and alien.  Moreover, from this writer‘s analysis, there are certain symptoms that can easily be construed as talent rather than symptoms, and these views will be given.

SYMPTOMS
The parents of autistic children commonly summarize their concerns by noting their children are “self-sufficient,” “like in a shell,” “happiest when left alone,” “acting as if people weren’t there,” “perfectly oblivious to everything about them,” “giving the impression of silent wisdom,” (Kanner, l943, pg. 18).  Additionally, they note the apparent non-affection of their child, and more precisely, the aversive reaction these children seemingly have to being picked up or cuddled. 

In The Autistic Child (1977) by Ivar Lovaas, he reports about a particular autistic child: “His parents became aware that he was different at 3 months, when he seemed to avoid social interaction or contact with adults or other children and was content to remain alone for long periods of time. He would respond to others by screaming and crying. He seemed insensitive to pain. . .”  The summary of symptoms follows:

1.  Extreme Autistic Aloneness.  Without exception, all cases reported these children’s predilection for privacy.  Any disturbance could be met with resistance and/or screaming and crying, and in some cases, tantrums.  Quite often, when alone, these children will engage in head-banging and other self-destructive behavior that, when mediated, meets with the same resistance.

2.  Insistence on the Preservation of Sameness.  This symptom had vague explanations and descriptions, but it appears any environmental change of routine can be very upsetting to these children.  In one case in Your Child is Asleep (1969), the author reports when confronted with the living room where a single small table had been removed, a child maintained a severe tantrum until the table was replaced.  A drive to the doctor’s office must occur along the same route; a new visitor to the household will be met with fear and apprehension above predicted norms.

3.  Child Appears Unoriented (not disoriented).  These children appear detached and disinterested in events about them and may occupy themselves for hours with repetitious activities involving the manipulation of an object or part of his own body (Des Laurers & Carlson, 1969, pgs. 25-27). They may engage in wall scratching, twirling an object, and ritualistic bizarre hand movements.  While doing so they were described by several authors as independent, self-sufficient and self-absorbed.

The particular behaviors of twirling and rocking appears consistently throughout the literature. Spinning in place, walking in a circle, and twirling a toy is very common for autistic children:

“She rocked from foot to foot in her crib so incessantly she wore out several mattresses.  She also spun bar stools and toy wheels, twirled her hair and the strings of her blanket, closely examined minute pieces of lint and dirt, giggled, laughed, and clapped her hands inappropriately and rubbed her own skin, ground her teeth, and looked out of the sides of her eyes” (Lovaas, l977, pg. 80).

Additionally, there seems to be a high degree of fascination with mechanical devices (vacuums, stoves, light switches, faucets), particularly the sounds they emanate as witnessed by an autistic boy of 8 who had a pre-occupation with washing machines.  It seems, upon close observation, he would mimic the sounds of the washing machine, imitating each cycle, taking approximately the proper time for each cycle to finish. (Coffey & Wiener 1967, pg. 20)

As an opinion, what is called “unoriented” by authors may be quite oriented to these children.  A fascination with all their senses, as well be shown, is a common trait.

4.  Eating Difficulties and Peculiar Eating Habits.  While autistic children are described as generally healthy, and particularly beautiful (Des Laurels & Carlson, l969, pg. 30), ingestion is a problem.  It is often reported eating skills develop late and there are often no signs of hunger.  Also, autistic children sometimes refuse to chew and are insistent on certain meals. One girl reportedly refused to ingest anything but milk for the first 6 years of life (Rimland, 1962, pg. 8). Another case spoke of the insistence of one 4-year-old boy to only eat squares of chocolates, and not round pieces (Rimland, l962, pg. 10).  Also, Lovaas (1977) reports a 2-year-old boy who refused to eat objects of certain colors; he would not put anything red in his mouth.  Smelling and licking of objects and people is common.

5.  Physical Ability
Autistic children, when picked up as infants can become either stiff and unpleasant, or lump and listless.  Gross motor skills are not good, and these children may appear clumsy in gait.  However, very often they exhibit a high degree of fine muscle coordination and are quite adept at twirling, spinning, and picking up small objects (DeLaursers & Carlson, l969, pg. 26).  In fact, manual dexterity is said to be extremely well developed by some authors.  Ritvo (l976) reports of a 17-month-old boy who could quite easily catch and throw a ball with either hand.  Tinbergen & Tinbergen (1972) state that autistics have a distortion of motility that can include hyperkinesis, catatonia, and bizarre postures (pg. 8).  Regarding this symptom, there seems to be little follow-up or investigation as to its utility in treatment, with tracking over time non-existent.

6.  Speech
Of all the behaviors of autistics, how they communicate, or don’t communicate, is perhaps the most intriguing, and the most confusing and unusual.  It is reported by several authors speech is non-existent in about 50% of reported cases, with communication taking place by pointing or grunting, or by moving the observer’s hand or body to the desired object.  Indeed, many autistic children are first diagnosed as deaf or dumb or even blind:

“Linda was first suspected to be deaf and blind. She showed no startle response to a loud clap behind her yet would react to the sound of the opening of a gum wrapper.  She would stare at the light on the ceiling or at a point on the wall, and not look at people who approached her, but would look right through them, even when they attempted to distract her” (Lovaas, 1977, pg. 50). 

In the cases where speech does occur, it is said to be quite peculiar, and has four distinct characteristics: a) affirmation by repetition of questions (absence of yes), b) pronominal reversal (absence of I), c) delayed Echolalia, d) Irrelevant and Metaphorical use of language.

a)  Affirmation by Repetition of Question (absence of “yes”).  If asked the question do you want a drink, an autistic child may respond in the affirmative by stating “do you want a drink.”  Several authors make a distinction between this and echolalia, deducing this response as a “yes” to a question rather than simply an echo.

b) Pronominal Reversal (absence of “I”).  When asking for something, or referring to himself, the autistic child is quite likely to use second or third personal pronouns, most often singular, i.e., “you want a piece of candy,” instead of “I want a piece of candy.”  It should also be noted it is very common for speech to be in a monotone, high pitched voice, without use of pronouns, modifying words, or articles. (Coffey & Huber, 1967, pg. 20.)

c) Delayed Echolalia.  As illustrated by the boy who could quite easily mimic the sounds of the cycles of a washing machine, these children possess an ability to remember phrases of speech or sounds, long after they first heard them.  In Psychological Experiments with Acute Children by B. Hermelin and N. 0’Connor (l970), there is much evidence autistics have excellent rote memories.  It was found in their experiments comparing autistic, mongoloid, and normal children, autistics did as well as normal children and did better at rote memory exercises with a list of nonsense words (pg. 18).

d) Irrelevant and Metaphorical Use of Language.  A stimulating, if not poetic, example that caught this writer’s attention that sums up this symptom (or ability!) is seen by a 6-year-old girl who said, “Real is real, touch the ground or wall…dreaming is when you sleep — and imagination is when you are awake” (Coffey & Weiner, 1967, pg. 35).  These children may know “brush and comb,” “shoes and socks,” or “mommy and daddy,” but may have difficulty in labeling the single object, and may interchange the nouns, or more likely use them both when referring to one.  “Bumped the head” was used by one boy when he sought comfort for any type of injury (Rimland, 1963, pg. 48).  One mother reports she once intervened with her 3-year-old son when he was about to do something inappropriate and told him “Don’t throw the (stuffed toy) dog off the balcony.”  For months he would repeat the phrase “don’t throw the dog off the balcony” verbatim whenever he meant “no” (Rim1and, 1962, pg. 50).

Speech, to summarize, may begin early or late, or not at all.  Quite often, as evidenced in A Child Called Noah (Josh Greenfie1d, 1972), a book in diary form by the father of an autistic child, speech may begin, and then, by the age of 3 or 4, disappear.  Speech is said to be of the “peculiar non-communicative kind” (Rimland, 1962, pg. 15), a rather peculiar statement.

To digress, rather than symptomatic, many behaviors expressed can be seen as abilities or talents.  Bizarre to be sure in many cases, nonetheless when described as what they do, as opposed to what they don’t do, or do “bizarrely,” treatment possibilities seem to exist. This will be explored later. 

Much of the literature is contradictory.  In Hermelin and O’Connor’s work (1970) which compared autistic, mongoloid, and normal children, their results were:  

1) Autism is not a marked distinct aloofness from other people.  Autistics respond less frequently and for a shorter period to a whole range of stimuli;

2) Relatively fast adaptation to Iight at the cortical level;

3) Unresponsive to verbal and non-verbal auditory stimuli;

4) Autistics show more activity which is non-stimulus directed and are less able to use visual information in perceptual motor tasks (pg. 350).

Finally, while not described as a symptom, there is a rather remarkable behavior most autistic children seem to possess – marked musical ability.  One of Kanner’s (1943) original cases did in fact become a composer.  In Parents and Children in Autism (Marian K. DeMayer, 1979) it is noted, “observations have been made that autistic children may have some normal or supernormal music abilities” (pg. 141).  Rimland (1964) has also stated special musical abilities are “nearly universal” in autistic children with 15% carrying tunes unusually well, and 15% having unusually well-developed rhythm (pg. 75).  Ritvo (1976) concurred, noting their “excellent memories and music abilities” (pg. 44).  

Indeed, Ritvo describes a boy of 17 months who spontaneously repeated in full an aria from Don Giovanni.  Between 18-36 months he sang “a remarkable repertoire of music, consisting of symphonies by Mozart and Haydn, songs by Schubert and Brahms, selections from Carmen, a Tchaikovsky Piano Concerto, and diversified well known songs” (pg. 80).  Ritvo also described an autistic child who would reorganize a set of blocks with pictures and numbers in precisely the same disorganized pattern days apart, with careful attention to where each block was to be placed, its angle, and where each number and picture belonged.  There are many instances of children completing jigsaw puzzles as readily as when the picture is face down, as face up.

ADDITIONAL CASE STUDIES
Reeve – 2 years 3 months
Normal pregnancy, C-section.  He has frequent ear and respiratory problems, colic, and allergies.  No evidence of neurological disease and no indication of brain damage.  No family history of psychological disorders.  Developmental milestones within normal limits.  His parents became aware he was different at 3 months.  He avoided social interaction with adults and children, remaining alone for hours on end.  He seemed insensitive to pain.  His mother reports he sat up on the operating table during hernia surgery (26 months) and only a few days after the operation attempted to walk up the stairs of his home.  He engaged extensively in self-stimulating activities such as gazing at his hands, at lights, or off into space. He chanted continuously, ran in small circles, rocked frequently in his crib, on the floor, and particularly next to a vacuum cleaner.  He compulsively lined up papers and toys in particular patterns.  He showed some destructive behavior consisting of head banging concentrated on sharp corners of furniture (Lovaas, 1977, pg. 66).

Timmy – 8 years old
“When disturbed he was an extreme head-banger.”  His pediatrician once reported when he went to his home to treat the boy for an earache, Timmy’s terror of the pain caused him to ram his head into a wall.  Though he seemed to show no pain reaction, if accidently hurt even slightly in some other area of his body, “Timmy would fall quite apart and act as though he was mortally wounded” (Coffey & Weiner, l967, pg. 33).

Bobby – (as an adult in an institution)
Born in l940 to a professionally trained father and a mother who later completed a teacher‘s education, Bobby has been mute since birth.  He is insensitive to pain and has not cried since infancy.  He developed no conversational speech but acquired a reading ability of 2000 words, mostly nouns referring to specific objects.  To express his needs, he grunts and points.  He has made no significant progress in any direction since his teens.  Bobby’s sex drive is low, and he does not distinguish between men and women.  He understands the watch and calendar, but money means nothing to him.  He writes words to show their patterns and similarities but not to convey meaning, though he can fill in a single missing word in a sentence (DeMayer, l977, pg. 111).

Mr. A – (Recovered or cured autistic adult)
Now in his fourth decade of life, Mr. A illustrates how poor emotional control and inability to read the nuances of social situations override the influence of superior intelligence.  He has difficulty holding a job, and has a continuing problem starting and maintaining friendships.  In describing his social problems Mr. A states, “I lack intuitive capacity. . . which makes it difficult to perceive the subtleties that other people find easy. . . I tried to learn what different kinds of situations called for.”  Mr. A went on to complain the adult autistic who is recovered receives help from no one, and complained autistic healers are biased towards those who are institutionalized.  Demeter, 1979, pg. 150)

DEMOGRAPHY
1.  Age – Most authors describe autism as beginning at birth (Kanner, 1943) (Churchill, Alpein, DeMayer, 1971) (Lovaas, 1977).  Hermelin & 0’Connor state the onset occurs before two. They diagnose these symptoms occurring in 8-year-olds and older as childhood schizophrenia. Those within the 3-5 range are difficult to diagnose, but symptoms are probably a result of a brain disease (1970).

2.  Sex –  More prevalent among boys.  Estimates range from 2.5 to 4.3 to l ratio of boys to girls

3.  Incidence – Autism is estimated to occur in ranges of 4.1 per l0,000, 4 per 9000, and 4.3 per 10,000.  There is also a greater incidence among first borns (Hermelin & 0’Connor, 1970).

4.  IQ – There is some disagreement here, but only in reference to “spikes.” It is accepted most autistic children are of subnormal intelligence (Kanner, 1943).  I.Q. can occur at all levels, though bias is towards the lower levels (60 or less) with 70% being below 55 (Hermelin & 0’Connor, 1970, pg. 4).  The spikes referred to account for some normal and exceptional abilities most autistic children possess such as fine motor skills, rote memory, pattern arrangement, and musical ability.

5.  Family & Socio-economic Background – Kanner (1943) first noted autistic children came from families of middle or upper socio-economic status, and the parents were of above average intelligence, noting this phenomenon differs from all other known psychiatric disorders in childhood.  He also describes parents as obsessive, intellectual, and cold (pg. 51).  Further, the parents were often described as humorless, detached, and highly or excessively rational and objective.  “Most of the parents declare outright that they are not comfortable in the presence of people; they prefer reading, writing, painting, music, or thinking.  They are, overall, polite and dignified people who are impressed by seriousness and disdainful of anything that smocks of frivolity” (Churchill, Alpine, DeMayer, 1971, pg. 75). “Parents have a single-minded dedication to purpose and are prone to conscientiousness” (Kanner, 1949, Pg. 421).

Des Laursers and Carlson (1959) provided their explanation for the occurrence of the high-intellectual and educational background of the parents of autistic children, suggesting, “There may be a spurious correlation due to the frequency that autistic children are frequently misdiagnosed the first time as mentally defective, brain-damaged, deaf-mute, or childhood schizophrenics.  It is reasonable to assume only those with financial means could afford the costs involved for second and third procedures.  Occurrence may be high in the Jewish community because of their well-known psychological sophistication and facilities.”  It is noted these reports, for the most part, were intuitive summations on the part of the authors.  No testing or studies to support these conclusions were found.

6.  EEG – Abnormal EEG‘s occurs in 50% of tested cases.  However, abnormalities are not associated with seizures or detectable neurological deficits (DesLaursers & Car1son, 1959).

7.  Response to Treatment – Treatment effects of psychoanalysis are said to range from poor (Kanner, 1943) to non-existent (Churchill, Alpein, DeMayer, 1971).  It is also agreed by all drugs have shown very poor results.  There is also no indication whether autistic children do better or worse than children with other disorders using operant conditioning.  There are some indications educational techniques may work (Churchill, Alpein, DeMayer, 1971).  In the book, Autism-New Directions in Research and Education (Webster, Konstantareas, Oxman, Mack, 1980) there is further evidence educational techniques are effective.  There has been good success using sign language, albeit particularly designed for the autistic child.

Perhaps the most promising and successful treatment intervention can be found in Barbara Knickerbocker’s book A Holistic Approach to the Treatment of Learning Disorders (1980).  For example, regarding head-banging, she states:  “Efforts to provide him with more suitable means to provide this kind of stimulation to the point of being satiated would be one method used in the holistic approach.” (pg. 59)

Further, as can be seen, her methods are prescriptive in nature and she speaks of letting the “child be your guide,” and to “feed the need”; that is, allow him to do as he does, under direction, (although she calls this technique “non-directive”).  She believes in “more structure, less instruction” and her rationalization is as follows: “Behavior such as this (twirling themselves and objects) is representative of an excessive need for stimulation of the vestibular system and a means of facilitating sensory integration.  When this need is satisfied the tendency to twirl himself and objects will be greatly diminished or may cease altogether.” (pg. 80)

8.  Long Term – A small minority recover by adolescence.  Of the adult population, 50% are in institutions, approximately 30-40% remain cared for at home, and some 10-15% are considered recovered.

EXPLANTORY HYPOTHESES
Etiologies are varied, and best summed up Hermelin & 0‘Connor’s book (1976):
(1) Bett1eheim (1967) views autism as emotional malfunction between mother and child.
(2) Knight (1963) Beres (1955) Mahler, et al (1959), suggest an impediment of the ego structure.  Rimland (1964) and Wing (1966) argue against this view on 3 points:  a) few orphanage children develop autism, b) no adequate demonstration of coldness or rejection of mother made available, c) mothers of autistic children have normal children.
(3) Bender (1961, 1963) and Chapman (1957) support a genetic view; however, no chromosomal studies support hypothesis. 
(4) Kanner (1954) suggests condition is congenital.
(5) Rimland (1964) and Hutt (1964, 1965) have developed a physiological hypothesis. 
6) Feister & DeMayer (1961, 1962) take an environmental point of view.
(7) Anthony (1963), using Piaget‘s stages in child development, has 3 theoretical explanations: a) Derangement of sensory input; b) interference with central coordinating and integrating mechanisms; c) disorder of output.

At this point, rather than offering this writer’s ideas, a digression is necessary.  Up to now, this paper has dealt exclusively with autism. Originally intended to find some common ground between autism, fetishes, self-mutilation, masochism, vagrancy, and passive sodomy, this endeavor, following the criteria of the ISFP, was frustrating, and for the most part, fruitless.

What were looked for in the literature in each category were common personality traits.  These were glaringly missing, as descriptions centered about the deviant behavior, with virtually no demographics given; or at least none, other than statistical, which would give clues to temperament.  There is very little information on fetishes other than historical tribal rites and old Freudian viewpoints, which described the malady and not the people. Such was the same with the other behaviors of the ISFP.

Perhaps the one exception is the information given on the vagrant.  At least it was the most romantic, and while perhaps not descriptive of the ISFP, it certainly describes rather well the SP in general.  In You Owe Yourself a Drunk; An Ethnography of Urban Nomads by James P. Spradley (1970) he states, “The tramp is on a perpetual journey and the trip is more important than the destination . . . The wandering may have boundaries – for some it is the world; others the nation; others the city” (pg. 252).  And “the highly sophisticated organization of behavior . . . is not that of a burned-out schizophrenic.  It is that of men adapting to a society whose structure and institutions hold no place for them” (pg. 258). He speaks of a world of strangers who are friends.

From The Hobo – The Sociology of the Homeless Man (Nels Anderson, 1923) it is reported Alfred Adler tested 100 hoboes and found that 43% had paranoid personalities, 35% had inadequate personalities, and 22% had emotionally unstable personalities (pg. 73). (Note: Not a healthy one in the bunch!).  From Old Men Drunk and Sober (Bahr & Cap1ow, 1973) it is noted only 20% of those living in the Bowery had no institutional experience, 47% were middle born, and 50% never married.

Wanderlust is a general theme of the Hobo.  Anderson (1923) prints a Tong poem written by a tramp unnamed, of which the first stanza is given:

Nothing To Do But Go
I’m the wandering son with nervous feet,
That were never meant for a steady beat,
I’ve had many a job for a little while,
I’ve been on the bum and I’ve lived in style,
And there was the road stretchin’ mile after mile,
And nothing to do but go. (pg. 198)

Wanderlust is the yearning to see new places, to feel the thrill of new sensations, to encounter new situations, and to know the freedom and the exhilaration of being a stranger (pg. 82). 

In the cases read, while sketchy at best, most men reported a failure in academia, or boredom, and had a marked ability with mechanical devices and tools, as seen in the case of W.E.: “a job on the railroad…job in the extra-gang… to a farm where he tired of ‘eating at the same table’ everyday…to a box factory in Kansas City where he became an expert at working with tools… was maintenance of way of tools on Railroad…got a job timbering…tried millwright work…went to a bridge gang. Each month he may come to town, spend his money, and each time he goes out to some different job” (Anderson, l923, pg. 74).

Unfortunately, there was again little information given on family background, or childhood, or additional personality traits.

Masochism, defined as submitting to physical or mental cruelty, was derived as a symptom from the writing of the Austrian, Leopold Von Sacher-Masoch.  Virtually all of the cases given were of a sexual content, including passive sodomy, and again were viewed in Freudian terminology – that is, explanations of deviancy were given with very little descriptive notes, and no personality clues given.

In the following section, whatever correlation is made to the seemingly diversified symptoms of autism, vagrancy, et al, will be done for the most part, regrettably, by intuition and inference.

PERSONAL FICTION
To give supporting evidence to this writer’s perspective, it is first necessary to review some of Keirsey’s remarks regarding the ISFP temperament.  Keirsey speaks of “the tendency of ISFPs not to express themselves directly, but through action,” they are “more inclined to the fine arts”; “they experience intensely, now”; and “the act is the ISFPs master.” Further, he notes about the ISFP temperament:

“They are usually quite oblivious to these accompaniments (fatigue, pain, or danger)… as they are wholly engaged by an action…the ISFP is attuned to color, line, texture, shading– touch, motion, seeing, and hearing in harmony . . .”kindness is unconditional . . .  sympathy carried to its most extreme form  . . . not interested in developing facility in speaking . . . speech, after all, is abstract, not concrete . . . this reluctant speech is not so much a lack of ability as it is disinterest . . . the number of great artisans . . .  who have been ISFPs is truly awesome.  (Keirsey & Bates, pg. 204-266).

The infant ISFP, as will be suggested, steps into a world of prejudice.

ISFP children evolve through action, love the senses of being, are enthralled by doing.  Unfortunately, what they do, innately, from the womb, they are asked not to do.  Perhaps as in no other type does this social stigma begin because of natural action as with the ISFP and is perhaps what Keirsey meant when he said they were the most misunderstand of all types.

If sensing and the senses are the life source of the autistic child, imagine what it may be like to hear for the first time, to see, to touch, to taste, to smell.  Colors, forms, patterns abound in the new world, and would be a source of constant fascination, and a never-ending source of doing.  What many authors called “an extreme autistic aloneness” can be seen as a fascination in what they are doing; a child described as “appearing unoriented in events about him and may occupy himself for hours with repetitious activities” can be quite oriented and interested –  in his own pursuits. 

Pronominal reversal and delayed echolalia, as these symptoms are described in the literature, may simply be a fascination for sound, with the content met with disinterest.  It can even be speculated a typical autistic phrase such as “don’t throw the dog off the balcony” when he means “no,” is a single, harmonious sound that quite readily serves its function to the toddling ISFP.

The whole idea of non-communication is rather a ridiculous notion.  Clearly, these children communicate, naturally, although in their own manner.  They are adept at getting picked up or put down, asking for toys, getting fed what they want to eat, and so on.  Messages are sent and received.  What is termed bizarre so often can be explained as misunderstood or not understood messages.  Interestingly enough, and to the credit of the autistic child, with time and persistence, he teaches his significant others his language.  It is not a coincidence sign language has been found to be particularly useful, action, senses, movement.

One author characterizes the bias we all, to some extent, possess when we try to describe symptomatic behavior of the autistic child (in reference to play activity), “. . . seen as profoundly disturbed play pattern, since it was perseverative and did not lead into any other interest,” as though perseverance and no other interest were symptoms of illness.  The psychological world is intent on describing and rectifying what people don’t do rather than observing what people do.  It would seem in the case of the ISFP child, this bias is pre-eminent. In effect, we ask a sparrow not to behave as a sparrow.

Social acceptance and the ability to “make it” is almost solely dependent on the interpretations of others, and that includes the very real prejudices, values, and judgments we all possess.  A lingering question remains:  At what point does this behavior become pathological?  That is, when do significant others decide the expressed doings of this child is no longer acceptable?

Imagine, again, the emergence of the ISFP to his environment with which he artfully plays.  If his parents were the seemingly cold, logical types, his actions could be seen as undirected and purposeless and an area of concern; he could be seen as lacking in “intellectual abilities.”  To the emotive, empathetic types, his aloofness to others and his “absence of warmth” would be an area of alarm; he could be said to be suffering from some emotional disorder.  Were he born to the socially conservative, salt-of- the earth types, his patterns of communication would be indeed worried over; he may be said to have brain damage or a low I.Q.  Combinations of types would only add to complexities.  It is also worth mentioning, professionals and adult concerns about these symptomatic behaviors are one-sided.  Until they are notified by the adults in their lives, these children are perfectly happy to pursue what comes natural to them.

Self-mutilation, sodomy, masochism, head banging, and other destructive behaviors tend to have an obvious connection – pain. Keirsey states the ISFP “simply doesn’t notice” pain. Perhaps it is as stated in Pain & Emotion by Roger Grigg (l970); “There is therefore some plausibility in holding that those who are apparently insensitive to pain are merely indifferent to it” ‘ (pg. 165).  To put self-inflicted or other inflicted pain in perspective, it may be necessary to re-define its content.  If pain were seen as an activity, a doing of something, as simply a sense to explore, play with, and manipulate, perhaps it would be easier to explain such strange behavior.  Indeed, many people report pain as a sensation, and not as uncomfortable nor even as something to avoid.  As it is so reprehensible to most others, it is hardly understood as possible, let alone something one would actively pursue . Whether an indifference or a lack of feeling, banging your head, or chewing on your lip, is something to do.  If, as Keirsey says, and action is their master, then surely pain would not be a deterrent.

How then, does one intervene?  Whether it’s “feed the need” or prescription of behavior, clearly the evidence indicates what works is to allow the ISFP to do what he does; to be what he is.  To the head-hanger, supply him a drum.  For the child who twirls get him a top or show him dance.  To those who are mute, get him a horn or show him how to hum.  To those who echo, teach them to sing.  What cannot go unnoticed is that classical and modern psychological techniques have universally failed.  Those techniques that have worked have been educational.  Perhaps psychological methods haven’t worked because this is not a psychological problem. The problem is misunderstood communication.  The responsibility lies with the adult in this reciprocal relationship; before you can teach someone else a new language, you first must understand their language.

The perspective here, to summarize, is simply stated.  With just the slightest manipulation, done carefully, the phrases and words Keirsey uses to describe the ISFP temperament can be seen as the very symptoms to describe the pathological autistic child.  Perhaps this malady is as Kanner put it – congenital.  But rather than something to change, rather than congenital, were we to change our understanding and call it innate, then perhaps this little sparrow could flourish and become the artisan we will, in later years, enjoy and admire.

~~~~~~~~~~~~~~~~~~~~

 BIBLIOGRAPHY

1. Knickerbocker, Barbara; A Holistic Approach to the Treatment of Learning Disorders Charles B. Slack, Inc.,

• Reik, Theodore; Masochism in Modern Man; Farrar & Rinehart, 1941.

• Spradley, James; You Owe Yourself A Drunk; 197O.

• Anderson, Neis; The Hobo – The Sociology of the Homeless Man; The University of Chicago Press, 1923.

• Eister, Robert; Man Into Wolf; London, Spring Books.

• Bahr, Howard & Caplow, Theodore; Old Men Drunk & Sober; New York University Press, 19?3.

• Hermelin, B. & 0’Connor, N.; Psychological Experiments with Autistic Children; Pergamon Press, 1970.

• Kanner, Leo; Autistic Disturbances of Affective Contact; 1943.

• Des Laursers, Austin, M., Carlson, Carole F.; Your Child is Asleep; Dorsey Press, 1969.

1. Lovaas, Ivar; The Autistic Child; 1977

1. Tinbergen, E.A. & Tinbergen, N.; Early Childhood Autism; Paul Parey Publisher,1972

1. Axlene, Virginia; “Dibs“- In Search of Self; Pelican Book, 1971.

1. Greenfield, Josh; A Child Called Noah; Holt, Rinehart and Winston, 1972.

1. Hassibi, Maken & Brewer, Harvy Jr.; Disordered Thinking and Communication in Children; Plenum Press, 1980

1. DeMayer, Marian D.; Parents and Children in Autism; Halstead Press, 19?9.

1. Coffey, Huber S. & Wiener, Louise; Group Treatment of Autistic Children; Prentice Hall, 1967.

1. Churchill, Don; Alpern, Gerald; DeMayer, Marian; Infantile Autism; Charles C. Thomas, 1971.

1. Webster, Konstantareas, Oxman, Mack; Autism-New Directions in Research & Education; Permazon Press, 19?0.

1. Ritvo, Edward; Readings In Autism, Special Learning Corp., 1978; Article: “Autism-From Adjective to Noun”, Spectrum Pub1ishing, 19?6.

• Rimland, Bernard; Infantile Autism; Appleton-Century-Crofts, 1962.

Goth Girl is about a 14 year old who was lost, self-abusive, and hearing voices. Medical doctors were forcing her to take chemicals for her “psychosis.” Placed in a mental health facility for “crazy kids,”  Evie lost her feelings along the way.  You already may know, that can be a terrible feeling.

ORIGINALLY PUBLISHED @ BESTTHINKING.COM – JUNE 2013

If we want a child to change his direction, we must understand what makes him move.   –  Rudolf Dreikers, M.D.

Part I: Meet Evie
I’ll call her Evie.  That’s not her real name, but her real name was just as pretty.  It’s best to honor her privacy, as a professional and as a fellow human being.  After all, this is her story, not mine.

Evie was 14 when I met her.  Six months earlier, she was involuntarily placed in an emergency mental health hospital (called a “5150” in California) for her “psychosis.” She was given chemicals almost immediately and, after the legally required 72-hour hold, she was declared medically fit to go back home.

About two months later another 5150 occurred.  This time, they gave her a new batch of chemicals (see Evie’s Chemical Cocktail above) and upon release 72 hours later, she was placed, without her consent, in a residential mental health facility for teenagers.  About four months later, I was brought in by the same agency as a consultant.  I was there to train and supervise the therapeutic staff, and to train the child-care staff.  For reasons you will see, I became Evie’s therapist.  She was my only client.

Evie was “hearing voices,” according to the notes I read from her prior therapist.  As I found out later, it was one voice.  Evie had a friend who would talk to her once in a while, especially when she was alone and when her emotions were in turmoil.  I’ll call him Vlad.  “Vlad is my friend, Dr.  Cima,” she once told me.  She wasn’t frightened.  Vlad “spoke” to her at times, and she wrote to him.

Temperament: Sphere
For those trained in Keirseyan temperament theory, Evie is a Sphere – a young Idealist.  That makes her rare (about one in twenty), and very hard to spot, especially in residential settings.  Young spheres tend to blend in and take on the characteristics of Stars (young Artisans) or Squares (young Guardians), though, for reasons I’ll talk about later, they rarely, if ever, take on the characteristics of Cubes (young Rationals).

However, when Spheres are alone with someone they trust, their vivid metaphorical imagery quickly exposes their identity to an observant adult.  We all use our imagination to some degree, now and again.  However, Spheres stand alone in their ability to express their life experiences with metaphorical language.  Little wonder why so many writers and poets are Spheres.  (A few famous adult Sphere/Idealists: Emily Dickinson, Pearl Buck, Charles Dickens, James Joyce, Leo Tolstoy, Upton Sinclair, Oliver Stone, Paul Robeson, Joan Baez – and Plato.)

Goth
Evie was “Goth.” Goth – from gothic – is one of those adolescent subcultures found in every generation.  “Hippies,” “Hip-hops,” “Emos,” “Grunges” – and don’t forget the “beatniks” of the 1950’s” – are just a few adolescent subcultures.  The more shocking and defiant the subculture, the more it brings out the worst in adults intent on “dealing with it.” Unwittingly, by “dealing with it” adults fortify one of the reasons kids join these subcultures – to gleefully irritate and annoy their supervisors.  Another reason?  Goth culture offers comforting refuge for some unhappy kids struggling to find their lost identity, especially true for Spheres.

Goth is often described as “somber, macabre, and glamorous.”  You can throw in a touch of romance too.  Black is the color of choice for the Goth crowd, and you could always find it in Evie’s lipstick, eye makeup, nail polish, and clothes – down to her black socks and black shoes.  Evie always wore something in her dyed black hair too, usually flowers, often a black flower.  Evie liked flowers.

She was introduced to Goth when she was twelve.  She told me she fit in almost immediately.  She started to read Gothic novels.  A combination of horror and romance, famous Gothic literature includes novels like the Headless Horseman, The Legend of Sleepy Hollow, and The Adventures of Ichabod and Mr. Toad.  Modern movie renditions include Edward Scissorhands, Beetlejuice and Batman.  (You can read more about the Goth subculture here.)

Something Else You Should Know
Evie was a “cutter.”  Cutting is a form of self-mutilation.  It occurs when a child takes sharp objects like razors, knives, or even pieces of glass and cut themselves, usually in secret.  It’s mostly done on the underside of the forearm, on the tops of thighs, but anywhere on the body is possible.  When it occurs in residential settings, it can be “contagious.”  Children vying for the attention of adults notice that “cutters” get a lot of attention.  Like no other child at this 40-bed facility, Evie had the attention of everyone, and everyone was worried.  She was an “active cutter.”  (Nearly all long term “cutters,” in my experience, are Spheres.)

Also, as if there wasn’t enough turmoil in her life, for reasons unrelated to this story, her assigned therapist abruptly left the organization the Friday before I started, without a goodbye.  Evie lost her only confidant, and she was devastated.  When I arrived the following Monday morning, a number of staff members let me know Evie had an emotional, “cutting” weekend.  I decided to be her therapist.

Summing up
Evie was emotionally turbulent.  Her family had deteriorated, and so had Evie.  She drifted into the Goth subculture a few years earlier.  She was talking to a voice in her head, and she was cutting on herself almost daily.  Four months earlier, she was removed from home and placed in a facility that was, as she would say over and over – “a place for crazy kids” – and she just lost her therapist, the one person she could trust.

The worst of this? The medical profession declared Evie “mentally ill” and gave her chemicals because she was “psychotic” and she was depressed.  Good thing I’ve seen this hundreds of times in my career or I would have been depressed too – and maybe a little “psychotic.”

Part II: The Story
Unlike most therapists in society who meet with their clients once a week in an office, in residential settings, the kids live and the staff work at a self-contained campus.  Bedrooms, classrooms, and therapist rooms are usually within short walking distance of each other.

That means, if you’re a therapist, it’s not unusual to have lunch with one of the teenagers, or to meet with her teacher, or to take a walk and have a private conversation – in addition to a more formal one-hour session in the office.  In fact, it was my job to make sure therapists didn’t linger in their offices too much.  “If you want to know how your kids are doing,” I would tell them, “go see them where they live.” So, I spent some time where Evie lived.

I began to see Evie, formally, once a week.  Our first meeting was cordial.  My job was to develop a trusting relationship, and Evie was rightfully cautious.  As I had lectured my staff ad nauseam over the years, the adult is responsible to earn the child’s trust, not the reverse.  I talked to her about things she liked.  She said she liked to write.  I asked what she wrote about, and if she would share them with me.  “Oh no Dr.  Cima,” she said, “I’d be way too embarrassed!”  I told her I understood and maybe she would share with me some day.  We talked about her life a little bit.  She told me she loved her mother very much, though she had many “acting out” episodes when she lived with her mom, especially in the last year or two.

I also learned Evie had sporadic, unpredictable contact with her stepfather.  He married Evie’s mother when she was three, and he was the only father she ever knew.  Her parents divorced a year earlier and were more or less estranged for at least two years before the divorce was final.  Evie’s stepfather had a girlfriend, and her mother was not dating.

Meet Pamela and Tom
I contacted Evie’s mother after my first talk with her.  I’ll call her Pamela.  Pamela lived by herself in her home about an hour from the facility.  She worked long hours in a responsible position.  I asked her if she was able to meet with me, she said of course, and we met the following Monday.

Over the next several months, I routinely met with Pamela at the facility.  The two of us would have a conversation, and then we would bring in Evie.  Pamela needed her own private time too.  A good mother, she was confidently independent.  She had a good enough paying job that she could afford to pay her bills and take care of her daughter even if her ex-husband didn’t contribute, which was often.  (For the temperament trained reader, Pamela is a Protector Guardian.)

Sometimes, though, she was overwhelmed with self-recrimination about how all this happened, about what happens next, how the ex-husband’s girlfriend “didn’t help,” that she had no interest in dating, how she is responsible for all of Evie’s troubles, how her ex-husband is responsible for all of Evie’s troubles, and everything else that occurs when couples, with children, divorce.  It’s important to keep in mind divorce is a process, not a date on the calendar, and it inevitably involves unavoidable upset for everyone involved.  Evie was Pamela’s only child, and they were always very close.

Evie’s stepfather – let’s call him Tom – was a blue-collar worker (from Pamela’s portrayal, probably a Promoter Artisan).  I never met him, though we did have one conversation over the phone.  From what Pamela told me, over the past three years, Tom has been less and less involved in Evie’s life, missing gifts for birthdays and Christmas, and often not showing up for scheduled visits.  Still, Evie wanted to see her dad.

In my one conversation with Tom, I told him he would have to make appointments to see Evie with me, and that I wouldn’t tell Evie about this until he showed up.  In the next six months, Tom called my office on two different occasions to arrange a visit with Evie.  He didn’t show up either time.  I emailed him a few times and I left a few voice messages.  I offered to go to his house to meet with him.  He never responded.  It was a choice he made.  This also meant Evie didn’t hear from him during this time either.  Evie let me know her feelings about this through her ongoing conversation with Vlad.

Making Progress
By the third or fourth time I met with Evie alone I asked again to read some of her stories.  I could tell she was glad that I remembered to ask a second time.  This time she said “okay,” with an apprehensive smile.  She gave me her well-worn spiral binder and she asked me if I could read it right away.  I told her I would.

I’ve read many stories and many poems from children in foster care over the years.  Anger is a common theme, as is fear, and so is freedom.  Despair is almost always part of them.  For many kids in foster care, futures can be dim.  Evie’s was different.  It really wasn’t a story.

When I first began to read her words, I couldn’t make heads or tails of what she was saying.  Her spelling was okay and her grammar was about the same.  She capitalized the first letter of every sentence, every sentence ended in a period, and each sentence made sense.  There were no questions marks, no exclamation marks, no quotation marks – just periods.  After a while, when I read the sentence “Where are you going Vlad,” I finally got it.

Imagine reading a novel, and the person who wrote it deleted everything in the novel except the dialogue.  There was no introduction, no building of the scene, no sense of when or where this was taking place, or even who was talking.  Instead, the first sentence of the story started in the middle of a conversation between two people, neither of them identified, one sentence after another.  I finally realized Evie wasn’t writing a story for someone to read.  She was writing down the conversation she was having with Vlad, like dictation.

What was the conversation about?  Well, for lack of a better description, it was about a “fair maiden in distress,” who was receiving advice by a loving friend named Vlad.  Vlad was heroic, sometimes dark (he spoke of werewolves and may have been one himself according to Evie).  Vlad loved the maiden in the conversation, Evie once told me, “just as a friend, Dr.  Cima.”  Nothing sexual about this relationship, at least in her written and spoken words, and Evie wanted me to know that.

Part III: An act of chivalry
When the three of us were in session – Evie, her mom, and me – I would read aloud the most recent additions to her conversation.  By now, she always wanted to hear what I had to say, and that was good.  She spoke of her many troubles, and Vlad comforted her with sound advice and concern.

I should tell you I already had a few private conversations with Evie’s mom about this.  Pamela told me Evie always had a vivid imagination.  She had “friends” she would talk to when she was a toddler, as many kids do.  Like most kids, she grew out of it by the time she started school.  Pamela never thought it was a problem.  She thought it was normal for some kids.  It is, of course, for all kids, with spheres by far the most adept at using their imaginings to tell stories about their life experiences.

Vlad arrived right around the time their marriage was “falling apart,” Pamela told me.  As she entered her teens, Evie was becoming increasingly alone, questioning everything her mother did or should have done.  She was becoming desperate as her father receded from her world.  She was angry, hurt, and isolated.

Once, while I read her story for the three of us, the fair maiden (the girl in the story didn’t have a name other than “maiden”) said to Vlad, “Thank you for your chivalry my friend.”  I smiled.  What could this sad and frightened little 14-year-old Goth girl from Southern California know about chivalry, I said to myself.  So, I asked her.  Before she could answer, Pamela interrupted, beaming, and proudly said, “She knows what it means too!”

“Really?” I said.  “What does chivalry mean, Evie?”

“Dr.  Cima!” She was a little angry.  “I know what chivalry means! It means that when a fair maiden is about to step into a puddle of water, the gentleman is supposed to take off his coat and lay it on the ground so she won’t get her feet wet,” she said grinning, with as much pride as her mother.  It was a good moment for all three of us.  From that time forward, we changed her story of desperation into her search for inspiration.

About That Voice-In-Her-Head
One day, sometime in the second month or so that I knew her, Evie asked me, causally, “Dr.  Cima, do you think I’m crazy?”  It was, I think, a question to test my answer more than anything else.  She had her fill of answers by then.

Her doctor told her, and her mother, she had “schizoaffective disorder” and something called “major depressive disorder,” and that she needed a chemical to make her better.  Her therapist told her she was “substituting Vlad for her father,” though she had a “psychiatric disease” too.  Her social worker told her she sent her to this facility for her “mental illness.” A few counselors, frustrated because she wasn’t improving, told her she was “psychotic.” The other kids at the facility? They told her she was a “wing-nut,” and other similar terms, as you can imagine.  All of this convinced Evie this really was “a place for crazy kids.”  I answered her question.

“No Evie,” I said, “I don’t think you’re crazy.”

“Ok, Dr.  Cima,” she replied, almost as a challenge, “then where does Vlad come from?”

I shrugged and said “I think it’s just you talking to you.  What do you think Evie?”

“Yeah,” she said with a sly grin, “it’s just me talking to me.”

That seemed to help.  After all, that’s what it is.  We should remember, parents and professionals alike, there really isn’t another person talking, and the voice isn’t coming from the clouds.  It’s her own imagination at work, nothing more.  She’s having a discussion with herself, it seems spontaneous, it seems to be real and, for the most part, she’s was okay with it.  We decided she was having “a wide-awake dream, that’s all.”  That seemed to make sense to her.  We never talked about why she was having her wide-awake-dreams, so it made it easier for her to talk to me about them.

After a while our conversations were about the words she wrote, and the metaphorical meanings they had in her life.  It was a great way for her to explain her inner turmoil, and a great way to encourage her candor.  She was, in the next few months, increasingly candid.

About That Cutting
About one month into our relationship, at a particularly vulnerable and honest moment, I asked Evie if I could see her scars.  She was very ashamed of her scars, in front of me, and she always wore long sleeve shirts to hide them.  Evie took off her jacket and extended her arms.  There were several dozen crisscrossed scratches from her wrist to three fourths of the way up both of her arms, most of them permanent scars.  When I gently held her arm to look, she started to cry.

I’m sorry, Dr. Cima,” she said, her eyes fixed on the floor.

“Sorry,” I replied, “why are you sorry Evie?”

“Because it’s a stupid thing to do!” she said, with a bit of anger in her voice.

She said, at different times, she did it because she couldn’t stop herself, and because Vlad said it was a sacrifice she had to make, and because she felt so empty inside, and because her dad wasn’t around, and because it brought her a lot of attention and, sometimes, because she was bored.  Mostly, she said, “I do it when I don’t feel anything.”

Not a small item for Spheres, the loss of feelings.  Feelings provide Spheres their life energy.  Spheres without feelings are like Cubes without a puzzle to solve, or Squares without a job to do, or Stars without a game to play.  In desperate times, in a strange place for “crazy kids,” feeling something is better than feeling nothing.  We talked about her feeling nothing, and decided that feeling nothing was a feeling too.  Even if it felt terrible and empty, it was a feeling.  At least, we decided, she was feeling something.  Evie slowed and then stopped cutting herself six weeks after we met.

About That Chemical Cocktail
I convinced Pamela her daughter didn’t have a “disorder” or a “disease.”  Frankly, and not surprising to me, it didn’t take that much to convince her.  She never saw any improvement in her daughter’s behavior, despite the number of chemical cocktails they tried.  She consented because a doctor said her daughter needed “medicine.”

This is a common experience for the many hundreds of parents I’ve worked with in my career.  Parents will say they saw improvement in the first few weeks, then things began to get back to where they were.  Chemicals were increased, or decreased, or changed, or added – it didn’t matter much.  Over time, nothing changed, often their child was worse, and now their child was living in “a place for crazy kids.”

Pamela expressed her right as a parent and asked that her daughter be taken off her “medication.”  The doctor cautioned her against doing so, however, Pamela insisted.  With my support, we began a titration schedule, and simply reduced and eliminated both her chemicals in a matter of a few weeks.  Good riddance, and a huge boost to the self-confidence of Evie – and her mom.

How Did it End?
Evie went home to her mother about six months after I arrived.  She had stopped cutting for more than four months, she was still writing in what we were calling her journal by then, and most important to me, she was chemical free.  Evie called me two times in the first month just to say hello and to say that she was doing okay.  She was in school, and she was glad to be home.  She thanked me a few times, and I thanked her for trusting me.  We never spoke again.

About four months later, Pamela called.  She wanted to let me know that Evie was still in school, doing okay.  She said Evie seldom wrote anything in her journal anymore.  She also said she thought Evie may have a boyfriend.  Nothing had changed with the relationship with her step-father, although Evie, according to Pamela, was more stable with this unstable, one-sided, relationship.  Finally, Pamela told me she was dating.  She met a man at work, they had lunch, and they had dinner.  A third date was planned.  She sounded happy.  I think that’s why she really called, but that’s just me.

This is how it usually ends in my business.  It’s rare to have much contact with children and their families once they leave these kinds of facilities, as it should be.  After all, we are there to help them during an extended life crisis, not to ensure everyone lives a good life.  Our job is to provide them with our security, our trust, our guidance, and to discover and encourage their strengths, as children and families work to move forward in their lives.

Epilogue
I started writing “Goth Girl” two weeks before I found a video about another girl.  Her name is Emily Longden.  She was hearing voices too.  I wrote a blog about her at “Your Kid’s Aren’t Sick.” You can learn about the Hearing Voices Network, and you can meet – and see – this brave young woman @ https://www.youtube.com/watch?v=AgZHOSxN5cE&feature=youtu.be.

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READER COMMENT:

Eitan Schwarz, MD FAACAP DLFAPA

June 11, 2013 at 12:55 am

You have described Evie beautifully.  In this age of increased emphasis of the mind as a function of the brain, you remind us of the need for balance.  As a child and adolescent specialist for 40 yrs, I have met and sought to understand several Evies.  They can be very different from each other.  They have in common a blend of fierceness and delicacy, lace and leather.  They are worthy conversationalists and usually quite expert in something interesting.  Some try their own chemicals.  Many have had decent therapists who helped them accept their medication and became happier Goths for longer.

I also know of how varied kids are and frightened parents are.  I know that there are some doctors and “therapists” out there unworthy of trust because they don’t talk with people and don’t think carefully about the symptoms or diagnosis, like the type and function of “auditory hallucinations” and then misdiagnose and mistreat, often overmedicating with the same drugs.  I am always glad to see folks alert to that.

Yet I wonder to myself what is really new about your approach — it is pretty standard for the rest of us who work with kids and like to see their lives improve, except we don’t jump into a therapy relationship in quite the way you describe your involvement too often.

Your POV is not unusual either.  But would you consider that the medical chemicals made it possible for Evie to connect with you initially?

REPLY:

Dr.  Schwarz: Thank you for your comment, and sorry for this very late response.  My wife and I were on a long overdue, extended vacation.

The short answer to your question, politely, is no – the medical chemicals had nothing to do with connecting with Evie.  It was an on obstacle to overcome – for her, her mother, and me.  The long answer is a little more telling.

Evie – and her mother – first had to be convinced she wasn’t crazy when the evidence (5150, removal from home, “psychosis,” etc.) was just the opposite – topped off by those chemicals to fix her diseases.  Having done this many hundreds of times, I know parents are very reluctant to take their children off medication.  That’s a problem to solve too.  So, no thanks, medication has never been an asset to developing a relationship with a child.  Evie didn’t trust me because she was taking a pill.  I had to earn her trust.

Sounds like we both have been doing this work since the 70’s.  We both know these so-called medications were being used for kids on an experimental basis in those days.  I know from first hand observation, the experiment failed – and most professionals deny it.  You should know that too.  Unequivocally, from watching thousands of children, I’ve never seen these chemicals do any of them any good, and always did harm.  I know of no exceptions.

Nonetheless, I don’t deny that you have a knack for what we do.  You must.  You’re instincts about Evie were so accurate.  I can tell you’ve had Evie – and kids just like her – in front of you many times.  Lucky for them.  I suggest you had those instincts with you as you entered grad school and medicine.  That knack (or connection) can’t be taught, and it has nothing to do with medicine.

A psychiatrist friend told me a long time ago “I try to make sure my training doesn’t get in the way of my effectiveness.” I suspect you do the same.  I applaud your effectiveness.  You, in particular, didn’t need to prescribe any chemicals to anyone.  You’re the vessel of efficacy, not a chemical.  Respectfully, prescribing chemicals not only masks “symptoms,” they often mask the impotence of the prescriber.  Medicine is needed for broken bones, not broken hearts, broken families, or broken spirits.

ORIGINALLY PUBLISHED @ BESTTHINKING.COM – OCTOBER 2012

Dear Reader:

I wrote the essay – The Era of Chemicals – in 1988. A year earlier, I was awarded my Ph.D. in Clinical Psychology. I was in my second year as the Director of a 66-bed residential facility in Southern California for boys placed from probation, social services, and mental health agencies. It was the first of three large mental health facilities than I’ve managed. I wrote this essay late one night in my office.

I never did much with it. I used to give it to my colleagues to read. I continued to do that over the years until I retired. I dusted it off to publish it now, because, well, it’s time. In fact, as you will see, it’s overdue.

When I managed facilities as the Director, I didn’t allow children to be given chemicals for their behavior. Admittedly, it was a lot easier in the mid-1980’s. The psychiatric Medical Model didn’t have the stranglehold on our profession as it does now. I just said no.

I had my reasons – professional, theoretical, philosophical – and they all added up to no. There was no wiggle room either, by the way. You’re either all in or all out with this failed model, so I didn’t allow any dabbling. There were many times I had therapists – especially new therapists – in my office cajoling, begging, angrily advocating, with articles-in-hand (no internet back then), to allow them to encourage the psychiatrist to prescribe a chemical “just for this one kid – please!” I said no. Luckily, they liked working with me, and I liked their work too – and we did good work together. By the time I started my third agency in 2003, I was more seasoned, less strident and, I’m happy to say, as successful.

The essay is a little awkward and stiff and some of the sentences go on forever. I ask for your patience, please. This was my first attempt at writing something serious about the subject. Nonetheless, other than some grammar and structure and other similar kinds of things, I wouldn’t change anything, so I didn’t.

I admit, though, there is the one thing that haunts me. The last paragraph. I used the word “perhaps” four times, including the last word of the essay. I was naïve. I was hoping the essay would have lost its relevance by now. It didn’t, I’m sorry to note. 

I’ll tell you this now, a quarter century later: there’s nothing “perhaps” about it. We’ve gone from a few hundred thousand children given these toxic chemicals, to eleven million – and counting. It’s our shame, and our responsibility to put an end to it.

For now – The Era of Chemicals – from 1988. 

~~~~~~~~~~~~~~~~~~~~~~~~~~~

We learn early in life that there are simple solutions to complex life problems. Whether a headache, tension, stress, depression, excessive activity, insufficient activity, insomnia, bed-wetting, bad grades, bad dreams, hallucinations, poor reading skills, too much appetite, not enough appetite, and so on, a simple trip to the drugstore, to the liquor cabinet, or to the “corner connection,” will ease these annoying and sometimes pervasive life-symptoms.

It’s as if unpleasant personal interactions, disappointments, tragedies, elations, moods, lack of skills, uncomfortable thoughts, undesirable physical appearance, and other events experienced by most human beings are best dealt with by the ingestion of one type of chemical or another. There may be a day when these chemical medications will carry the disclaimer: “Caution: The Surgeon General has determined that living may be hazardous to your health.”

The Medical (or Disease) Model is the prevailing theory in the helping professions. When discussing people who are sick or ill pertaining to a psychological description of behavior, the Medical Model is inferred. Indeed, the body’s chemicals do have an effect on behavior. As the chemist will state, in some ways “it’s all chemical.”Neurons are chemically stimulated, and they, in turn, chemically stimulate muscles and organs, and so on. Yet with some theorists, scholars, and students of human nature there exists a vast difference between the physiology of motion and the cause of behavior.

When someone behaves in a socially inappropriate way the physician seeks to explain the behavior by discovering the chemicals that are either missing, are in short supply, or are in overabundance within the individual. This is the cause of the disturbance, and they will treat the anomaly with chemicals of their own. When questioned, the physician will claim there is an imbalance of some kind, in less than understood ways. Yet there is offered little, if any, explanation of what “balance” means. The fact the depressive is elevated by Elavil is enough to conclude the effects are beneficial, and that this is evidence of the efficacy of the drug. Most often the physician is at a loss to explain why the chemical works, how the chemical works, what can be predicted about its effects, or how long the person being treated will have to use the chemical.

Another concern is found in the term side-effects. This euphemism is used to water-down the stigma of the unwanted physiological and psychological consequences of chemical use. Drugs only have effects. With chemotherapy, for example, hair loss, loss of appetite, and other effects of the chemicals used are well known. However, when psychotropic medication is given to human beings for a psychological disturbance of some sort, unavoidable problems arise. The term “Thorazine shuffle” was coined by the employees in psychiatric settings, as their observations of the side-effects of this drug were noted.

The use of Ritalin, or methylphenidate hydrochloride, provides another example. This overused and misused drug has been around for over a quarter of a century and is almost exclusively used for children. Its main purpose is to “calm” the hyperactive child. How does this work? How does a stimulant have just the opposite effect with very active children? No one seems to know. Turning to the Physicians’ Desk Reference, a volume of over 2200 pages that give a detailed description of all legal chemicals, here are some remarks about Ritalin. The PDR, states:

Ritalin is a mild central nervous system stimulant. The mode of action in man is not completely understood, but Ritalin presumably activates the brain stem arousal system and cortex to produce its stimulant effect. There is neither specific evidence that clearly establishes the mechanism whereby Ritalin produces its mental and behavioral effects in children, nor conclusive evidence regarding how these effects relate to the condition of the central nervous system. (Physicians Desk Reference – 1987 edition)

The authors of the PDR also state Ritalin should not be given to children under six, and it is contraindicated when the child has marked anxiety, tension, and agitation as Ritalin may aggravate these symptoms. Continuing, they note data on safety and efficacy of long-term use of Ritalin in children is not yet available noting: “although a causal relationship has not been established, suppression of growth (i.e., weight gain, and/or height) has been reported with the long-term use of stimulants in children.”         

And what are the side effects of this stimulant? Nervousness and insomnia are the most common reactions, along with hypersensitivity, skin rash, anorexia, nausea, dizziness, palpitations, headache, dyskinesia, drowsiness, blood pressure and pulse changes (up and down), tachycardia, angina cardiac arrhythmia, abdominal pain, and weight loss, to name some. An overdose may induce vomiting, agitation, tremors, hyperreflexia, muscle twitching, convulsions, euphoria confusion, hallucinations, delirium, sweating, flushing headache, hyperpyrexia tachycardia, hypertension, hydrias, and dryness of mucous membranes.

The most common place that a child first comes in contact with medication is in school, due to “disruptiveness”or “inattentiveness,” or in general, “poor school performance.” Dr. David Keirsey, author and professor emeritus has these remarks about the use of medication with school children:

The parents blame the school, as they should, but the school blames the child. He’s “dyslexic,” has “minimal brain dysfunction,” is “hyperactive,” has a “learning disability.”  Therefore, says the school, he “needs medication.” Then some well-meaning but ill-advised physician prescribes massive daily doses of some stimulant drug, parroting others’ assumption that the stimulant has a “paradoxical effect” of acting as a depressant. The victim is thus given his daily fix and its false high, his teacher claiming that he’s “calmer and works better.” Who wouldn’t be with that big a fix? And of course the child need not aspire to much; after all, what can you expect of a person with a bent brain? And later on? No. The child’s real problem is the school, not his brain; his brain is just fine.                                                     Portraits of Temperaments – Pg. 26

So why is the use of medication so pervasive with particular children? Usually because the child is a management problem, although this is most often denied. The child is ostensibly given drugs “to help him.” Yet close observation will note it is the teacher who needs help, or the mother, or the counselor. The belief is if someone is in profound psychological distress due to chemical imbalances, and this is interfering with more traditional treatment, then chemicals are prescribed to ease the distress in order to enter into a therapeutic conversation. Yet this seldom, if ever, occurs.

Instead, the teacher is initially relieved she was heard, and while the child’s behavior doesn’t really improve, “at least he’s being treated.” Mother is now reluctant to take her child off medication for fear of a recurrence of past events, even though her son is tired all the time and doesn’t eat right, and in a bad mood constantly. Ironically, even the most ardent disciples of the Medical Model make no claim chemicals used for psychological disturbances cure the disturbance. Instead, most will say some people will have to be on medication for “the rest of their lives.”

All professionals, including therapists, teachers, child-care counselors, teacher’s aides, social workers, and others, should become familiar the with the PDR. There are good reasons for this. Once a child is placed on medication designed to treat a psychological shortcoming of some sort, it soon becomes impossible to distinguish with any degree of accuracy between behavior that is due to the child’s psychological distress and behaviors due to the side-effects of the prescribed chemicals.

Is the child agitated, now, because of internal strife, or is the prolonged use of medication affecting him? Is the child awake at night because of a sense of unbelonging, or is she simply exhibiting an effect of the particular chemical she is taking? When the child becomes disruptive at school and breaks another window, does this mean an increase in the medication, another type of medication, a decrease in medication, the medication is an irritant, or what?

Medical personnel refer to this process as “adjusting the meds.” The pursuit, really, is to adjust the child. Many experienced physicians are adept at creating just the right high, so the child is awake, yet sedate. Often out of frustration and desperation – and genuine care – a child is referred to a doctor for his medical problem. However, when chemicals are used to manage the recalcitrant child, other more damaging side-effects inevitably follow.

Once medicated, the child has a disease in addition to stressful life experiences he may have to endure. This disease is something beyond his control, something which he and his family now may have to cope. The child is seldom told of the prescription until it has been decided by others “for your own good.” He is given vague reasons as to why he has to take the medication (“to help you”), can soon become dependent (“I can’t go to school without my meds”), loses control over his behavior (“I can’t help it/it’s not my fault/I’m not responsible – I’m hyperactive”), lowers his own expectations about his future, mimicking the view others’ have of him, because of his “handicap.”

Chemicals have the effect of altering the physical-emotional-psychological affect or consciousness of human beings. About that there is no doubt. Yet this is a poor reason to give medication to children in psychological distress. “Why Mellaril instead of a ‘shot of booze’” asked one professional.” There is no good answer. Chemicals, for the most part, create dependence rather than independence. Most disturbing is the dependence created in many professionals and lay persons alike. After a confrontation it is not unusual to hear in some settings: “somebody take him to the psychiatrist and get his meds straight!!”

Chemicals taken into the body do have an impact on the human being. Give a child Ritalin, and his body is affected. Introduce Valium to the overworked bank teller and watch him calm. Allow the lonely housewife her vodka for the day and see a different housewife. Many simply can’t go to work without a cup of coffee. Others must smoke a cigarette as soon as they wake in the morning. And so on.

The use of drugs permeates every level of contemporary society. If one was to include all legal drugs in addition to the illegal drugs, then there are very few of us who are truly drug-free. In fact, it could be argued the cause of the drug problem in our society lies not in the area aimed at by our “war on drugs,” which is the attempt to eliminate the use and distribution of a handful of illicit drugs. Instead, it could be argued the thesis the origin of the drug abuse problem in this society falls at the feet of the 3200+ legal drugs, and the permeating idea of quick fixes that begins at a very early age. Moreover, as the distribution of legal drugs is a multi-billion-dollar industry, new so-called breakthroughs are common as the relief of life-symptoms can be done even more effectively with the “new and improved” products.

George Washington, after retiring from his two-term presidency, lived his final days in Mount Vernon. It’s likely this national hero and “father of our country” would have had the most updated and best medical professionals of his time at his calling. The state-of-the-art, unfortunately for Washington, proved to be unsuccessful. He was inadvertently bled to death in an attempt to cure him.

With hindsight, his treatment seems uncivilized and uninformed. Yet within the medical profession this was the best solution at the time. With foresight, one may wonder how our progeny will view the use of drugs in our current society. Perhaps they will look back and view us as uncivilized and uninformed. Perhaps they will wonder what we were doing to ourselves. Perhaps they will, as they review their history, refer to us as living in the Era of Chemicals.

Perhaps.

ORIGINALLY PUBLISHED @ BESTTHINKING.COM – DECEMBER 2012

Dr. Dean Edell started his radio broadcast in 1978. His common sense and clear answers earned him the accolades of millions of Americans. Dr. Dean retired in 2010. “No nonsense, no BS, no medi-babble” could have been his motto. Enjoy your retirement, Dr. Dean.

I was listening to him in the late seventies and early eighties when he would periodically tell his listeners there was no such thing as a sugar high. More than that, he implored his audience to pass this information around to others. I was surprised. How, I asked myself, could Dr. Dean be so wrong about this, and so right about most everything else?

At the time my wife and I were living with 8 boys ages 12-17 years old in a group home. They were active. We got them up in the morning, readied them for school, greeted them after school, helped them with chores, ate dinner with them, helped them with homework, and got them to bed. As professionals, and as surrogate parents, we stopped giving them sweets because we knew sweets added to their already too active behaviors, and we cared about these kids.

We knew about the behavioral power of sugar because we heard it from all of our sources at the time including psychiatrists, psychologists, social workers, therapists, teachers, teacher’s aides and other parents. My wife and I were parents with young children at the time. Like our friends and family who had young children, we all knew about the “sugar high,” the “sugar rush,” and, though less well known, the “sugar crash” – that’s what happens when sugar is depleted and all of the child’s energy is spent. The child “crashes.” We were informed parents and, as knowledgable child behaviorists, we were compelled to educate colleagues and the general public whenever we could.

Dr. Dean ruined all of that.

I did some homework, which was a lot more difficult back then. The internet wasn’t born yet. I was working towards my Master’s degree at Cal State Fullerton and I had access to their library. I used to study there before class, and from time to time I would research this question. To my utter dismay, I found out Dr. Dean was right. Conclusive. No kidding. No doubt. There was – and still is – no scientific evidence anywhere to support the idea that sugar has anything to do with increased activity – child or adult. There is no “high,” there is no “rush,” there is no “crash” either, even though those terms were so much part of our culture back then and, most distressing, still are.

I succumbed to this truth. I quickly converted, cleansed myself, and became a disciple. I felt obligated to pass this information on to friends, family and colleagues, as Dr. Dean suggested. Together we could help kill this myth, and get on with the task of helping children.

Not so fast there buddy. When I would tell people there’s no such thing as a sugar high, many would get mad at me, and the rest would ridicule me – as if I needed to modernize my thoughts. The same psychiatrists, psychologists, social workers, therapists, teachers, teacher’s aides – and nearly all parents – refused to listen to this. This is still true, and it’s 2011.

Well informed mothers, fathers, caretakers and professionals are quick to point out they have watched children’s behavior become “manic” when too much sugar enters their blood streams. They’ve witnessed what is clearly a physiological effect with their own eyes and, way too often, their own ears. It’s obvious to anyone, they say without hesitation. Too much sugar “hypes” kids. So obvious that many parents dread birthday parties, Christmas cookies and, God-forbid, Halloween.

The simple reply is, respectfully, no, you didn’t see what you said you saw. You may have seen your child’s activity increase, but it didn’t have anything to do with sugar. You get madder still.

So, nowadays, in the 21st Century, I refer everyone to their own encyclopedia, the world wide web. Please, when you have an extra 20 minutes, take the time to Google, Yahoo, or Bing “sugar high” or “sugar rush.” See what you find. In the meantime, here are excerpts from five different sites I selected – there are many more – with their web addresses:

From The Straight Dope: In 1995 the Journal of the American Medical Association published a review of 23 comparatively rigorous studies conducted between 1982 and 1994. These were your classic controlled double-blind affairs: two groups of kids, one fed a bunch of sugar, the other given a placebo (i.e., artificial sweetener), everyone kept sufficiently in the dark as to who’d gotten what, etc. The results? No discernible relationship between sugar ingested and how the kids acted. It didn’t matter how old they were, how much sugar they got, what their diets were like otherwise — nothing. The JAMA authors stopped shy of drawing any definitive conclusions, but if there were a legitimate sugar-high effect out there, you’d like to see it turn up in the lab every so often.(http://www.straightdope.com/columns/read/2747/does-giving-sweets-to-kids-produce-a-sugar-rush)

From a nutritionist in Hawaii: It is not unusual, due to the misinformation that abounds out there in the public media (books, magazines, newspapers, word-of-mouth testimonials), to think that a ‘sugar high’ is a real thing. In some of the research that I have done with adolescents (almost 200 of them, at one time), we fed the boys as much sugar as we could cram into a breakfast, and not a one had a hormonal profile that suggested hypoglycemia; and, none of them experienced anything resembling a ‘sugar high.’ In fact, if you follow the biochemical pathway of sugar (glucose or sucrose) in the body, what it predicts is a calming effect of sugar, providing nothing else is eaten at the same time.(http://www.madsci.org/posts/archives/2000-01/947564807.Me.r.html)

From a Yahoo source on Health and Wellness: Here’s the big news. The scientific research that has been conducted not only finds no direct correlation between hyperactive activity and sugar, but actually has produced evidence that sugar may well have a palliative effect.(http://www.associatedcontent.com/article/515073 sugar_high_myth_or_reality_pg2.html?cat=5)

From a mother, at Daily Dose of Common Sense: My daughter had a birthday yesterday, and I had several well-wishers ask if she was bouncing off the walls because of sugar. Well, no, actually she was no more hyper yesterday than any other day. Yes, she ate a cupcake, Cracker Jack, Nerds, and a bunch of other junk, but she’s a healthy kid. That, and there’s no such thing as a “sugar high.” I know, it takes a second for it to sink in. We have been led to believe that sugar makes people (especially kids) hyper. But, it’s just not true. Our bodies do a really good job of regulating the sugar we intake. Many studies have been done on this topic and the conclusions are the same: the amount of sugar that a kid eats does not affect his or her level of activity. Jessie from Rational Moms did a great in-depth debunking of the sugar high myth. I highly recommend giving it a read. So, don’t worry about your kids being up all night after eating a bunch of sugar. They’re up late because they want to be up late. Duh. (http://www.dailydoseofcommonsense.com/2009/07/22/the-sugar-high-myth/)

Finally, and maybe you should go here first, this from Rational Moms: Even confronted with this evidence it can be difficult to believe. I’ve heard people grudgingly accept that it may not cause hyperactivity in children but insist that it causes rapid spikes and falls in blood sugar levels which create the feeling of the “Sugar Rush” and the “Sugar Crash.” . . . In this study all mothers identified their children as “sugar sensitive”. All the children were given a placebo (aspartame) but half of the mothers were told that their child was given a large amount of sugar. The mothers who thought their child was given sugar tended to stay physically closer to their child, criticized, looked at and talked to their children more then the parents who knew their children had the placebo. The mothers who thought their children ate sugar also rated their children as significantly more hyperactive than the control group.(http://www.rationalmoms.com/2008/12/01/the-myth-of-the-%E2%80%9Csugar-high%E2%80%9D/)

So, you’ve read the excerpts. More important, I hope you took some time to research this on your own. Good. Now you know for sure – a certainty – that there is no physiological sugar high, rush, or crash in human beings, and that includes little human beings. Not because I said it, or Dr. Dean said it, or those others you read on the web said it. But because, now, you say it. When it comes to behavior the unequivocal answer is no, children aren’t sugar sensitive, there isn’t a sugar high, a sugar rush, or a sugar crash – and there isn’t any wiggle room.

Why is this important? For a few reasons.

One. You and I – and everyone else convinced at one time or another that too much sugar causes children to be hyperactive – are mistaken. That includes your doctor, psychiatrist, teacher, aide, school psychologist, therapist, social worker, and any other professional you’ve relied on to make sure you are accurately informed.

Two. We become frantic when our children eat too much sugar, especially at the wrong time. Sometimes we even chastise the child because he – and it’s almost always he – doesn’t monitor his own sugar intake. After all, he should know by now that he has “ADHD” or an “imbalance” or “sensitivity” of some kind. He is, in a word, sick, and we’re just being cautious about his “condition.” We now know – you and I – this was never true. (By the way, maybe you know someone who has a very bright, 14 year old boy who has said on more than one occasion: “Sorry mom. I know I got hyper last night! I couldn’t stop! OK, OK, you were right! I had too much candy! Sorrreeeee!” Now you know for sure – and so does the 14 year old boy – it’s not the candy.)

Three. We can no longer place responsibility for a child’s behavior on this chemical because of a flaw in his body that was never there in the first place. This idea is going to become very important in Part II.

Four. We both now know our beliefs – even strong, heartfelt beliefs based on our care, our concern and our professional consultation – can alter our perceptions. Whoops, our bad. We need to make up for our mistake, and apologize to our children. You can still say he’s “too active,” however, you at least know now to eliminate sugar as a cause.

What’s the big deal? Is it really that harmful – this false truth about children that we’ve kept alive for way too long? My goodness, parents are educated to believe their child is sensitive to sugar in the way a diabetic is sensitive to sugar. A range of informed professionals explain to parents in convincing detail – usually something about brain chemicals – that their child may be “sugar-sensitive,” or worse, may have a “psychological disease.”

And what do conscientious parents do with this information? They seek out a doctor for their child’s medical condition. The doctor tells parents to monitor the child’s sugar intake, that much is obvious, and that maybe your child should take some medicine – usually Adderall or Ritalin or some other amphetamine – and your child’s disease is treated. Never fixed or cured – there are no fixes or cures available from these doctors – but medically treated.

Here’s an idea, if you have the gumption. The next time you have the opportunity, maybe in private, ask your child’s doctor, therapist, counselor, teacher or teacher’s aide if too much sugar causes children to engage in too much activity. If the teacher tells you it does, correct this common, misguided, and harmful answer. If the therapist persists, share your information and ask that it be checked out. If the doctor becomes frustrated trying to make you understand that you’re a layman, well, when you can, as politely as you think necessary, find another doctor. This one is woefully uninformed – and stuck in it – unlike you. Dr. Dean warned us decades ago that the most resistant to this information are informed professionals. Please, help them out.

Is there a physiological effect of taking in too much sugar? Sure there is. Ask anyone who substituted a pound of Sees candies or a quart of Ben and Jerry’s ice cream for their dinner. When finished with their indulgence, they yearn to nap. In fact, an abundance of sugar does have a calming effect on human physiology, especially on an empty stomach. Also, sugar is often referred to as “empty calories,” and sweets certainly add to the obesity epidemic, not to mention the part it plays in tooth decay. And, as you already know, sugar certainly has a role in diabetes. (More about psychiatry’s dastardly psychi-babble use of diabetes in Part II).

You may guess my point about this. If we could both be so wrong about what we thought was so right, then are there other “truths” that need to be revealed as myths or comfortable conventions or false science? My goodness yes. Psychiatry is the biggest offender, as you will see in the upcoming article.

Finally, fellow convert, please help. To obliterate this harmful lie – and to make it right to all those kids we falsely accused and to ensure the next generation is accurately informed – we must be bold. When you’re at the check-out stand and you hear a stranger talk about “sugar high,” with a smile, ask them to “Google it.” When you’re at your PTA meeting and parents are concerned about all those “sugar snacks” the school is giving, make sure it’s because of calories and general health, and not because “sugar hypes kids.” Keep smiling, and educate them. And the next time you have a family reunion, deliberately bring this subject up so you can get into a friendly family argument and have it settled on the internet. You’ve just done a world of good for the kids in your family, and that’s always good for a smile.

Lest I forget, you can also forward this article to your friends, family members, doctors, teachers, therapists, neighbors – everyone. It’s 21st Century information. It’s not mine. It’s not Dr. Dean’s.

Now it’s yours. Make it someone else’s.

Let’s put the sugar lie to bed – for good.