neurodiversity.net | leo kanner: autistic disturbances of affective contact (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 thirtythree-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 learning to ask questions or to answer questions unless they pertained to rhymesor things of this nature, and often then he would ask no question except in single words." His enunciation was clear. He became interested in pictures �nd 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 got 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 interest in." 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 remember anything about the walk." The mother, a colege 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, 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. They 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 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, C�cile for red, etc. Then, going through a series of color mixtures, he proceeded in this manner: "Annette and C�cile 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 spilt 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, echolalia-like. 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 brides 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 autistically. 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, 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. Mumblers 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 he has improved very much, Don is much more independent, wants to do many things for himself. He arches 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 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 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 insofar as he addressed them when he needed or wanted to know something. He never looked at the person while talking and not use communicative gestures. Even this of contact ceased the moment he was told or given what he had asked for.

A letter from the mother stated in Octber, 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

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 pertrified 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 log time, he does it all of a sudden. He wants to be sure he does it right.

He has 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 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 21/2 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 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 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 was 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 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 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.

Library of the History of Autism Research, Behaviorism & Psychiatry

Autistic Disturbances of Affective Contact

CASE 1

CASE 2