neurodiversity.net | leo kanner : childhood psychosis: a historical overview (1971)

In 1867 Maudsley, the noted British psychiatrist, included in his textbook, Physiology and Pathology of Mind, a 34-page chapter on "Insanity of Early Life." In it he not only tried to correlate symptoms with developmental status but also suggested an elaborate seven-point classification, which went as follows:

Anyone superciliously critical either of the terminology based on the then circulating coinage or of the cohesion of the grouping may be reminded that the differentiation of the childhood psychoses has to this day not gone far beyond a degree of controversial floundering.

Maudsley was severely taken to task by his colleagues for daring to acknowledge the existence of "insanity" in childhood. Undaunted, he retained the chapter in the 1880 edition but deemed it necessary to lead off with an introductory paragraph that masterfully combined a seeming apology with a forceful affirmation. He wrote:

"How unnatural!" is an exclamation of pained surprise which some of the more striking instances of insanity in young children are apt to provoke. However, to call a thing unnatural is not to take it out of the domain of natural law, notwithstanding that when it has been so designated it is sometimes thought that no more needs to be said. Anomalies, when rightly studied, yield rare instruction; they witness and attract attention to the operation of hidden laws or of known laws under new and unknown conditions, and to set the inquirer on new and fruitful paths of research. For this reason it will not be amiss to occupy a separate chapter with a consideration of the abnormal phenomena of mental derangement in children.

There have been earlier sporadic anecdotal reports about misdeeds of "mentally deranged" children. Rarely does one come upon an effort to look for explanations on other than pseudomoralistic grounds. All that even the great Esquirol had to say in 1838 about a "little homicidal maniac" was that the 11-year-old girl who had pushed two infants into a well "was known for her evil habits." Maudsley himself, searching for an etiologic common denominator, stated that "neurotic parents" implant a genetic predisposition for the fulminant effects of fright, chorea, convulsions, or cerebral trauma; he raised the question whether all "insanities" of children could be forms of "larvated epilepsy."

Maudsley's chapter is a major landmark in the history of childhood psychoses, which soon became a legitimate topic of psychiatric curiosity. It is worthy of note that in the first 45 volumes of the American Journal of Insanity (1844-1889) there was not a single article pertaining to children. In 1883 Clevenger, compiling a review of the world literature on mental illness in childhood, got together 55 references. In the same year, Spitzka devoted considerable space in his Treatment of Insanity to infantile psychoses, which he declared to be rare and caused by heredity, fright, sudden changes of temperature, or masturbation.

Thus, a little less than a century ago, after some initial reluctance, the doors of academic psychiatry were opened to the childhood psychoses. In the subsequent two decades, the number of case reports in the periodicals increased perceptibly. Four textbooks appeared which dealt exclusively with the subject � one by a German (Emminghaus, 1887),. two by Frenchmen (Moreau de Tours, 1888; Manheimer, 1899), and one by a Scotsman (Ireland, 1898).

All this happened at a time when a newly introduced classification of adult psychoses, which to this day still governs our nosologic nomenclature, was creating a stir in the profession. It is customary to refer to the chaotic state in the pre-Kraepelinian era when genetic terms, such as madness, lunacy, or insanity, constituted an ideational cobweb covering up the distinctive features of basic dissimilarities. A few disease patterns had already been singled out. Kraepelin pulled together catatonic, hebephrenic, simple deteriorating, and certain paranoid states, considered separately before then, under the unifying name dementia praecox. Once this was generally accepted, the question inevitably arose whether and to what extent the new concept could be applied to children.

De Sanctis in Italy noticed among "phrenasthenic" (retarded) children some whose "vesanic" (psychotic) symptoms caused him to study the relationship between mental deficiency and dementia praecox. In 1906, he concluded that, while primarily feebleminded children can display psychotic behavior, others, though neurologically intact and intellectually well endowed, deserve the term dementia praecocissima because of the very early age at which dementia praecox becomes manifest. Soon the Italian and Central European literature abounded with case illustrations and discussions of this "disease." In the course of time, the term lost its validity because the group thus designated was found to be made up of an assortment of disparate, etiologically unrelated conditions.

Nevertheless, De Sanctis did a pioneering job. His careful descriptions and observations led others to compare and contrast and, through their own discoveries, to take a growing number of clearly specified units out of the originally assumed homogeneity.

In 1908, the Austrian educator Heller reported six cases of an infantile affliction that took an unusual course: Onset in the third or fourth year of life after normal development; increasing malaise; rapid diminution of interests with loss of speech and sphincter control; final complete idiotic regression, with retention of an intelligent physiognomy and of adequate motor functioning.

The story of this extremely rare condition highlights a dual and intertwined dilemma of psychiatric nosology � that of generalization versus specification and of assumed nonorganicity ("functional" psychosis) versus demonstrated organicity. Heller's disease was first regarded as the earliest form of dementia praecox and hence "functional." It was evicted from this location when in 1931 brain biopsies revealed "acute diffuse degeneration of the ganglion cells" in the lower layers of the cortex; it was moved to the category of a specific ailment sui generis, "organic" in nature.

Bleuler announced in 1911 that he looked on schizophrenia (his term for what until then was known as dementia praecox) as a common name for a cluster of related conditions. He spoke not of schizophrenia in the singular but of the "group of the schizophrenias." He wrote: "This concept may be only of temporary value inasmuch as it may later have to be reduced, in the same sense as the discoveries in bacteriology necessitated the subdivision of the pneumonias in terms of various etiologic agents."

In retrospect, it is indeed easy to stand in admiration of Bleuler's prophetic vision. He himself had next to nothing to say about children. Having made the above-quoted reservation, he gave a brilliant general summary of adult and adolescent schizophrenia (in the singular) with its Kraepelinian varieties. Meyer, stressing the significance of constitutional factors as well as life experiences, saw schizophrenia as "still definitely an entity with nosologic pretense," as "an abnormal reaction which certain individuals develop as an inadequate adaptation to the total life situation," as "a habit disorganization on constitutional ground."

It took more than two decades before a sufficient overall grasp could develop to allow a similar characterization of infantile schizophrenia. In 1933, Potter formulated a set of criteria that could be applicable to children: To justify the diagnosis, there must be (a) a generalized retraction of interests from the environment; (b) dereistic thinking, feeling, and acting; (c) disturbances of thought, manifested through blocking, symbolization, condensation, perseveration, incoherence, and diminution, sometimes to the extent of mutism; (d) defect of emotional rapport; (e) diminution, rigidity, and distortion of affect; (f) alteration of behavior with either an increase of motility, leading to incessant activity, or a diminution of motility, leading to complete immobility or bizarre behavior with a tendency to perseveration or stereotypy.

By the middle of the 1930's infantile schizophrenia was plainly on the map. It was placed there differently from the manner in which its adult counterpart had been placed. Kraepelin had assembled several previously described syndromes under one common nosologic roof. The observers of children at first took over the same structure in toto. Eventually, looking under the roof, they noticed that their patients displayed some obvious dissimilarities of incipiency and clinical course. Independently of each other, Homburger in Germany, Sukhareva (2) in Russia, Lutz in Switzerland, and Despert in this country recognized two distinct varieties � those with acute onset and those with insidious onset. Bender, widening the roof beyond the Kraepelinian boundaries, distinguished under it three clinical types: pseudodefective, pseudoneurotic, and pseudopsychopathic. In 1943 Kanner reported the syndrome of early infantile autism as "a pure culture sample of inborn autistic disturbance of affective contact." In 1949 Mahler and Furer introduced the concept of symbiotic psychosis occurring in "constitutionally vulnerable infants." In 1956 Goldfarb described a contrast between "organic" and "non-organic" infantile schizophrenia.

For quite some time, "constitutionality" or "innateness" was spoken of diffusely as an absolute prerequisite. Bender went beyond this generality by stating more specifically that schizophrenia is

a psychobiologic entity determined by an inherited predisposition, an early physiologic or organic crisis, and a failure in adequate defense mechanism; schizophrenia persists for the lifetime of the individual but exhibits different clinical or behavioral or psychiatric features at different epochs in the individual's development and in relationship to compensating or decompensating defenses which can be influenced by environmental factors.

This formulation reduced the major dilemma still floating about as a leftover from the old body-mind dualism. It helped to lay at rest the either-or antithesis of functional and organic by pointing to the fusion of innate as well as experiential components.

In the early 1950's, Rank created the concept of the "atypical child" as an overall designation for children presenting signs of "ego fragmentation" in close connection with maternal psychopathology. The underlying idea was: Why bother about questions of genetics, organicity, metabolism, or anything else if we can proceed promptly with the psychogenic denominator common to all disturbances of the ego? Thus a pseudodiagnostic waste basket was set up into which went "all more severe disturbances in early development which have been variously described as Heller's disease, childhood psychosis, childhood schizophrenia, autism, or mental defect." With a perfunctory bow in the direction of "heredity and biology," mother-infant involvement was decreed to be the sole key to everything that goes on within or around the neonate.

On the whole, however, there has been a tendency in the past three decades to study infantile psychoses with close attention to all their variations and to investigate all conceivable etiologic and developmental factors. The scientific refinements in the past half century have made this increasingly possible. One may enlarge a bit on Bleuler's bacteriologic analogy. There was a time when all "fevers" and "plagues" were referred to a nondescript "miasma"; the discoveries of the microbes broke it up into specific pathogens producing specific diseases and suggesting specific methods of treatment and prevention. We have entered on a similar stage with regard to the childhood psychoses. We have been moving away from miasma-like summary explanations based on opinions, wholesale postulates, and armchair play with semantics in search of factual data of origin, phenomenology, pathology, epidemiology, and psychodynamics. What is more, the accumulated findings, fractional though they still be, led to a manifold array of experimental and heuristic therapeutic endeavors, beginning to be checked by controlled followup studies.

Exactly 90 years ago, Maudsley felt called upon to apologize for so much as making childhood psychoses mentionable. At present we are witnessing a veritable avalanche of publications with thousands of articles and hundreds of monographs crowding the international literature. A helpful incentive has come from groups of parents who had become impatient with the laissez-faire preoccupation of earlier academicians with generalities, speculations, and satisfaction with would-be diagnostic name-calling. By far the greatest incentive is coming from child patients themselves who, not having read those articles and monographs and unconcerned about existing nomenclature, present themselves as they are and thus, as individuals, continue inviting further refinements of criteria for differential diagnosis.

So acute has been the understandable excitement about trying to solve the riddles of infantile autism and schizophrenia that other psychotic conditions of childhood have received relatively little attention. Of late, there have been serious considerations of manic-depressive episodes. There has been, regrettably, a reduction of interest, stimulated by Weygandt in 1915, in psychotic phenomena observed in children with basic mental deficiency. Moreover, the psychotic behavior associated with clearly demonstrated cerebral and metabolic disorders has, at least in this country, been dealt with rather sparingly; Stutte in Germany and Bollea in Italy have become the principal exponents of these much-needed investigations.

This brings to a conclusion the admittedly sketchy outline of the history of childhood psychosis. A complete chronicle remains to be written and would best be reserved for a future date. For, after the preliminary events sketched above, the history is at present in its vigorous incipiency.

Hence, the time has now become ripe for a central depository for the variegated clinical and research activities in many related sciences and in many countries. We are still far from knowing all there is to be known but we are learning how to ask pertinent questions and how to go about looking for the answers. Luckily, the leading contributors, many of whom are well-known pioneers, have readily agreed to join an integral task force of collaborators in forming the editorial board of this new multidisciplinary journal "devoted to all psychoses and severe disorders of behavior in childhood."

(1) Requests for reprints should be sent to Scripta Publishing Corp., 1511 K Street, N.W., Washington, D.C. 20005.
(2) Also known in the Western literature as Ssucharewa.

SELECTED REFERENCES

Bender, L. The nature of childhood psychosis. In J. G. Howells (Ed.), Modern perspectives in international child psychiatry. Edinburgh: Oliver and Boyd, 1969 (210 references).
Despert, J. L. The emotionally disturbed child, then and now. New York: Vantage Press, 1965.
Goldfarb, W., & Dorssen, M. M. Annotated bibliography of childhood schizophrenia. New York: Basic Books, 1956.

Library of the History of Autism Research

Childhood psychosis: a historical overview

SELECTED REFERENCES