Discussion

The eleven children (eight boys and thrre 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. buteven 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 intorduced 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 ordianry way to people and situations from the begining of life. Their parents refferred to them as having always been “sel-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 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 motio or noise as threatens to disrupt the aloneness is either treatd “as if it were’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. Althought 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 universl experience is supplied by the frequency with 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 podition in the least when the parents, upon coming home after a few hour’s 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-monthold 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 adjusting. Herbert was at that time capable of sitting, standing, and walking.

Eight of the eleven children acquired the ability to speak either at the usual age or after some delay. There ( 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 eady-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 more and more verses, zoologic and botanic names, titles and composers of victrola record pieces, and the like. Thus, form the start, language-wich 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 theeight 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 shaping his mouth in silent repetition of  words when asked to say certain things. “Mute”Virginia-so her 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 symbolof 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 sholuders. 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 it 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, 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 readly 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 children echothings 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-pwerful 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 taht overeating often resulted 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 gret deal during the first year”), Barbar (“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 all of a sudden began eating satisfactorily.

Another intrusion comes from loud noises and moving objects, whith 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 the children was even afraid to go near the closet in which the vaccum 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 ca 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 markde limitation inthe variety of his spontaneous activies. 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 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 manner as before. He looked pleased, ll 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 thougt there was no definite design. The children’s memory ws phenomenal in this respect. after the lapse of several days, a multitude of blocks could be rearranged in precisely the same unoganized 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 had to be completed from beginning to end in the manner in which it had to be completed from beginning to end in the manner in which it had been started originally. It was impossible to return fron a walk without having covered the same ground as had been covered before. The sight of a broken crossbar on a garage door 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 reulting 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.It 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 thraten to interference 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 spu 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 orgastic 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, hewould at times, while moving between them, gently touch a hand or a knee as on other occasions he patted 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 child needed, the child struggled and became angry with the hand or the foot, wich was dealt with perse and became angry with the hand or the foot, which was dealt with perse 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 placitidy. 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 frustation, 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 gorup photograph, he asked seriously when the people would step out ot the picture and come into the room.

Even thougt 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. Theri 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 hummong 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 gain and gross motor performances, byt 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 2Ѕ years old, and who at 5Ѕ years had two series of predominantly right-sided convulsions. Frederick had a supernumerary niplle 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 in the goverment Patent office, one a plant pathologist, one a professor of forestry, one an adevertising 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 freelance writer, a physiciam, 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.