Comment

The combination of extreme autism. obsessiveness, stereotyp, 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 konwn instances of childhood schizophrenia.

First of all, even in cases with the earliest recorded onset of schizophrenia, including those of De Sanctis’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 alonenness from the verybeginning of life, not responding to anything that comes to them from the outside world. This is most characteristically expressed in the recurrent report 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 theri 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 consistenbly 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 ingredientes 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”patters, 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 shool 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 solitude, an acceptance of at least some people as being within the child’s sphere of consideretion, and a sufficient increase in the number of experienced patters 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 cautions feelers into a world in which they have been total stragers 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 questio-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 wich they satisfy his needs, answer his obsessive questions, teach him how to read and to do things. Second, though people are still regarded s nuisances, their question are answered and their commands are obeyed reluctantly, with theimplication that it would be best to get these interferences over with, the sooner to be able 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 our patients 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 nursey 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 tothe type of the early paental 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 regarging 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.