Thursday, April 2, 2015

Autism Awareness: Leo Kanner 1943

The Plough Circa 1943 ©Am Ang Zhang 1989       
“In 1943 Leo Kanner published a paper that would, with Asperger’s work a year later, form the basis of present day understanding of Autistic Spectrum Disorder. He considered five features to be diagnostic. These were: a profound lack of affective contact with other people; an anxiously obsessive desire for the preservation of sameness in the child's routines and environment; a fascination for objects, which are handled with skill in fine motor movements; mutism or a kind of language that does not seem intended for inter-personal communication; good cognitive potential shown in feats of memory or skills on performance tests, especially the Séguin form board . He also emphasized onset from birth or before 30 months.” From the book, The Cockroach Catcher.

A case extract from his original paper:

Donald T. was first seen in October, 1938, at the age of 5 years, 1 month. "Eating,......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."

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 this nature, and often then he would ask no question except in single words." His enunciation was clear.
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 home-comings, and was indifferent to visiting relatives.

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.

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 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 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 college graduate, is a calm, capable woman, to whom her husband feels vastly superior.

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

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?"

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.

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 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.

When asked to subtract 4 from 10, he answered: "I'll draw a hexagon."
The paper is quite a gem and students of child psychiatry are well advised to read it. Leo Kanner continually questioned the given wisdom of the day; couple that with his keen observation power and curiosity and a natural irreverence to authority, it was only natural that he should have created history by being the first to describe Autism.

Leo Kanner “thought what nobody has yet thought, about that which everybody sees.” 
Erwin Schrödinger Nobel Prize in Physics 1933


The following is an abstract taken form the DISCUSSION SECTION of Kanner's original paper. It may be useful to have another look at what Kanner observed all those years ago. Fortunately for us, he had no other motive except for his keen medical curiosity and observational power:
......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."

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.

Eight of the eleven children acquired the ability to speak either at the usual age/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.

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.

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. 
It is difficult to know for certain whether the stuffing as such has contributed essentially to the course of the psychopathological 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.

"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.

The same type of literalness exists also with regard to prepositions. Apparently the meaning of a word becomes inflexible and cannot be used with any but the originally acquired connotation.

Personal pronouns are repeated just as heard, with no change to suit the altered situation.

The repetition "Are you ready for your dessert?" means that the child is ready for his dessert.

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.

Our patients, reversely, anxious to keep the outside world away, indicated this by the refusal of food. One child had to be tube-fed until 1 year of age. 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. 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.

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 everyday acts are carried out, can drive him to despair.

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. 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.

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.

It was impossible to return from a walk without having covered the same ground as had been covered before.

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.

Two patients began in the second year of life to spin everything that could be possibly spun.

The children sensed and exercised the same power over their own bodies by rolling and other rhythmic movements.

Every one of the children, upon entering the doctor’s office, immediately went after blocks, toys, or other objects, without paying the least attention to the persons present.

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.

There is a far better relationship with pictures of people than with people themselves. Pictures, after all, cannot interfere.

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 commonly used.

They all come of highly intelligent families. All but three of the families are represented either in Who's Who in America or in American Men of Science, or in both.

Autism: Frances Tustin & Entrenchment. 

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