Mildred Creak, “Psychoses in Children,” 1938

Mildred Creak, “Psychoses in Children: (Section of Psychiatry),” Proceedings of the Royal Society of Medicine 31, no. 5 (1938):519-28.

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Mildred Creak was a British physician who headed the Children’s Department of the Maudsley Hospital in London in 1931. The Maudsley, which opened its doors in 1923, was the first mental hospital in England to offer treatment for mental illness on a voluntary basis and became the country’s largest psychiatric training center. Children were admitted to the Maudsley from the very beginning and pediatric services expanded rapidly during the 1930s. Along with her colleagues, Creak believed that studies of childhood psychoses offered significant insights into adult mental disorder as well as opportunities for the new field of child psychiatry.

The clinical material is supplied by the discharges from the Maudsley Hospital Children’s Department, both in- and out-patients, during the years 1935-36 and 1937 to the end of September. The children are boys and girls below the age of 16, and the cases include all those who were given, on discharge, a diagnosis of a psychosis…. [T]he organic psychoses—i.e. psychosis with known cerebral lesions such as congenital G.P. I. [General Paralysis of the Insane, an enduring diagnosis that expressed optimism that psychiatry was faced with the same kinds of biological disease entities that challenged other medical specializations]—are not here considered. Nor are those cases with epilepsy, encephalitis and chorea included, since a major part of the responsible pathological process is known.

Limiting inquiry in this way, there are 35 discharged cases under review….

It was not realized until after a preliminary survey that this study could be regarded as one of schizophrenia. The affective psychoses in children are known to be rare—a point made by Kasanin (1931), and Kanner (1935) speaks of them as exceedingly rare. Since the total number of discharges from the Children’s Department during the period under review was 1,265 cases, it is surprising, but corroborative of these views, that the series included no instance in which a certain diagnosis of affective psychosis could be made….

This leads to the very difficult question as to what exactly constitutes a schizophrenic illness in a child…. Our clinical conception of schizophrenia in its developed state is built up mainly from the observation of adults, many of whom have already regressed considerably. How far is the picture modified when it is considered in relation to the child, whose intellectual, physical, and emotional growth is still proceeding, so that a regression to an infantile level is by no means a rare occurrence, or necessarily one of singular import?…. The path of maturation is a long one, and at any stage a regression of a purely temporary kind may occur. What is the characteristic which distinguishes such behavior from similar examples which are at once seen as significant stages in the evolution of a serious psychosis? Is it the age at which such events occur…., their temporary nature, their understandability (although the patients rarely understand their mechanism), or is it that they are merely seen as episodes in a life-history, which in other respects appears to be pursuing a normal course?….

Kraepelin (1913) noted and described a small group of cases in young children in which during the first decade of life, a progressive dementia sets in, with features indistinguishable from those marking the schizophrenic dementias of older patients…. Sante de Sanctis (1906) described as “dementia precocissima” a group of cases in young children, some with recovery but others going on to catatonic states resulting in more or less severe states of mental defect. Since the formative years in a child’s emotional development are held to be those before 5 years of age, the contention that environmental factors may be disregarded in these early cases can no longer be supported. Nevertheless, some of them arise so dramatically in a situation which seems to bear no relation to the ensuing illness, that one is driven rather to the conviction that further investigation will reveal an organic and demonstrable cause….

Among the 35 cases here considered, a group can be singled out in which the schizophrenic illness is superimposed on a defect known to have existed from an early age. In four such cases there is a straightforward history of backwardness in school, and mental testing done with a fair amount of cooperation from the child gave intelligence quotients of 78, 66, 67, and 72….

In so far as the findings can be summarized, out of the 35 cases considered, 12 remain ill and unfit to work, five at home and seven in mental hospitals; 14 cases have improved or are having good remissions, three of these 14 have had long periods of hospitalization, and only one of them improved after treatment with cardiazol [a convulsant]; nine remain untraced. Since these 35 are selected out of a total number of juvenile discharges over the period considered, of 1,265, the great rarity of psychoses in children is demonstrated, the proportion being about 2.8%.

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