“Autistic Disturbances of Affective Contact,” 1943

This iconic 1943 case study by child psychiatrist Leo Kanner is often considered synonymous with the discovery of autism. In it, Kanner described eight boys and three girls seen in his clinic at Johns Hopkins between 1935 and 1943. Their bizarre behavioral similarities helped make autism visible as a new clinical syndrome.

The eleven cases included children who were mesmerized by objects but indifferent to people, had feeding difficulties in infancy, reacted fearfully to loud sounds, and preferred rigid, repetitive routine over any kind of novelty. Kanner noted their detachment and inaccessibility, their “anxiously obsessive desire for the maintenance of sameness,” and hypothesized that mastery over objects made the children feel powerful. So did the rhythmic spinning, jumping, rolling, and other unusual bodily movements he observed.

The children’s linguistic behavior also set them apart. They frequently confused the pronouns “I” and “you.” Some were echolalic; they repeated the last words or sounds spoken to them. Others had no language at all. Several experienced dramatic regression after making normal developmental progress whereas others had simply failed to develop at all. With such deficits, the fact that a number of the children also had idiosyncratic talents—astounding memories for words, numbers, events, and patterns—was notable. The unusual combination suggested something very different from mental deficiency or feeblemindedness, even though all of the children Kanner saw had been so labeled at one time. Confusing autism with mental retardation was an error, Kanner insisted. All eleven children looked smart to him. They had serious facial expressions and were “endowed with good cognitive potentialities.” This potential could be difficult to see, however, hidden as it was behind bizarre behaviors produced by disordered affect. The children’s normal or even superior intelligence was simply overwhelmed by their dramatic emotional deficits.

The “total picture” of autistic disturbances appeared very similar to “basic schizophrenic phenomena,” Kanner conceded, but all eleven children showed one fundamental commonality that departed sharply from the known symptoms of childhood schizophrenia. Their extreme isolation had existed from the very beginning of life, suggesting that “the children’s inability to relate themselves in the ordinary way to people and situations” was autism’s signature. Children with autism did not withdraw from the human community, according to Kanner, as psychotic children did, because they had never participated in it in the first place.

Without exception, Kanner described children with autism as profoundly, permanently alone. They did not make eye contact and failed to anticipate being picked up by their parents, social responses that healthy infants learned quickly. Social disconnection was eventually publicized as the quintessential autistic attribute. In 1943, however, when Kanner published his case study, autism was not even a familiar word, let alone a recognizable clinical syndrome. The handful of professionals who had seen such children agreed that autism was  extremely rare.

Kanner’s 1943 article offered fascinating, detailed, and memorable clinical observations about how children with autism behaved. In contrast, Kanner was ambivalent about the possible causes of autism. He concluded that autistic disturbances were “inborn,” largely because they were present from the earliest moments of life. But he also profiled the parents of autistic children, characterizing them as obsessive, cold, and overly intellectual people who were concentrated in scientific and technical fields, including medicine. Four of the eleven were children of psychiatrists! The others had parents who were lawyers, plant pathologists, forestry professors, mining engineers, chemists, and clinical psychologists. One father was a businessmen. Nine of the eleven children had mothers who had college degrees and were employed in professional occupations.

Demographically speaking, these children represented very atypical families in the 1930s and 1940s. “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,” Kanner wrote. These observations made it possible to imagine two things at once: that autism was transmitted genetically and that certain types of accomplished, affluent couples created environments at odds with the love and attachment required by newborns.

Donald Triplett was case 1 in Leo Kanner’s famous 1943 article describing autism. Kanner saw him for the first time in 1938 at age 5. He eventually went to college, worked in his family’s bank, and led a successful life at odds with the pessimistic findings of Kanner’s 1972 follow-up study. (courtesy of The Atlantic and the Triplett family)

In the decades after Kanner’s article was published, his clinic saw hundreds of additional children with autistic behaviors. In 1972, he personally followed up on the eleven original cases. All of the children were now middle-aged. None of them had outgrown or been cured of autism. One of the children, Donald T, had completed college, and he and Frederick W were both employed. Both were still living at home with their parents. The others had been institutionalized, mostly in state schools and hospitals, “tantamount to a life sentence…. a total retreat to near-nothingness.” One had died at the age of twenty-nine.

Donald Triplett, case 1 in Leo Kanner’s famous 1943 article, at age 77. After attending college, he went to work in his family’s bank, traveled widely, and enjoyed playing golf. Autism’s “first child” led an exceptional life. (courtesy of Miller Mobley/REDUX)

These dismal outcomes suggested to Kanner that little progress had been made in spite of clinicians’ greater familiarity with autism and their improved ability to diagnose it. It had been almost thirty years since his 1943 article described autism. No one had yet discovered “a therapeutic setting, drug, method, or technique that has yielded the same or similar ameliorative and lasting results for all children subjected to it.”

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