Leon Eisenberg (1956)
Bill Long 12/12/07
"The Autistic Child in Adolescence"
Even though Kanner's historical "snapshot" of autism in 1943 was very helpful in identifying some cardinal features of the disorder, it needed some kind of confirmation or "follow up" study before clinicians could make conclusive remarks about autism. Thus, there was a lot of interest in 1956 when Eisenberg published this article, also appearing in the Pscyhopathology textbook (pp. 15-24), primarily because its focus was on what happened to children with autism when they became adolescents. Did their autism "go away"? Did it become more severe? More pronounced in some predictable way? How did it manifest itself? This essay focuses on Eisenberg's conclusions 13 years after Kanner's pathbreaking study.
Definitions--Once Again--and Results
In order to make sure we are all on the same page, Eisenberg repeats the two pathognomonic features of autism which had been identified by him and Kanner: (1) extreme isolation manifested in the first years of life; and (2) obsessive insistence on the preservation of sameness. Then he gives us the sample size they studied. Eighty children were known to the clinic (at Johns Hopkins) for at least four years and had attained nine years or over. Sixty-three of the 80, or 79%, were traced. Of the 63 cases, 34 were in full-time residential settings and 29 were at home with parents or foster parents. Nine of the children lived at some distance from Baltimore, and Eisenberg had to rely on familial correspondence to "update" his study. He did note, however, that families of children with autism were diligent, and even obsessive, note-takers about the children's autism.
The results were as follows: of the 63 in the follow-up study, three had attained a "good" result (i.e., a person functioning well in an academic, social or community setting); 14 a fair result (i.e., a person who could attend classes in school with age-group peers and have some meaningful contacts with them but who continued to exhibit "schizoid" peculiarities of personality that single him out as "deviant" or to cause "interference with function"), and 46 a poor result (i.e., a person who is markedly maladaptive). It looks like a pretty bleak picture indeed, doesn't it? What more can be said?
Further Comments on the "Results"
There was one feature, however, which was paticularly marked in the group.
"It soon became apparent..that those children who were so isolated from human contact that they failed to develop ..did much more poorly than the others. If we choose as the line of demarcation the presence of useful speech at the age of 5, the total series can be divided into 32 "speaking" and 31 "nonspeaking" children. The outcome of the first group of 32 can be classified as good in 3, fair in 13 and poor in 16 instances. Contrariwise, the outcome of the 31 nonspeaking children was fair in one and poor in 30 cases," (p. 17).
Now you have emerging not only a specific diagnosis or "picture" of a child with autism, but you begin to see that acquisition of language by the age of five is the predominant feature in determining whether a child will have positive prospects for the future. Another conclusion is arresting:
"Our follow-up study fails to reveal any correlation between formal psychiatric treatment and the clinical outcome," (p. 17).
Eisenberg then provides three illustrative case histories to show what he is talking about. I only want to mention one of them, because of what you might call the "Kanneresque" negative inference of mothering that is present in the example. George O. had a fair outcome, even though he was "nonspeaking." But characteristic of his parents was their emotional distance from George. The father was a successful physician and had little to do with his children. Then comes the description of the mother:
"Interaction between mother and child was graphically illustrated when she was requested to place him on her lap. The two sat much like an Assyrian statue, rectangular, distant, rigid...," (p. 19).
Yet, over the ensuing years and infrequent counseling at the clinic a "remarkable" change in mother and child took place. As she became more animated and attentive to his needs, George began to speak and was able to simulate social relations with other children. He scored 91 on his Binet IQ test. The change had been remarkable.
Here are Eisenberg's 1956 conclusions about autism. First, the language issue, cited above, is a good "index" of the extent of autistic isolation. In the absence of speech the probability of "emergence is vanishingly small, apparently without regard to which of the currently available treatment methods is employed" (he doesn't go into what these methods were in 1956).
Second, the separation of early infantile autism from other cases of childhood schizophrenia is now clinically justified. Autism, then, is launching its own boat, so to speak, into the harrowing and turbulent waters of a separate syndrome or disorder. Because language difficulties are normally present with children with autism, the tendency can be to group them with schizophrenics, even though few clinicially detectable hallucinations or delusions are evident.
Third, most of the adolescent children with autism are now functioning at what is, to all intents and purposes, a severely retarded level, even though "they remain distinguishable from cases of 'simple' retardation by their affective isolation" (p. 21).
Fourth, severely autistic children exhibit a preoccupation with the sensory impressions stemming from the world about them, but seem unable to "organize perceptions into functional patterns" (p. 22). For example, an autistic child doing a jig-saw puzzle assembles puzzle parts by the shape of the parts but without respect to its content. Indeed, some children with autism acquire a large vocabulary but with little or no intent to communicate meaning. One may memorize astronomical charts or maps of street car systems but with no interest in the principles or practice of astronomy or transportation.
Finally, they are characterized by a "failure to subordinate individual concerns to social necessity" (p. 22). They have little ability to empathize with the feelings of others. Successful results happen when one has learned to "simulate" the behavior spontaneously exhibited by peers. The dysfunction in autistic individuals
"results in perceptions that are diffuse and stimulus-bound, thinking that is tangential to human goals, and behavior that is maladaptive," (p. 23).
Eisenberg doesn't try to hypothesize further about the etiology of autism, nor does he emphasize any types of treatment that may "help." We saw from his and Kanner's 1956 article that progress was made in those cases where parents and school districts were both committed to helping the child.
It seems that the crucial factor identified by 1956 that might hinder progress is the acquisition of speech. If chidren with autism could be taught to speak by the time they were five years old, then prognosis for a "fair" or "good" outcome was much better.
Thus, even though in 1956 we are grateful for the clinical care in the description of autism, it seems like the best clinicians are in the dark on the causation and treatment questions. We are just beginning...