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Kanner(1968)
Polan and Spencer (1959)
Goldfarb (1964)
Rimland (1964)
Lotter (1966a)
Ruttenberg et al. (1966)
Wing (1966)
O'Gorman (1967)
Rutter and Lockyer (1967)
Creak (1964)
White, DeMyer, and DeMyer (1964)
3) Insensitivity to pain S A A A P P
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1967, and Wing, O'Connor, and Lotter 1967), psychosis. As the children mature, psychotic be-
others have found no differences (Alanen, haviors remain dominant or evidence of organic
Arajarvi, and Viitamaki 1964, Levine and Olson damage or retardation increases; there are few
1968, McDermott et al. 1968, and Wolff and Chess reports of complete remission. In a 1- to 7-year
1964). There is no evidence of increased pater- followup of 17 nonreactive child psychotics, only
nal age, and evidence regarding maternal age is two (12 percent) were judged nonpsychotic
mixed (Lotter 1967, Lowe 1966, and Wing, O'Con- (Alanen, Arajarvi, and Viitamaki 1964); in a 6-year
nor, and Lotter 1967). Indications of a lowered in- followup of 43 childhood schizophrenics, 58 per-
cidence of broken homes (Lowe 1966) and of an cent remained schizophrenic, while 33 percent
unelevated or lower incidence of familial psycho- were diagnosed as mentally defective (Gittelman
sis (Alderton 1966, Gittelman and Birch 1967, and Birch 1967); and in a 30-year followup of 12
1968). Although behavior-modification tech- children, Boer (1968) reported that adult-directed
niques have been successful in decreasing self- behavior was absent except when initiated by an
mutilation in some cases (Lovaas 1966, Simmons adult and that only one child engaged in any
and Lovaas 1969, Tate and Baroff 1966), they measurable amount of child-directed behavior.
have been unsuccessful in producing prolonged These results are similar to those found by Hutt
cessation in others (Churchill and Bryson 1968). et al. (1965). Hermelin and O'Connor (1963), in
The data suggest that self-mutilative behaviors comparing autistics and retardates, found that
may originate as rhythmic behaviors which are psychotics demonstrated more alternating ap-
then utilized as adaptive responses by children proach-avoidance behavior and produced fewer
lacking other means of responding to their en- verbal responses to an adult than did retardates.
vironment. It has also been demonstrated, however, that ap-
propriate social behavior can be increased
response to persons) and that avoidance re- condition and duration of failure on sign-lan-
sponses may be related to inability to perform guage tasks.
required tasks.
Parental Reports of Early Symptomatology
Using retrospective questionnaires completed
Repetitive Behaviors by parents, Wing (1969) compared the occur-
Several studies have been specifically directed rence of abnormal behaviors in the early child-
to the measurement of ritualistic or repetitive be- hood of autistic, normal, mongol, aphasic, and
havior. Although individual differences in quan- partially blind/partially deaf children. While be-
tities and patterns of repetitive behaviors have haviorally different from the normal and mongol
been found among psychotic children, their in- groups, the autistic group was quite similar to the
ative indicators as lack of cooperation, lack of at- ported by actual testing. Although Goldfarb,
tention to test materials, absence of physical Goldfarb, and Pollack (1969) reported IQ in-
stigmata, and relatively normal gross motor creases of at least 10 points over a 3-year treat-
skills. More and more children are being tested, ment period in 11 out of 26 childhood schizo-
however, and evidence of severe deficits in many phrenics, Menolascino and Eaton (1967) found
areas of social, intellectual, and perceptual func- no improvement in test performance despite en-
tions is accumulating. hanced cooperation. The administration of in-
The Vineland Social Maturity Scale does not fant items appears to reduce lack of responding
require the direct cooperation of the child and (Alpern 1967 and Alpern and Kimberlin 1970).
has proved useful as an indicator of the nursery Employing an adaptation of the Cattell Infant
school performance of young psychotic children. Scale with autistic children ranging in CA from
these children of mean CA 8-6 (Whittam, Simon, Birch 1967), and to later educational outcome
and Mittler 1966). (Mittler 1966). Furthermore, IQ scores for se-
Although the large majority of psychotic chil- verely psychotic children were found to predict
dren tend to score at extremely low levels, higher educational outcome as well as or somewhat bet-
levels of functioning and large variations in ob- ter than test scores for groups of borderline
tained scores have been observed both within psychotic and nonpsychotic subnormal children
and between groups. IQ ranges of from 50 to 129 (Mittler 1966).
for 30 cases (Schopler 1966), from 54 to 125 for Reports of extreme scatter among subtest
26 cases (Goldfarb, Goldfarb, and Pollack 1969), scores are common, with autistics performing at
from 15 to 60 for 24 cases (Gibson 1968), and higher levels on manipulation or visual-motor
from 20 to 102 for four cases (Krall 1967) have tasks than on verbal comprehension items (Gold
been reported. Spivack and Levine (1964) found 1967, Rutter and Lockyer 1967, and Wassing
the nine scales and significantly lower than sub- and delayed eciiolalia, or impaired communica-
normals on three of the nine scales. tive function. As shown in table 2, the incidence
The increasing administration of standardized of mutism in psychotic children reported in vari-
psychological tests indicates that: 1) Infantile ous studies ranges from 28 to 61 percent; ade-
psychotic children are testable if low-level items quate or normal speech development occurs in 5
are employed; 2) relatively few psychotic children to 43 percent of the reported cases.
obtain IQ scores within the normal range, and Immediate or delayed echolalia is the most
most function at a severely retarded level; 3) IQ common characteristic of psychotic children
scores are remarkably stable over either brief or who do speak. Rutter (1965b) reported that 75
prolonged periods of time, regardless of clinical percent of the speaking children in his study ex-
changes in behavior; 4) scatter within subtest hibited echolalia and 25 percent exhibited pro-
scores tends to be largely a function of poor nominal reversal. Although pronominal reversal
Sample Adequate or
Investigator size Mute normal speech
Percent Percent
Fish, Shapiro, & Campbell (1966) 28 61 *
Gittelman & Birch (1967) 97 36 *
Gold (1967) 7 29 0
Lotter (1966 a & b) 32 28 16
Pronovost, Wakstein, & Wakstein (1966) 14 57 43
Rimland (1968) 24 42 *
level than original speech productions (Prono- Since speech production and comprehension
vost, Wakstein, and Wakstein 1966 and Rutten- are the primary forms of communication between
berg and Wolf 1967). The degree of echolalia is individuals, the relationship between speech de-
negatively correlated with level of language de- velopment and other variables is especially im-
velopment .61 between echoisms and sen- portant. It has been found that speech develop-
tence length—(Cunningham 1966); it has also ment is closely related to: 1) IQ (Fish et al. 1968,
been reported that previously echolalic children Gittelman and Birch 1967, Lotter 1966a, Rutter,
progress to the use of more complex and spon- Greenfeld, and Lockyer 1967, and Spivack and
taneous speech faster than previously mute chil- Levine 1964); 2) degree of improvement in re-
dren (Lovaas 1966a). sponse to placebo and drug treatment (Fish et al.
Other speech characteristics have been de- 1968); and 3) development of relationships with
people (Ruttenberg and Wolf 1967). Wolff and
tistics, while autistics made the most efficient use one of the children learned to discriminate be-
of kinesthetic or motor cues (Frith and Hermelin tween words, and one of the children failed to
1969). Thus, it appears that the general descrip- learn the discrimination between music and si-
tion of autistic children as having well-developed lence in over 13 hours of training. This evidence
visual-motor skills may no longer be appropriate of serious deficits in the processing of auditory
and may, in fact, be misleading, unless the spe- information has been supported by a number of
cific skills in each task are evaluated. investigators who required more specific re-
sponses.
Visual Discrimination Skills Cross-Modal Information Processing
A relatively large amount of data is available to
demonstrate the poor visual discrimination skills Visual-to-Tactile
of psychotic children, even though visual acuity It has been found that psychotic children are
Thus, while the quantity of words accurately re- scribed as having surprisingly good rote memory
peated did not differ among groups, the re- skills, the small amount of empirical information
tardates and normals utilized the meanings of the available in this area is contradictory. In com-
words more frequently than the autistics. paring the auditory-to-vocal memory abilities of
autistics and retardates, Hermelin and O'Connor
Auditory-to-Visual
(1967b) found no differences between groups in
There is a large amount of evidence that autis- the quantity of words recalled. A comparison of
tic children have particular difficulty in under- auditory and visual short-term memory skills
standing language and in making simple audi- of autistics and normals also failed to uncover
tory-to-visual associations (see Peabody scores quantitative differences between groups
above). Cowan, Hoddinott, and Wright (1965) (O'Connor and Hermelin 1965b). Both of these
found that only two out of 12 autistic children studies support the hypothesis that what is im-
essing. Whether these patterns are unique to psy- DeMyer (1964) examined records of 162 children
chotic children or are also characteristic of other who were divided into five groups: autistic,
low-functioning children will remain an unre- chronic undifferentiated early childhood schizo-
solved question until further research involving phrenic, nonpsychotic with acting-out behavior
comparison groups is completed. disorders, neurotic, and psychiatrically normal.
Neurobiological Studies None of the psychiatrically normal children and
only one of the 10 neurotic children showed ab-
Since many of the current theories of early normal EEG activity, but 51 percent of the other
childhood psychosis allow for possible organic three groups demonstrated abnormal EEG's,
involvement, it is not surprising that over 40 stud- most frequently characterized by irregular par-
ies of neurobiological correlates have appeared oxysmal spike-and-wave complexes.
since 1964. However, the results of these investi-
Hutt et al. (1964 and 1965) also found differ-
priate followup tests are indicated for all cases marked effect on the parasympathetic system.
of childhood psychoses, including autism. Abramson (1967), in reviewing some of the
earlier LSD studies, reported that large doses of
Drug Studies LSD and Sansert may be safely administered to
The limited number of drug studies performed psychotic children for long periods of time, with
in recent years with psychotic children has not no obvious brain damage and some general im-
produced dramatic results in terms of consistent provement. Mogar and Aid rich (1969) reviewed
or marked improvement but has strongly sug- seven independent studies in which psychedelic
gested differences in pharmacological reactivity agents were used with psychotic children; they
in psychotic and control children. Mixed results concluded that, since the results consistently in-
have been obtained with a variety of different dicated some improvement, these drugs should
drugs. When trifluoperazine was administered be more extensively used with this population.
Severity of the endocrine imbalance appeared to control serum. A followup study (Gold 1967) re-
be positively related to degree of psychotic dis- ported that larger numbers of animals died when
turbance. injected with psychotic serum than with control
Shapiro (1965) noted a distinctive indentation serum. Although this latter study found no dif-
between thumb and first finger of both hands of ferences in seizure time, it verified the presence
11 severely autistic children (CA 3 to 8) which re- of epileptogenic factors in the serum of psychotic
sembled the configuration of the hand in normal children. Heeley and Roberts (1965) found that
children up to about CA 3. Silver and Gabriel nine of 16 psychotic children had a tryptophan
(1964) found primitive postural responses and metabolism defect. All children with the defect
decreased muscle tone in 30 of 39 schizophrenic had deviant behavior from an early age, whereas
children (CA 8 to 12), while they found this same children who regressed later had normal metabo-
disorder in only one of 39 normal, two of 13 lism. Because of reports that magnesium imbal-
lack and Woerner (1966) noted a significantly from their controls in that they had a significantly
higher incidence of prenatal complications in shorter postrotatory nystagmus than normals
psychotics than in control groups, with the most when tested with eyes open in a lighted room
frequently reported complications being toxemia, after rotary stimulation induced by the Barany
vaginal bleeding, and severe maternal illness. chair. There was no significant difference when
Taft and Goldfarb (1964) reported that prenatal subjects were rotated in a dark room with a blind-
complications were particularly characteristic of fold. The authors suggested that their results
male psychotic children. The data regarding pre- supported the hypothesis that such children have
maturity are contradictory: Zitrin, Ferber, and a unitary organic disease which becomes ap-
Cohen (1964) found a higher incidence of pre- parent with the presentation of multiple stimuli
maturity, while other investigators have reported (rotation plus visual input).
no differences between psychotic and control In a preliminary report of their psychophysio-
received no intensive psychotherapy often ego functioning and the resolution of intrapsychic
showed a better recovery rate than those receiv- conflicts. Alpert and Pfeiffer (1964) reported gen-
ing therapy. This failure of conventional therapy eral behavioral improvement following muscle
has stimulated the development of new therapeu- and rhythmic stimulation of a psychotic child.
tic approaches for the psychotic child, including When body stimulation is used, Wilson (1966)
body stimulation techniques, group therapy, edu- feels that the therapist must approach the child
cational programs, and behavior therapy. rather than wait for the child to make the initial
Psychotherapy move toward bodily contact.
In spite of Rimland's conclusions, the use of In their treatment program for autistic children,
traditional therapeutic methods with psychotic Des Lauriers and Carlson (1969) pointed out the
children is still reported (Des Lauriers 1967, importance of sensory-affective experiences
(tactile, kinesthetic, and proprioceptive stimula-
sary for behavioral improvement. They feel that nell 1966, and Schulman 1963).
these children should be helped to develop basic Other Methods
skills—or at least a means of communication. Two unusual methods for treating infantile
Such broad programs of remedial education re- autism have been reported by Schechter et al.
semble behavior-modification techniques (see (1969) and Robertson (1966 and 1969). In the
below), but descriptions of them usually make no former study, psychotic children were perceptu-
direct reference to the use of reinforcement ally isolated for a period of 6-12 weeks. Each
methods. child was individually placed in a sensory isola-
Elgar (1966) considers psychotic children as tion room void of all furniture except for a mat-
handicapped rather than emotionally disturbed; tress; food was given on an irregular schedule,
she directs her efforts towards alleviating their as was contact with the therapist. During isola-
deficiencies in speech and visual learning through tion, demands and novel stimuli were gradually
efforts to shape new behaviors extremely time- behaviors as simple imitative and more complex
consuming. Although most therapists develop at- tasks of a social and vocal nature. During a rein-
tending responses as the first step in a behavior forcement reversal period, the behavior also re-
modification program, a few have specifically versed but was quickly reinstated once the
concentrated on developing an attentive set. schedule was reestablished, indicating that the
Brooks, Morrow, and Gray (1968) worked with schedule was maintaining control over the be-
a 19-year-old autistic deaf mute and success- havior. Metz (1965) and Hingtgen, Coulter, and
fully increased visual attending responses using Churchill (1967) successfully established imita-
food reinforcers. When reinforcement was dis- tive sets by reinforcing general imitative behavior
continued, response rates decreased but were in autistic children.
quickly reinstated when reinforcement was again
Speech Development
one autistic child. Later he (1965a) extended this tial improvements in the speech of psychotic chil-
program to the home where the parents rein- dren, the extent to which these techniques can
forced appropriate speech. develop spontaneous language, especially in
Some of the most important work in the area of mute subjects, is still unclear. Hingtgen and
speech development with psychotic children has Churchill (1969 and 1971), who used reinforce-
been done by Lovaas and his coworkers. They ment methods during an extensive training period
initially reinforced two schizophrenic children to develop vocal responses in four mute psy-
(CA 6) with food following any spontaneous vo- chotic children, reported a wide variation in re-
calizations (1966a). Gradually, through succes- sults. Although all subjects developed imitative
sive approximations, imitative vocalizations were speech, two of the children were never able to
shaped and subsequently only appropriate imita- make the initial auditory-visual and visual-vocal
tive vocal responses were rewarded. Many associations necessary for spontaneous speech.
hugging or kissing him. A later study from necessary nor appropriate when the goal is to
Lovaas' group (1966b and 1967) provided food develop new behaviors.
rewards for increases in such socially appropri-
ate behaviors as participating in preschool Other Studies
games. Three other studies employing reinforcement
In a 5-week treatment program, Carlin and methods deserve special mention. Hudson and
Armstrong (1968), working with brain-damaged DeMyer(1968) found that the initial use of food as
and psychotic children, used token reinforcers a medium during occupational therapy sessions
to shape social interaction and responsibility dur- facilitated the later manipulation of regular craft
ing group play. They found a reduction in disrup- media by psychotic children. A successful toilet
tive behaviors and an increase in playing to- training program for autistic children has been
Salvatore (1968) found no large differences be- Regarding the comparative effectiveness of
tween these approaches, but Kemph (1966b) in a the new types of therapy, no objective assess-
3-year followup of 51 subjects reported that the ment has been made to date. This problem is
greatest improvement occurred in the group that especially difficult since there are similarities in
had received the most intensive therapy. In a se- actual practice among the therapies, in spite of
ries of studies Goldfarb and coworkers (Goldfarb their different rationales. Body stimulation, group
and Goldfarb 1965, Goldfarb, Goldfarb, and Pol- therapy, and educational programs all involve
lack 1969, and Goldfarb and Pollack 1964) techniques that could be interpreted in terms of
rhatched 26 schizophrenic children for age, sex, behavioral techniques. On the other hand, be-
IQ, and neurological findings and divided them havior therapists do form relationships with the
into organic, nonorganic and unscorable (IQ) children, and such interpersonal responding can-
in the child for which the mother does not com- Weiland (1964 and 1966) and Mahler (1965)
pensate. distinguish between autism and symbiosis, al-
The interaction theories that emphasize break- though both syndromes are thought to originate
downs in the mother-child relationship postulate in the early mother-child relationship. Both in-
a basic failure to develop real object relation- vestigators suggest that autism stems from a ba-
ships. They differ, however, in their interpreta- sic failure to associate the mother as an external
tion of the underlying mechanisms. For example, object with internal need gratification, with re-
while Smolen (1965), Soddy (1964), and Garcia sulting lack of development of elementary ego
and Sarvis (1964) all consider the autistic dis- functions (Weiland 1964) and retraction of affec-
turbance to be due to a combination of organic tive contact (Mahler 1965). Their conceptions of
predisposition and maternal deficiency, Soddy autism differ in that Weiland does not consider
main forever new and novel to him. A similar hy- who is biologically or physically normal at birth
pothesis is presented by Freides and Pierce is prevented from effectively interacting with his
(1968), who suggest that, because of a chronic social and physical environment. One would ex-
imbalance between the nonspecific and specific pect that such deviant behavior on the part of the
somasthetic processing systems, somasthetic parents would be relatively easy to identify. In
stimulation is channeled largely through non- recent studies, however, there appears to be lit-
specific pathways with direct connections to the tle or no evidence of parental psychopathology.
reticular formation rather than through specific On the contrary, they demonstrate low incidences
pathways projecting to the cortex via thalamic of familial psychosis, broken homes, and sibling
centers. Again, the result is that the child is in a pathology, compared to control groups.
chronically high state of arousal which interferes Most nonorganic theories also postulate the
the early work with psychotic children. In the made in answering this question if investigators
first, the childhood psychoses were thought to were more thorough in describing subjects and
represent the earliest manifestations of adult routinely made comparisons with control groups.
schizophrenia. Therefore, the identification of At present, individual investigators employ
etiological factors and the development of effec- differing classification systems, which often are
tive treatment procedures for disorders of child- not readily communicable to the rest of the re-
hood were expected to broaden understanding of search community. For this reason, a number of
adult schizophrenia. In the second hypothesis, investigators have proposed a tri-axial classifica-
psychotic children were believed to be potentially tion system for all childhood disorders (including
capable of normal functioning in all areas of de- aphasias, hyperkinesis, and minimal brain dam-
velopment. If disruptive, environmentally caused age). The proposed system would have be-
and their scores tend to remain quite low regard- and language development and their possible eti-
less of concurrent improvements in cooperation ological significance. To accomplish this goal
and social behavior. When subtest scatter oc- will require greater employment of control groups
curs, it is generally associated with poor lan- (e.g., retarded, aphasic, and brain-damaged
guage development rather than unusual psycho- children) as well as further standardization of
pathology. Therefore, the low intelligence test testing procedures. Finally, to answer the ques-
scores characteristic of childhood schizophren- tion of whether test-item failure is due to low mo-
ics do not appear to be an ephemeral reflection tivational levels (including negativism) or inabil-
of emotional disturbance; instead they seem to ity to perform, techniques for increasing and
represent remarkably stable and useful predic- maintaining high motivational levels (such as
tors of later social adjustment and educational those used in behavior modification) should be
the development of pathology, both the psycho- Hypotheses of organic defects are more con-
dynamic and behavioral theories implicate pa- gruent with the existing empirical data which
rental (particularly maternal) pathology, either in demonstrate many types of neurobiological im-
the form of the parents' unresolved emotional pairment as well as a variety of severe intellec-
problems or their failure to provide sufficient re- tual, perceptual, and language dysfunctions in
inforcement. If we assume—as do proponents of these children. There is no conclusive evidence
nonorganic theories—that psychotic children supporting one organic theory over another, how-
were biologically normal at birth, we should also ever, and the data strongly suggest that there
expect that parental deviations severe enough to may be many forms of organic damage present
have produced such profound and pervasive be- which result in similar maladaptive behaviors.
havioral defects would be readily identifiable. Although some progress has been made, most
some educational programs are based on psy- areas. Only further work will determine whether
chodynamic theories, both the educational and these limitations can be overcome.
behavior therapy techniques emphasize training
in specific academic or preacademic skills (for Summary
example, speech and language development, Recent developments in the study of early
perceptual discriminations, and perceptual- childhood psychoses are reviewed in terms of de-
motor tasks), as well as attempting to increase scription, diagnosis, intellectualiunctioning, lan-
overall attention and social behaviors. guage characteristics, perceptual processes,
Because of difficulties in obtaining adequate neurobiological research, therapeutic proce-
descriptions of initial clinical state and subse- dures, and theoretical position. Despite the vari-
quent behavioral change, relatively few attempts ety of diagnostic classification systems, actual
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Acknowledgment
Preparation of this paper was supported by the
National Institute of Mental Health, PHS, Grant
No. 05154-09 and the LaRue D. Carter Memorial
Hospital, Indianapolis, Ind. We thank Drs. M. K.
DeMyer, J. I. Nurnberger, and Q. F. Moore for
their support and Phil Enz, Judith Smith, and
Janet Allen of the LaRue Carter Medical Library
for their assistance in obtaining the necessary
references. Special thanks are due Lynn Jenkins
for her outstanding technical skill during all
The Authors
J. N. Hingtgen, Ph.D., is an associate pro-
fessor in the Department of Psychiatry, and
a research associate in the Institute of Psy-
chiatric Research and the Clinical Researeh
Center for Early Childhood Schizophrenia,
Indiana University School of Medicine, In-
dianapolis, Ind. C. Q. Bryson, M.S., is alsb
affiliated with the Clinical Research Center
for Early Childhood Schizophrenia, where
she is a research associate.