724 SA MEDICAL JOURNAL 27 October 1979 Early Recognition of Infantile Autism M. VERA BOHRMANN SUMMARY comparative data about incidence, methods of treatment and outcome difficult. It has also led to assumptions This article is primarily concerned with the early recog- which are poorly supported. At the '3rd WHO Seminar nition of infantile autism. Since this syndrome is always on Psychiatric Diagnosis' an attempt was made to clarify a manifestation of disturbed interpersonal relationships, the criteria, but even here difficulties were experienced. the normal development of an early mother-infant inter- It is hoped, however, that the participants' helpful sug- action is described. It should thus be easy to observe gestions will receive general support. distorted interaction and to investigate the cause. Autism is one of several manifestations of impaired interaction. INCIDENCE S. Air. med. J., 56, 724 (1979). The reported incidence in the UK and USA is 2 - 4 per 10000. In less developed and less industrialized coun- The aim of this article is to discuss certain features of tries it is less; whether this is because the incidence is, infantile autism and to assess to what extent early in fact, lower or because cases go unrecognized is de- recognition of the syndrome is possible, the assumption batable. TO reliable figure for South Africa is available. being that the earlier the diagnosis is made, the more The general impression is, however, that among Whites accurately the presence of aetiological factors can be the incidence is less than 2 per 10 000; among Coloureds assessed, and that the earlier treatment is commenced the it is still less, and it is very low among Blacks. better the prognosis will be. The material is drawn from my experience with autisti" AETIOLOGY children and their families over a period of 20 years. The problem of autistic children in Cape Town became so There is little agreement about aetiological factors. pressing in the early 1960s that meetings with parents Opinions depend largely on the orientation of the research and interested professional people were started in 1964. worker and the particular area in this protean syndrome From this a Society for Autistic Children was formed in on which attention is being focused. In a detailed and 1966, and a private school for White autistic children painstaking study of 100 autistic children, Garcia and was started in 1970. Since 1973 this school has become Sarvis' clearly tabulated the aetiological factors. These a Government-subsidized special school. At first the few ranged from family psychopathology, circumstances and Coloured autistic children were seen at the outpatient traumatic events experienced by the child and his family department for child and family psychiatry at the Red to organic conditions such as impairment of perception, Cross War Memorial Children's Hospital, and also after and minor or gross neurological factors. In many cases, school hours at the school for White children. In 1973 several factors were operative. The aetiology, whatever a class was started with 1 teacher; this has developed into it is, makes it impossible for the infant to respond a recognized special school subsidized by the Department normally or to experience infancy in a normal way. of Coloured Affairs. My experience with the diagnosis, treatment and follow- up of autistic children in Cape Town confirms the above findings. I see autism to some extent as a reaction to DEFINITION an environment which does not make sense to the infant Infantile autism is by no means a well-defined condition. and young child. The environment includes both psycho- It is a syndrome, i.e. a group of concurrent symptoms logical and material factors which impinge on the child's which together are indicative of a disease or of mal- genetic endowment. These factors can be pre- and post- adaptive functioning. The Committee of Inquiry into the natal. A genetic factor has been postulated but has not Treatment, Education and Care of Autistic Children' yet been proved. used the following definition: 'early childhood autism Whatever the primary aetiological factors may be, the constitutes a clinically recognizable syndrome, starting result in all cases is one of impaired bonding. Bettel- before the age of 3 years and characterized by self- heim' describes this as 'basically a disturbance of the absorbed and detached behaviour, language disturbance ability to reach out to the world'. In the first instance and ritualistic compulsive phenomena'. 'the world' consists of the mother, and in this 'mother- The diagnostic criteria used by authors and research world' bonding is crucial. workers vary considerably from centre to centre and from country to country. This makes the collecting of BONDING Bonding can be defined as the development of primary Gansbaai, CP affectional ties between a mother and her newborn infant M. VERA BUHRMANN, M.B. CH.B., D.P.H., D.P.M. and the toddler. Much experimental work with animals Date received: 9 May 1979. has been done in this sphere, notably by Harlow and his 27 Oktober 1979 SA MEDIESE TYDSKRIF 725 ~o-workers, who used rhesus monkeys. Close observation interaction. In this field there is no substitute for pain- pf mother-infant couples and discussions with the mothers staking history-taking, not only of events affecting the pave confirmed and elaborated on the experimental find- child but also of how the child and events affect the jngs. Additional insights have been gained by analysts mother, and her relationship with this particular child and working intensively with patients during stages of marked with the rest of the family. regression. Sander: working at the Boston University School of Medicine, has described this process in five stages ranging DEVELOPME TAL mSTORY ~rom birth to about 18 months. He calls these 'adaptive Some features are fairly characteristic of the early relationships' and 'adaptive interaction'. Stage I is of histories of children subsequently diagnosed as autistic. initial adaptation between mother and infant on a primary, It must be made clear that many features encountered in ~hiefly biological, level. The infant's organic needs of being autistic children will be omitted, because some of these fed, being held closely, and being warm and dry trigger only develop at a later stage and also because autistic off specific appropriate maternal behaviour. Stage 11 is children have their own unique personalities which in- ~he period of socially affective behaviour such as the fluence the symptomatology. infant's first smile evoked by appropriate maternal be- Sometimes the early developmental history is apparently baviour and stimulation and is partly dependent on satis- normal, and the onset of deviant responses and behaviour factory interaction during stage I activities. Stage III is occurs after some event which the child experiences as ~hat of increasing interaction over a wider field initiated traumatic such as the birth of a sibling. If such a natural by the infant and calling for reciprocal co-ordinated re- occurrence can unsettle a child to such an extent, there sponses from the mother. During stage IV the mother is reason to believe that earlier normal adjustment had becomes a figure on whom need-satisfying may be actively not taken place. Sometimes the initial stages of adjustment localized by the infant. Stage V is one of co-ordination could have been normal but circumstances were such that of functions and behaviour which can be maintained by the mother was unable to behave in a normal spontaneous the mother and infant in the face of his increasing self- way, nor could she permit her infant to behave normally. assertion and strivings for independence. This can be a It is not uncommon, however, to obtain a history in difficult period, but if the earlier stages were satisfactorily which a mother states: 'he was impossible and difficult established the relationship will be sound enough to from the day he was born'. The opposite is also not un- withstand the anger and frustration felt by both mother known, the parents reporting: 'he was so quiet, we hardly and infant. knew we had a baby in the home and he was even for- In my own experience I have been impressed by the gotten at times'. The parents in both groups almost in- observations of mothers about their response to their variably feel that they 'have no contact with him', 'can't babies. The baby either immediately aroused feelings of get through to him', 'do not understand him', or 'he's responsiveness and closeness or mothers had little in- different from other children'. These statements clearly stinctive feeling for their infants. This emotional reaction illustrate their confusion and despair. seems to be the first evidence of the presence or absence One of the earliest signs of maladjustment is that of bonding. Physical contact immediately after birth seems the infant's anticipatory movement to being picked up is to facilitate a feeling of closeness and a sense of belong- absent. It must be mentioned that this is also often the ing which promotes bonding. case with the blind child. On being held, the baby's body Harlow' states: 'Of all the variables that produce normal is often rigid and he is described as 'not being cuddle- infant-mother affection it seems to me that contact is some'. The opposite response is that the baby's body feels the most important, though nursing is apparently a variable limp and shapeless and melts into the body of the person of measurable importance and warmth is very obviously holding him. This is sometimes incorrectly described as a variable of measurable importance'. being cuddlesome. Bonding can be impaired by many factors because it The first smile is delayed, and when it does appear it is a delicately balanced emotional interaction in which seems vacant and not in response to any person. There intrapsychic factors as well as external and emotional is no direct eye contact, and the gaze seems to be directed factors are operative. In my opinion some of the harm- to a point beyond the observer. This later develops into ful external factors can be reduced. Impaired bonding obvious and apparently deliberate avoidance of eye con- always has an adverse effect on the personality develop- tact. rnent of the child. Such abnormal development naturally Another early developmental milestone which is fre- disturbs family interaction, but fortunately it rarely leads quently absent is that of babbling. In this aspect the to infantile autism. When it does lead to infantile autism, autistic child is like the deaf one. Babbling is the found- the effect on the child and the family is so tragic that ation of normal speech and, if it is absent, normal speech every effort must be made to prevent it, or to recognize development is always impaired. At a later stage the child it as early as possible so that appropriate steps can be may utter a few words, but these are not used for meaning- taken to deal with it and thus reduce much human ful communication. The parents often suspect deafness be- ~uffering. cause speech fails to develop and there is no response to Early recognition depends on an extensive knowledge their spoken communications or to noise. It is not un- ()f development and behaviour during early infancy and common, therefore, that the first special investigation <:hildhood as well as a sensitive awareness of mother-child which is requested is an audiometric one. This can be an 726 SA MEDICAL JOURNAL 27 October 1979 extremely difficult examination, and special techniques same applies to speech therapy. Intensive psychotherapy may have to be resorted to such as an EEG under sedation is rarely practical or feasible. It has been practised success- with evoked responses. fully with a limited number of children in other parts of The ocial respon es towards the parents and siblings the world, and has contributed very much to the under- which usually develop during the first 6 months of life standing of the psychodynamics of the condition. are often absent or feeble. There is no gurgling or kicking One of the most important aspects of any treatment of the legs which serve as expressions of joy. The child strategy is assisting parents to cope with the situation; rarely produces tears when crying, and when upset can making them members of the treatment or educat(onal be difficult to comfort. team by giving them greater insight and understanding, Feeding and sleeping problems are common on the teaching them alternative ways of handling the child, whole, but the typical or nuclear autistic child without and giving them support and assistance during crisis detectable evidence of organic brain damage is usually periods. physically healthy. The early physical milestones such as PREVENTION crawling, standing and walking are normal, but the child tends not to explore the environment in the purposeful It seems that assistance to parents should be available way of the ordinary toddler. Aimless hyperactivity is from the birth of any child where there are indications fairly common, and seems to be associated with overt or of undue stress and anxiety, or where there is evidence covert anxiety. For the above reasons these children are of impaired bonding. The early histories of autistic often regarded as mentally retarded and many of them children almost invariably reveal stress of some kind, and are. it is conceivable that early intervention could prevent the development of the irreversibly detached behaviour so DIAGNOSIS characteristic of autism. Full diagnostic assessment requires a team approach, I have described the kind of intervention possible at because it is crucial to assess all the aetiological factors well-baby clinics in two articles. 7 ,8 It is possible to as correctly as possible. Diagnosis entails more than mere observe impaired bonding at an early stage; by working labelling. with the mother on psychotherapeutic lines this can be The team should consist of a child psychiatrist, psycho- corrected in certain cases, especially those where the child logist, paediatrician, neurologist, and, if available, an is organically normal. It should be mentioned that bonding educational centre for observation. Specialists in other can be a pathological state in the sense that the mother fields related to child health should be available when cannot tolerate the disturbance of the primary unity with required. Before this stage is reached the family doctor, her child. In such cases a symbiotic relationship persists paediatrician and health visitors will be in a position to beyond the normal stage, which deprives the child of the observe deviations from the normal or average. opportunity to develop his independence and unique By the time the child is 15 - 20 months old, it is usually identity. This can lead to the symbiotic psychosis described clear that affectional bonds are poorly developed. The by MaWer.· general picture is one of an absence of effort at meaning- CONCLUSION ful communication, either verbal or non-verbal; the child treats people like objects, looking through them and All health personnel dealing with infants and their parents walking over them; there is no or little separation anxiety from birth and even before birth should be sensitized to but there is self-absorbed pre-occupation with repetitive, any deviation from the normal, i.e. the mutually satis- meaningless activities such as flicking pieces of string, fying experience of being a parent and of being an infant. spinning objects around, or tearing of paper. Some abnormal behaviour patterns are easily corrected, If a diagnosis with as accurate as possible assessment others are not. The common reassurance to parents that of the aetiological factors can be made at this or at 'he will outgrow it' should be used with great circum- an even earlier stage, and a practical treatment plan spection, and only when the behaviour pattern is well can be worked out, the prognosis will be better than at recognized as being normal for a certain age and a part- an older age and in a more chronic state. icular situation. There is little agreement about the details of treatment. Brief periods of 'autistic' or 'stand-offish' behaviour The rationale of most methods depends primarily on can occur in the normal development of most children trying to establish affectional bonds with the therapist and should not be considered to be abnormal. If the or teacher, thus promoting trust and the desire to social- abnormal behaviour persists and other aspects of the ize and learn; stimulating perceptual and cognitive ability syndrome appear, the family should be referred for further and developing whatever skills are available; and treating investigation, The differential diagnosis can be difficult specific organic handicaps such as impaired hearing or because some children react with autistic-like behaviour vision, or epilepsy. If an educational approach is decided in a variety of situations or to an organic handicap which on it can best be done at a special school with specially only manifests itself at that particular stage. trained teachers, special equipment and a high teacher- Assessment clinics for young children are now available pupil ratio. at several centres attached to teaching hospitals and Other methods of treatment are also advocated. Be- children's hospitals, and all doubtful cases should pre- haviour modification techniques have limited application ferably be referred there in the first instance. At present when divorced from a wider educational programme. The only two centres for the full diagnosis of autism exist, 27 Oktober 1979 SA MEDIESE TVDSKR1F 727 one at the Red Cross War Memorial Children's Hospital, 2. Rutter, M., Lebovici, S., Eisenberg, L. et al. (1969): J. Child Psycho!., 10, 41. Cape Town, and the other at the Transvaal Memorial 3. Garcia, B. and Sarvis, M. A. (1964): Arch. gen. Psychial., 10, 530. Hospital for Children, Johannesburg. 4. Bellelheim, B. (1967): The Empty Fortress. ew York: Free Press. 5. Sander L. (1964): J. Amer. Acad. Child Psychial., 3, 231. 6. HarlO\-:, H. F. ill Foss, B. M., ed. (1963): DetermillalllS of IlIlallt REFERENCES Behaviour. p. 29. London: Methuen. 7. Biihrmann, 1. V. (1962): S. Afr. med. J., 36, 901. I. Departmenl of alional Educalion (1971):. Report 01 the Commillee of Inquiry into the Treatment. Educau'!l1 alld Care of Autistic Idem (957): Med. Offr, 47. 335. Children, p. VII. Pretoria: Government Printer. 9. Mahler. M. S. (195): 1nl. J. Psychoanal., 39, 77. Genel'GI PI'Gclice The Treatment of Anxiety States by Drugs and Other Means W. LINFORD REES SUMMARY severity and duration. They may occur as acute severe attacks of panic, may be acute and mild, or may be The place of pharmacotherapy, behaviour therapy and chronic, mild or severe. The prevalence of anxiety states 'biofeedback techniques in the general strategy of treat- in the UK has been given as 2 - 5'% of the total popu- ing anxiety states is critically discussed. The dangers lation and 7 - 16% of psychiatric patients. , and disadvantages 'of barbiturates are described an<l the Anxiety is a common feature of many clinical states value and limitations of other drugs are considered. Beta- and may be found in any medical and surgical condition. adrenergic receptor blocking drugs have a limited but It may be a prominent feature of many psychiatric ill- valuable role in some patients, neuroleptics have a strict- nesses, and is frequently found in depressive illnes es, ly limited place in treatment, and the role of an'(idepres- and in its most severe form in agitated depressive states. sants of various kinds is considered when anxiety is It is also found in obsessional states and is an essential part of a depressive illness. The benzodiazepines are the feature of phobic conditions. Anxiety also occurs in most important group of drugs available for the treat- acute toxic confusional states and may occur in any form ment of anxiety states. The differences between various of dementia, particularly when the sufferer ha to attempt benzodiazepines are presented, with particular reference tasks which are at or beyond hi capacity. It is not in· to their onset of action, half-life and the relevance of frequent in mentally handicapped patients when they try active metabolites of some of these drugs. A knowledge to undertake ta ks difficult for them. It may occur in of the pharmacokinetics of the benzodiazepine drugs is of any form of schizophrenia and is very marked in the practical importance to the clinician. Emphasis is placed form known as pseudoneurotic schizophrenia; contrary on the doctor-patient relationship and psychotherapeutic to popular belief, anxiety may be present in conversion management in which drugs and other treatment serve as hysteria. Anxiety may be an integral part of epileptic tactical aids in the general strategy of care. phenomena, particularly of the temporal lobe variety. S. A fr. med. l., 56, 727 (1979). GENERAL STRATEGY OF TREATME T Anxiety states are disorders in which anxiety is the In the treatment and management of anxiety states, in- primary and dominant part of the clinical picture, the vestigation is an integral part of treatment. The first mood being relatively fixed and persistent and of such step in treatment is the taking of a history, during which degree of severity or duration as to impair well-bein~, the patient is allowed to talk about his past and present efficiency or normal adjustment. A!1Xiety states vary III problems and life situations freely, with minimal inter- ruption from the doctor. The interview enables both the physician and the patient to see which factors in the Department of Ps)'chiatry, Uniyersity of London and St environment, in interper onal relationships or in the Bartholomew's Hospital, London, UK patient's own conflicts may have contributed towards the W. LINFORD REES C.B.E., D.SC., M.D., F.R.C.P., F.R.C. PSYCH. development of his anxiety state. It also enables the (HON.), F.R.C. PSYC~., F.A.C.P. (HON.), Professor and Physician -in Charge physician to develop rapport with the patient and can be the beginning and the foundation of a good doctor / Leclure delivered at a meeting sponsored by Wyeth Laboratorie. (PlY) "Ltd, and held in Cape Town on 17 Apnl 1979. patient relationship.
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