Early Recognition of Infantile Autism by gyvwpsjkko


									 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.
   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
                                                                  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.
   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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