refrigerator mothers

You could be forgiven for assuming that the ‘refrigerator mothers’ theory for the cause of autism has been consigned to the wastebasket of history. That might be true for children with a formal diagnosis of autistic disorder, but parents are still often under suspicion if their children have autistic characteristics but no diagnosis, or indeed any unusual behavioural characteristics but no diagnosis. Bruno Bettelheim is often credited with inventing the term ‘refrigerator mothers’, but Leo Kanner appears to have come up with the refrigerator analogy first.

Leo Kanner

Leo Kanner

In the comment section at the end of his 1943 paper, Kanner weighs up the evidence for the possible causes of autistic behaviour. The children have schizophrenic characteristics, but their condition differs from schizophrenia because it’s been present from birth – suggesting a biological origin. On the other hand “in the whole group, there are very few really warmhearted fathers and mothers” (p. 250), suggesting that development could have been disturbed by parental behaviour. In the end, Kanner concludes “The children’s aloneness from the beginning of life makes it difficult to attribute the whole picture exclusively to the type of the early parental relations with our patients. We must, then assume that these children have come into the world with innate inability to form the usual, biologically provided affective contact with people, just as other children come into the world with innate physical or intellectual handcaps [sic]” (p. 250).

But Kanner later changes his mind. In 1949 he describes his patients as in refrigerators which did not defrost.* In his 1956 paper with Leon Eisenberg he contrasts the low incidence of psychosis and neurosis in the children’s relatives (a sample of around 1000) with the much higher incidence in families of children with schizophrenia and concludes “Thus, if one limits his search for genetic factors to overt psychotic and neurotic episodes in family members, the results would appear to be negative” (p.8). After some discussion of parental characteristics, he decides; “The emotional frigidity in the typical autistic family suggests a dynamic experiential factor in the genesis of the disorder in the child” (p.8) and “These children were, in general, conceived less out of a positive desire than out an acceptance of childbearing as part of the marital contract” (p.10). But less than a decade later, when Bernard Rimland, in his book Infantile Autism: The Syndrome and Its Implications for a Neural Theory of Behaviour suggested that autism might have its origins in the brainstem, Kanner wrote the foreword. And in 1969, Kanner told the first annual meeting of the then National Society for Autistic children “I herewith especially acquit you people as parents” (Feinstein, 2010).

The discussion in the 1956 paper sheds light on what initially appears to be wavering on Kanner’s part about the cause of autism – now he’s blaming biology, now he’s blaming the parents. Kanner wasn’t so much undecided as aware that both factors could be involved. He goes into some detail about the interaction of biological and environmental factors in producing autistic characteristics and describes early infantile autism as ‘a total psychobiological disorder’ – in other words, it isn’t a case of its cause being either genetic or parental. As Michael Rutter observed; “What we have to differentiate is evidence of a broader phenotype. Kanner switched back and forward, which is a mark of his integrity” (Feinstein 2010).

Bruno Bettelheim


Bruno Bettelheim

For Bruno Bettelheim there was no uncertainty about the cause of autism. At first glance, Kanner and Bettelheim appear to have a good deal in common. They were both born into Jewish families in central Europe around the beginning of the 20th century. Both had their studies interrupted; Kanner by military service, Bettelheim by the death of his father. Both fled to the USA as ethnic refugees, both married and raised families there, and both became successful, respected figures in the field of child development. There the resemblance ends.

Bettelheim was born into a well-to-do Viennese family in 1903. As a teenager, he was fascinated by psychoanalysis and read all he could about it. He enrolled as a student of philosophy and history of art at the University of Vienna, but postponed his studies when his father died from syphilis and he had to take over the family lumber business. In 1930 Bruno married his first wife, Gina, who worked at a Montessori nursery. The couple took in a young American child, Patsy, whose mother had sent her to Vienna for therapy with Editha Sterba, a member of the Vienna Psychoanalytic Institute. Bruno was in therapy with Editha’s husband Richard for a while, and his connections with Patsy, the nursery and the Sterbas were to prove a turning point in his career.

Eventually, he was able to resume his studies and was awarded a doctorate in February 1938. Within a month, German troops had entered Austria and Gina had left for the USA with Patsy. Bruno remained in Vienna with his mother and sister. In June, he was arrested, jailed and then taken to Dachau. In September he was moved to Buchenwald and released the following April in an amnesty to mark Hitler’s 50th birthday. Patsy’s mother, Agnes, had managed to arrange a visa for him, and Bruno was reunited with Gina in the USA in May 1939. By then it was obvious that their marriage was over – both had had affairs – and Bruno settled down with Trude, a former girlfriend. His experience with psychoanalysis and child development also got him a job in the education department at the University of Chicago, which led to his appointment as director of the university’s Orthogenic School in 1944, where he was to remain until the early 1970s.

Most of these biographical details are from Richard Pollak’s fascinating biography of Bettelheim The Creation of Dr B. Pollak is aware that his account might be seen as biased. His younger brother, Stephen, had attended the Orthogenic School until his death in an accident whilst on holiday. Bettelheim’s disdain for the boys’ parents and his claim that Stephen had committed suicide despite Richard witnessing Stephen’s fall from a hayloft, and Bettelheim’s suicide in 1990, were what prompted Pollak to research Bettelheim’s life. Although Bettelheim probably had the children’s best interests at heart and certainly changed the Orthogenic School for the better, reactions to him were mixed to say the least. Comments from school staff, parents, children and his students are peppered with reports of admiration, intimidation and humiliation. There’s little doubt that he beat the children and there are some stories of sexual contact, although these accounts, if true, need to be set in context; corporal punishment was common at the time and the psychoanalytic theory embraced by Bettelheim saw sexual expression as natural. Some people hated him, but others felt that Bettelheim’s methods, even if frowned upon, were well-intentioned.

Refrigerator mothers

Probably more widespread harm was caused by Bettelheim’s view of parents, especially mothers. Bettelheim disapproved of children at his school going home for visits and viewed mothers as cold, uncaring and responsible for their children’s behavioural problems. Bettelheim set out his ideas in a series of books including The Empty Fortress: Infantile Autism and the Birth of the Self. Despite the popularity and influence of this book, it’s not clear how much experience of autistic children Bettelheim actually had. He claimed that two autistic children had lived at his home, although Patsy appears to have been the only one, and she wasn’t diagnosed as autistic. Visitors to the Orthogenic School commented on the fact that the children appeared to be normal, if troubled, kids. Bettelheim admitted only children with no physical or intellectual impairment, thus ruling out more severely autistic children. And the success of his techniques was called into question too. In the 1980s a study showed that during Bettelheim’s period as director Orthogenic School, of 220 children entering the school, only 13 were admitted with a diagnosis of autism (Bettelheim diagnosed many children himself) and not all the children had made the progress he claimed.

Aside from contrasts in their life experience, with regard to their contribution to autism research I want to highlight two key differences between Kanner and Bettelheim; the way they used evidence and their level of relevant expertise.

Use of evidence

Kanner had a medical background, derived testable hypotheses from the best theory available at the time, and wasn’t afraid to change his conclusions if the evidence dictated. Bettelheim had trained in philosophy and appears to have made up his mind in advance about the cause of autism and then selected evidence to support his theory. Pollak refers to an essay Bettelheim wrote about the philosophers who shaped his thinking as a student. Significantly, the philosophers – Lessing, Lange and Vaihinger – all saw historical truth as a construct of the mind. Vaihinger argued in his book The Philosophy of “As If” that even though fictions should not be mistaken for true propositions, they can work As If true (Pollak, 1997; p.15). Bettelheim seems to have put Vaihinger’s ideas into practice; in a cv compiled in 1942 he exaggerated his credentials and frequently reported events in a way which conflicted with the recollection of other witnesses.

Level of relevant expertise

Kanner was aware that his theories about the cause of autistic characteristics were limited by the biological knowledge available at the time. Nonetheless, he clearly understood the complexity of child development and was careful to rule out a number of possible causes for autism before arriving at his conclusions. Without doubt, Bettelheim was also knowledgeable, about psychoanalysis and theories of child development that is; the reference section in The Empty Fortress is extensive. But he appears to have had little knowledge about biology and his explanations for the children’s behaviour are in terms of psychoanalytic concepts only. Indeed, he was actively opposed to biological theories for the causes of autism, attacking Kanner and Rimland in The Empty Fortress and telling Thomas Kemper that his brain studies must indicate a different kind of autism (Feinstein, 2010).

Bettelheim’s influence

What puzzles me is how Bettelheim’s book could become so influential amongst professionals with medical training, long after research into genetics and brain function had shown that psychoanalytic and psychodynamic theories of child development were lacking. Bettelheim was preoccupied by psychoanalytic symbolism. He saw the children’s interest in balls, balloons, light fittings and automobile headlamps as symbolic of their relationship with the breast. Their words had deep symbolic meaning – ‘breakfast’ meant ‘break breast’, ‘Connecticut’ meant ‘connect-I-cut’ and even an interest in the weather on the part of a non-verbal child symbolized her fear that she might be devoured (‘weather’ meant ‘we/eat/her’). This should have been enough to suggest that his theory might not have a solid grounding. Bettelheim’s use of symbolism extended to his lectures, resulting in the (in)famous knitting/masturbation story. Bettelheim is reported to have said to a female student, knitting during one of his lectures; “Don’t you realize your knitting is nothing but a sublimated form of masturbation? You’re sitting in front of the entire class masturbating.” The student is alleged to have replied; “Dr Bettelheim, when I knit, I knit! And when I masturbate, I masturbate!”

Despite the lack of evidence for his theories they were very influential. The Empty Fortress was the first book on autism translated into Spanish, Bettelheim’s lectures were shown on French national tv, in the 1980s most of the books on autism in Danish libraries were by Bettelheim, and it wasn’t until 1998 that the International Association for Child and Adolescent Psychiatry and Allied Professions decided that “parents have absolutely no responsibility for their children’s autism” (Feinstein 2010). As Judy Barron, the parent of an autistic child, observed when she read The Empty Fortress, “I wasn’t a scientific reader and I certainly wasn’t a researcher; I was a twenty-four-year-old mother; but I just didn’t see any evidence to support his pronouncements” (Pollak, 1997, p. 275).

The use of evidence and levels of expertise; two factors that I plan to explore further in the next post.


References

Bettelheim, B. (1967). The Empty Fortress: Infantile Autism and the Birth of the Self. The Free Press.
Eisenberg, L. & Kanner, L. (1958). Early infantile autism 1943-1955. In C. F. Reed, I. E. Alexander and S. S. Tomkins (eds.) Psychopathology: A Source Book, Harvard University Press.
Feinstein, A (2010). A History of Autism. Wiley Blackwell.
Kanner, L. (1943). Autistic disturbances of affective contact. Nervous Child, 2, 217-250.
*Kanner L (1949). Problems of nosology and psychodynamics in early childhood autism. American Journal of Orthopsychiatry, 19, 416–26.
Pollak, Richard (1997). The Creation of Dr B, Simon & Schuster

*Paper behind paywall – the citation is from various sources.

image of Bettelheim: Ottofroehlich under Creative Commons licence

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from syndrome to spectrum

Eagle-eyed readers will have spotted a big difference between Kanner’s 20 ‘essential common characteristics’ and the three characteristics of autistic disorder (impairments in social interaction and communication, and restricted and repetitive behaviour) outlined in fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published in 1994. What happened to Kanner’s syndrome in those 50 intervening years?

To summarise the transformation of Kanner’s syndrome, I want to focus on two papers, one a review by Kanner and Leon Eisenberg in 1956 (I used a reprint of this paper from a book chapter), and the other by Lorna Wing and Judith Gould published in 1979 – the account of their famous Camberwell study. Comments from the authors in Adam Feinstein’s excellent resource A History of Autism shed further light on the changes that took place.

Reviewing Kanner’s syndrome

Kanner’s proposal that he’d found a new syndrome generated considerable interest, debate – and confusion. Similar syndromes with different names were puzzled over. There was much discussion about whether Kanner had found a new syndrome and whether (or in what way) it was related to schizophrenia. By 1956, Kanner’s syndrome had been diagnosed in over 120 children “with reasonable certainty”. Kanner and his new colleague at Johns Hopkins, Leon Eisenberg, reviewed the syndrome in their paper ‘Early infantile autism 1943-1955’ and tried to clarify the situation.

They first collapsed Kanner’s 20 essential common characteristics into five;

the five characteristics of early infantile autism

Several of the original 20 characteristics were omitted;

ability to speak
• physically normal
• food
• masturbatory orgiastic gratification
• from highly intelligent families.

The authors then identify two features as ‘pathognomonic’ (distinguishing characteristics); ‘extreme self-isolation’ and ‘obsessive insistence on the preservation of sameness’. An impairment in communication was no longer seen as a critical feature; “The vicissitudes of language development, often the most striking and challenging of the presenting phenomena, may be seen as derivatives of the basic disturbance in human relatedness.” (p.5). Adam Feinstein asked Leon Eisenberg why he and Kanner had left out the language impairment. Eisenberg said: “I was following Kanner’s lead. It wasn’t that we had extensive discussions.” (Feinstein, 2010; p.47)

Despite this attempt at clarification, the confusion over syndromes and symptoms continued. In 1958 the child psychotherapist E.J. Anthony observed wryly: “The cult of names added chaos to an already confused situation, since there did not seem to be a sufficiency of symptoms to share out among the various prospectors, without a good deal of overlap.” (Wing & Gould, 1979)

Kanner complained in 1965 about a “pseudo-diagnostic wastebasket into which an assortment of heterogeneous conditions were thrown indiscriminately. Infantile autism was stuffed into the basket along with everything else…Such looseness threw all curiosity about diagnostic criteria to the winds as irrelevant impediments on the road to therapy, which was applied to all-comers as if their problems were identical. The therapeutic cart was put before the diagnostic horse and, more often than not, the horse was left out altogether.” (Feinstein, 2010; p.41)

Carl Fenichel, who founded a treatment centre in New York thought differently. At the Leo Kanner Colloquium on Child Development, Deviations and Treatment in 1973 he said; “We scrapped these labels 18 years ago at our place….We found that all these labels are just meaningless… We learn more about these kids from working with them on a day-to-day basis. Too many people feel that sticking a label on them means that they now know what this kid needs. I think this is a dangerous, misleading and destructive process.” (Feinstein, 2010; p.53)

The Camberwell study

The situation was in desperate need of clarification. In 1977 Lorna Wing and Judith Gould, based at the Maudsley Hospital in London, began a study designed to sort out the classification of disorders of social interaction. In 1979 they published their findings. Their paper opens with list of syndromes similar to Kanner’s, which illustrates how confusing the picture was at the time;

dementia precoccissima
dementia precoccissima catatonia
primitive catatonic psychosis of idiocy
dementia
symbiotic psychosis
autistic psychopathy and
early infantile autism.

The symptoms of the syndromes tended to overlap, so rather than starting with the syndromes, Wing and Gould began with the children’s characteristics. They screened 914 children in the London Borough of Camberwell who were known to health, education or social services as having a physical or mental handicap or behaviour disturbance. They identified 132 who showed either the key features associated with impairments of social interaction in the literature (social interaction and verbal or nonverbal language and repetitive, stereotyped activities) or signs of severe retardation.

They found the children could be divided into two groups; the ‘sociable severely retarded’ group who showed social behaviour appropriate to their mental age, and the ‘socially impaired’ group, who didn’t. The only named syndrome that matched the characteristics of any of the children was Kanner’s early childhood autism, so the socially impaired group were sub-divided into autistic (according to Kanner’s criteria) and non-autistic children. (There were further sub-divisions that I’ll look at another time.) Two of Wing and Gould’s findings are especially relevant to a discussion about Kanner’s syndrome.

First, they found a cluster of abnormalities “consisting of impairment of social interaction, repetitive activities in place of imaginative symbolic interests, and impairment of language development”. This cluster became known as the Triad of Impairments. (Incidentally, if anyone knows when this term was first used, I’d be interested to know. My inquiries so far have drawn a blank.)

Secondly, although some children met the criteria for Kanner’s syndrome, the pattern of abnormalities Wing and Gould found within their socially impaired group wasn’t clear-cut; “Unlike the other named syndromes, the behavior pattern described by Kanner could be identified reliably, but the findings of the present study bring into question the usefulness of regarding childhood autism as a specific condition.” (p.27)

Wing and Gould concluded: “The distribution of the variables among the subgroups suggested that they formed a continuum of severity rather than discrete entities”. (p.26)

Later, the continuum became a spectrum. In an interview with Adam Feinstein, Judith Gould said; “we first called it the ‘autistic continuum’ and then we realized that the word continuum had an implication of discrete descriptions along a line, whereas that was not really what it was. It was not a question of moving in severity from very severe to mild… The concept is more like a spectrum of light, with blurring.” (Feinstein, 2010: p. 153.)

Wing and Gould were surprised by their findings. Lorna Wing commented:

“…Leo Kanner would have found it very difficult to accept the idea of an autistic spectrum, because he was so wedded to his idea of a unique syndrome. I myself started off quite convinced that Kanner was right. … meeting the children … showed me that the idea of a neat barrier between Kanner’s autism and the others was rubbish. And slowly, my view was changed. I had to accept the experience in front of my very eyes.” (Feinstein, 2010; p.151)

Wing and Gould’s findings showed that although some children did have the essential common characteristics described by Kanner (presumably Kanner and Eisenberg’s two pathognomonic features), they appeared to have those features by chance, rather than because they had a specific disorder with symptoms as described by Kanner.

What was also clear was that some children’s social skills were not commensurate with their mental age, that impaired social skills were associated with repetitive behaviours and impaired language, but that these impairments varied considerably between individuals. Wing and Gould’s findings have been supported by subsequent research and are reflected in the DSM-IV criteria for autistic disorder.

It’s interesting to note that as the number of children found to have impairments in social interaction went up, so the number of essential characteristics they had in common went down. Those common characteristics also became less specific. There’s a reason for that, which I’ll move on to in a later post.

What can we conclude about Kanner’s syndrome? I’ve suggested there’s little evidence to support what he thought was the cause of his syndrome (essentially a disruption of the social instinct), and Wing and Gould found little evidence to support the idea that childhood autism was a specific condition. Although we can probably reject Kanner’s hypothesis that he had found a unique syndrome, the children he described were clearly showing atypical development, so we’re still left with the question of why autistic disorder, as it’s now called, shows such a wide variation in symptoms and, of course, what causes them.

Before moving on to more recent theories about autism and its causes, at the risk of labouring the point, I next want to revisit the idea of the syndrome, a concept that still underpins the classification of mental disorders.

References

Feinstein, A (2010). A History of Autism. Wiley Blackwell.

Kanner. L.. & Eisenberg, L. (1956). Early infantile autism 1943-1955, American Journal of Orthopsychiatry, 26, 55-65.

Reprinted as:

Eisenberg, L. & Kanner, L. (1958). Early infantile autism 1943-1955. In C. F. Reed, I. E. Alexander and S. S. Tomkins (eds.) Psychopathology: A Source Book, Harvard University Press.

Wing, L. & Gould, J. (1979). Severe impairments of social interaction and associated abnormalities in children: Epidemiology and classification, Journal of Autism and Childhood Schizophrenia, 9, 11-29.