The Early Natural History of Childhood Psychosis Henry N. Massie, M .D.

This paper reports on two cases of early ch ild hood psychosis, and on findings obtained from an intensive an alysis of movies of the infancy and early ch ild hood of. the two ch ild re n . In both cases, the parents made these films before they reali zed their children were ill, and therefore before any diagnostic or therapeutic intervention. Thus, the films ser ve as a kind of prospective study documenting many aspects of two ch ild re n's infancy. The movies show the children developing th e first signs of psychosis in their first year, and its features toward th e end of their fir st yea r and in their second and third years . The film analyses, coupled with the clinical investigation made when the cases came to professional attention, provide a rare opportunity to study the early natural history of childhood psychosis. Although thi s is a report of intensive case studies of two children with autisticlike psychoses , it is also the pilot phase of an extensive research project involving man y cases with home movies. I report it now to illustrate the theory and methodology of film observation , and the kind of new information that it ca n provide; and also to present the important data that these two cases have revealed, with their implications for understanding the mechanism of symptom ~evelopment and preventing and treating ea rl y childhood ps ychoSIS.

Under ordinary clini cal and research conditions, early history is Dr. Massie is Research Psychiatrist at Mount Zion Hospital , San Francisco, and Coordinator of Mental Health Services for Children, Division of Outpatient Servi ces, San Francisco General Hospital . The sources of methodology and 7TUlny of the original insights in this in vestigation are hard to distinguish. / would like to express my deep indebtedness to Al Schejlen at the Albert Einstein College of Medicine. Many of the original ideas and much of the methodological approach grew out of collaborative viewing sessions with him . Am ong 7TUlny others who were helpful during these sessions were Daniel Stern of Columbia University and El ean or Galenson at Albert Einstein in Neui York City. Essential support came from Calvin Settlage , J oseph Aftenna'l, and Hal Samp son at Mount Zion H ospital. Contact with Justin Call of the Un iversity of California was also invaluable, af has been the assistance of the staff of the East Bay A ctilJity Center, Oakland, California . Reprint. 7TUly be requested fro m the author at Department of Psychiatry, Mount Zion H ospital and Medical Center , 1600 Dioisadero, San Francisco, Calif. 94115.

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elusive for several reasons. Our knowledge of it is based largely on retrospective history taking or on secondary reconstruction during the course of therapy. But, as the film study demonstrates, such history taking is prone to faulty recall and unconscious distortion. Also, a history records only conscious material, and many of the most important developmental aspects of a mother-infant relationship do not become conscious. Furthermore, the task of describing the early natural history-either through assembling historical material, or through organizing prospective studies with enough subjects so that a small sample would develop illness-demands that the investigator know what kind of information he is seeking. In contrast, some of the most important information obtained from the two cases that this paper reports has not been obtained or reported. It may not have been sought or obtainable through history taking; or, in the few prospective studies of the development of psychosis in early childhood, it was not sought. In my two cases, frame-by-frame analysis of the filmed movements of mother and child reveals that in such aspects of their relationship as mutual eye and body posture movements, the mother and child form a dyadic, organic unit. This unit was deranged when compared with "normal" units in control films. My approach to studying the nonverbal aspects of relationships owes much to recent work in kinesics (Scheflen, 1972; Birdwhistell, 1970), ethology (Kendon, 1967; Ferber, 1972), and infant studies (Stern, 1971; Call, 1964; Korner, 1972). It also builds upon such pioneering infant observation studies as those of Spitz (1965) and Escalona (1963). However, the latter workers described motherand-child interaction in a more holistic manner than do the analyses of two children's films in this article and some of the recent nonverbal behavior studies. The pioneering infant studies both built upon existing theory and expanded it. Similarly, the microanalytic study of these films reveals new data about mother-and-child interaction, initial signs and symptoms of illness, and constitutional and neurological integrity of the infants-data consistent with theories of childhood psychosis. But it also suggests several avenues for future research, for clarification and development of theory and nosology, and for clinical application. The next sections of the paper present the clinical case histories, the technique of the film analysis, and the data derived from the home movies. Following this is the discussion of the findings. The histories of the two children-Joan (case 1) and Tony (case 2)-are somewhat altered for reasons of confidentiality.

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I:

685

JOAN

Joan came to treatment when she was 3Y2 years old, after a nursery school teacher suggested a psychological evaluation because of her isolation from other children and her lack of speech. She had been enrolled in the nursery school on the advice of her pediatrician, to spur development. The parents themselves had for the first time become concerned about their child's uncommunicativeness and unresponsiveness shortly after Joan's only sibling, a brother, was born when she was 3. When first seen at age 3Y2, the child showed many of the classical signs of autism (Kanner, 1943). She spent most of her time by a wall in repetitive, stereotyped activities, such as spinning and dropping blocks, sifting sand, or staring out the window. She would also cruise around the room, repeating a course that included touching objects and occasionally spinning herself. Not only did Joan not make eye contact with her therapist or parents; she assiduously avoided any eye contact by moving away, or, less frequently, by turning only her head away while remaining near. She gave the appearance of existing in a self-contained world, except for rare instances when she approached her mother or father, turning away about three feet before reaching them. She then seemed content to playa stereotyped game close to them. Speech consisted of occasional mumblings, a rare disconnected word or short phrase, and rare appropriate words or phrases such as "no, give me, go home." The child's affect was largely one of contented self-absorption. If frustrated or if prompted by internal cues, she might cry piteously. There was no aggressive display. Although she resisted being held, if vigorously swung in the air her initial anxiety often gave way to pleasure or excitement. She was physically attractive. Coordination and locomotion were unremarkable, except for episodes when she waved her hands in a Happing motion and her fingers in a dancing motion. These movements or aut.isms were

sometimes accompanied by standing on tiptoe, and frequently occurred when she became excited. Joan had not achieved bowel and bladder control; she used a cup and fed herself with her hands, refusing to eat with utensils. Given Joan's obvious disturbance, it was hard to understand how a psychological evaluation had not been made until she was 3Y2. Since the parents were intelligent and not isolated, there must have been a great deal of denial of their child's condition. The father, in

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his late 20s, was an actuary; the mother, in her mid-20s, had worked as a secretary before becoming a full-time housewife and mother and pursuing various activities in the community. There were several striking features in the histories of both parents. The father was the middle child in a family of several brothers and sisters. A younger sister suffered the first of several schizophrenic decompensations in high school. An older brother and sister were his father's favorites, he felt; they became lawyers. He described his mother as kind, but less influential than his autocratic and selfdramatizing father. As a teen-agel', he had felt that his father belittled him when comparing him to his brothers and sisters. To this he responded by excelling in school, feeling that he could not trust emotions but only intellect. He felt he might hurt himself or others if he became emotional, for he might get too angry. He described himself as consequently shy and was drawn to his wife, when they met in college, by her similar shyness and intellectual interests. Joan's mother was the oldest of several sisters. Significant in her recollections was the feeling that in spite of the large family, she was an unwanted child. She spoke of her mother as overwhelming and intrusive, and had a painful childhood memory of her father taking food from her. She had friends, but felt chronically timid; and the recurrent emotional theme of her life at many stages was that of being used and not supported by her parents, suggesting a paranoid quality. Although Joan's mother was an attractive, wellmeaning woman, her actions with her daughter-and with most people-were wooden, mechanical, and uncertain. She had marked difficulty looking people in the eye; she called it her shyness and insecurity, and related it to her battles with her powerful mother. At one level, this difficulty suggested strong inhibitions and conflicts about exhibitionism and the visual conveyance or perception of aggression. At another level, there were indications that this represented a more serious fear of and defense against ego dissolution or fusion with another person. Thus, when the therapist left on vacation after a year of treatment of the mother and child, she spoke of fearing death and recalled similar fears in her childhood when people left for short periods. It seemed as if the mother's pathology around the issue of separation paralleled in a less severe way her daughter's failure of individuation. Joan's developmental history revealed a normal pregnancy, delivery, and neonatorium. The milestones of social smiling, sitting, standing, and walking all occurred within normal limits. The parents described their child as always placid and content, making

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few demands. eating regularly and well, and sleeping easily. The mother breast fed, and by the third month the child gave up her demand for a nighttime feeding and slept through the night. Several events of great significance were telescoped into the fourth month. A great-grandfather, to whom the mother felt a strong attachment, died, leaving the mother depressed and tearful but still pursuing her activities. The father also experienced a family loss. During this time, Joan was weaned in a single week because she had begun taking solid food and the mother thought this was an indication to stop breast feeding. In addition, she was moved out of the parents' bedroom. The parents recalled no response from the child to these events. In retrospect, however, pernicious features began to appear in the second half of the first year. There was no recollection of stranger anxiety then; and subsequently, in the second year, no evidence of separation anxiety when joan began to wander freely about the backyard and out of her parents' presence even in strange places. When she could stand at 9 months, she began a persistent and frequent habit of awakening in the middle of the night and bouncing at her crib rail or sitting and dropping toys while humming or singing nonsense syllables. Later, in the second year, she behaved in this self-involved manner with a peaceful or serious expression on her face in the company of friends or relatives. The parents felt that she was growing into a very independent, serious girl. At about 12 months. a few words appeared that sometimes seemed to be used appropriately. "Mama" and "dada" appeared early in the second year, but the parents could not recall with any conviction that the child used these words to identify them. Toilet training was attempted futilely at the beginning of the third year by sitting the child on the potty after meals, but there was no indication that Joan had any recognition of genitalia or other body parts. Her medical history had always been negative. At the time of psychiatric evaluation, neurological examination, EEG, and other medical screening tests were all normal. Technique of Film Analysis

The family provided approximately 2,000 feet of home movies of their child's early life . The movies began within hours of the child's birth and terminated when Joan was 3 years old, the age she was diagnosed as ill. Initial viewing of the films revealed that they were not unlike home movies an average family might take. The films included footage from most months of the child's life, capturing

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most often holidays, anniversaries, and family gatherings. The father generally photographed the daughter without posing her, while she pla yed by herself or was with her mother. Clinicians have examined such movies from time to time, generally for their narrative elements; that is, they have noted a child's and a family's life , and filled in the history of symptom appearance. Going be yond this, I applied what can be called a microanalytic examination to the mo vies in the belief that certain essential features of the mother-infant interaction might become apparent only through such examination. Following the technique used by Birdwhistell (1970), the movies are viewed once in entirety for first impressions, which are recorded. They are then viewed at least ten more times for further impressions of such key parameters as social interaction, postural kinesics, individual behavior of the mother and of the child, and psychomotor development and symptomatology of the child. Again, these impressions are recorded. By this time, certain phenomena may have appeared particularly noteworthy. Film segments of these phenomena are then examined microanalytically. For example, slow motion and frame-by-frame analysis resolve suble ties of movement, behavior, and interaction. The research generates three categories of observations. The first category-social interaction analysis--includes the observation of the mother-infant dyadic gaze patterns (the pattern and rhythm of mutual looks and eye movements between mother and child). It includes observation of recurrent activities like feeding, holding, playing, and stimulating. It includes postural kinesics, an attempt to characterize the general quality of interaction-the rhythm, the use of space, the use of arms and hands, affect, posture, body tonus, and kinesthetic quality. In all of these observations, key elements for study are first, the pattern of initiation, maintenance, and termination of an activity involving social interaction, and second, the giving of and responsiveness to social cues. The second category is the recognition of the initial signs and symptoms of childhood psychosis, and the observation of their development and change. The third category is the psychomotor development of the child, based on the standard norms of the Yale Child Study Center schedules. In addition, within this category the observer notes any gross signs of neurological dysfunction or lack of constitutional integrity. Objectivity has been attempted in several ways. A series of control home movies of normal families has been studied, and observations of them are at variance with observations of the two subject films. In addition, within this category the subject films themselves

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provide a control, since it is sometimes possible to compare the actions of the mother with the infant who becomes ill to her interactions with a normal sibling. Moreover, clinicians have assisted in consensual validation of the findings. Finally, observers evaluate in a double-blind manner films of normal and subject families. Results

of the Film Analysis

The movies of Joan's infancy before diagnosis demonstrated that: 1. On the basis of gross clinical impressions of her physical and motor development, Joan was an intact child without gross neurological stigmata. 2. The crucial development milestone of eye movement, eye focus and fixation, and the social smiling responses were unremarkable until the sixth month. 3. Motor behavior (as demonstrated in general body movement, head and torso control, and manipulation) also appeared normal until the sixth month. Later, major motor milestones such as sitting, crawling, standing, and walking all occurred normally. 4. From birth, the child had less activity, visual pursuit of objects and people, and reaching than normal children have. Such observations were usually made in footage taken when Joan was lying alone in the crib or in the company of toys and family members; they were compared with later footage of Joan's normal brother, with control films, and with clinical observations of other children. 5. From birth and into early childhood, Joan's body tonus is more flaccid than is normal. This judgment derives from observation of the child's muscle tension, muscular activity, and posture during periods of rest, quiet activity, vigorous activity, and even pleasurable arousal. 6. For the first 6 months, Joan's mother repeatedly avoided making eye contact with Joan, although she did look at her child. This is perhaps the most important observation, and is in the category of social interaction analysis. It requires detailed description to make sure of its significance. In one scene when Joan was 3 months old, the mother forcibly turned the child's head away when she tried to look at her. In another scene at 4 months (a scene long enough to permit detailed analysis of dyadic gaze behavior between mother and infant), the mother repeatedly avoided making eye contact with the baby. Her eye and postural behavior was dyssynchronous with the child's, so that she removed her head from the baby's field of vision when the baby turned to her mother. Figures 1-4 are a set of sequential drawings of this interaction. A composite of the sequence, the figures cannot detail every movement,

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since they cannot reproduce all of the steps that the frame-byframe analysis of the film reveals. The full sequence is described below, illustrated by the drawings that most closely depict each phase of the interaction. At the beginning of the sequence the child is being held by the mother (Fig. I). Both child and mother appear relaxed and content. At first smiling, the child then turns both head and eyes toward her mother's face. The mother's expression becomes tense; and as she tenses instead of turning to her child, the baby also loses her smile (Fig. 2). The mother then (Fig. 3) inclines her head backward and to the side of the child's face so that the child's head is blocked. The baby cannot turn her head further to bring herself face to face with her mother; the child's eyes are to the right as far as she can turn them, but she cannot reach her mother's face or eyes with her own. The baby's affect in quick succession becomes tense, then desperate, then dejected. Finally (Fig. 3), the child has given up trying to turn to her mother; the mother herself is more relaxed (Fig. 3), the evasive actions having been successful. The mother and baby then (Fig. 4) resume the same postures as in the beginning of the sequence, although the child's affect is initially depressed on reverting to this position. At this point (Fig. 4), the mother begins to caress her daughter's head; the baby drools slightly with pleasure and begins to smile. This completes the sequence of illustrations. At this point in the movies, however, the whole interactional sequence repeats itself, for the child again attempts to look at her mother. Rare scenes did appear when the mother met Joan's gaze. However, she was at arm's reach from the baby and outside of the child's best focal distance. On one occasion, the mother met her daughter's gaze while a relative held her. She held this position for a moment before placing her face directly in contact with the child's. This also effectively blocked dyadic gaze. That this behavior was strikingly aberrant is confirmed by comparison to control films, as well as to later scenes with the younger, healthy sibling. There are many scenes in which the mother fixes her gaze on the younger sibling's face while holding the baby comfortably in her arms. The interactional analysis of case I reveals that from the baby's first month, the mother rarely initiated activity that might arouse a response in the baby. The mother was stiff and self-contained; the movies captured no cuddling or playfulness. On the other hand, the child actively initiated contact with her mother in the first half year.

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Figure I. Mother and child are relaxed. Mother touches baby's cheek,

Figure 2. Child turns her head and eyes toward mother's face. Mother's expression tenses and her eyes shift away from child's face . Child tenses.

Figure 3. Mother shifts her he ad backward and to the side of the child's face , blocking child's facial approach and obstructing eye contact. Mother relaxes. Child appears dejected,

Figure 4 . Mother and baby resume original poSlUres, not in eye contact, Child's expression shifts from dejection to pleasure and drooling appears when mother pat s child's head.

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7. Symptoms of childhood psychosis first appeared when Joan reached 6 months. Starting about this time, the child no longer initiated eye contact with her mother, and since she no longer looked at her, Joan lost visual pursuit of her mother at close or long range. Between 6 to 8 months, her expression became more and more self-absorbed and her affect more and more constricted, showing little pleasure or displeasure. By 9 months, she began to have episodes of what appeared to be hallucinatory excitement-a response not to people or things in her environment, but to some internal stimulus. At 9 months, she also began to show intense pleasure in accompaniment with her increasing ability at locomotion. By 9 months, Joan had fixed psychotic behavior. She kept physical distance from people and looked only at objects. Moreover, she had developed peculiar shaking and rotating movements of her hands and dancing movements of her fingers, as if she were playing an imaginary piano. These autisms appeared frequently and lasted for a few seconds, often when she was excited, often for no apparent reason. Although symptoms were not apparent until 6 months, Joan may have had prodromal signs of childhood psychosis as early as the first 3 months. Prodromal signs in the first 3 months, for example, may have been her less-than-normal activity, visual pursuit, and reaching, and her flaccid body tonus. Prodromal signs in the second 3 months may have been her lack of attentiveness to, fixation on, and excitement at people or objects, Table I summarizes the film analysis of case I, and serves as an overview of the research, giving a chronological picture of the mother-child relationship, the longitudinal course of key behaviors, and the appearance of symptoms. CASE

2:

TONY

The oldest child in a family of three children, Tony first came to psychiatric attention just before he reached 3 years. His parents felt he was too aggressive with his infant brother, born when he was I Y2. He also did not play with other children, had too few words, and responded unpredictably or not at all to his parents. On evaluation at that time, the only word he uttered was "byebye." There was no interactional play; his activity mostly consisted of handling objects or randomly throwing balls. There was eye contact between the child and his mother and his examiners, but it was unpredictable. So was interpersonal contact; the child only occasionally responded to a message from his examiners or his

Table I Summary of Film Observations of Case I (joan) Age in Months

0-3

Dyadic gaze C. attentive between mother to ~1. and infant M. does not look at C. Mood of infant and moth er

I nitiation of activity and re sponsiveness of mother and infa nt

Sign s and symptoms of child hood psychosis Atypical or del aved d evelopment

C. content. has prominent social smile . M. has fixed smile throughout first 2 years. M. wooden; no initiation of cuddling or playfulness.

3- 6

1>--9

C. atte m pts eye contact with M . ~1. avoids C:s eye s and blocks C:s facia l a pproach . C. d ej ected when blocked fro m seeing ~1 :s face . C. gen erally irrit able.

C. no lon ge r looking at or atte m pting eyc contact with M.

M. places C. in d ouble bind\1. pat s c.. C. smiles a nd tr ies to look a t \1.. \1. pull s a way. C. is d ej ected a nd givcs up. M . th en re pea ts scque ncc . Lack of a tte n tive ness , fixati on. o r exci teme nt a t peopl e o r obj ects. Less than normal act ivity. visual pursuit. a nd reaching. Flaccid bod y tonus.

9-12

12-15

C. selectively avoids M:s looks.

M. now begins to look bri efly at C.

C. inc reasing ly sel f-a bsor bed ; little a ffect ex cept pleasure with locom ot ion .

C. ceas es to

C. looks onlv at inanimate objects.

attc m pt cyc or bod y contact.

C. keeps distance from peopl e. Parents attempting contact with C.

No visu al pu rsuit. Srer eotyp ic hand and finger mot ion s. :-.I 0 eye cont act.

Looks only at objects. keeps distance from people.

Self-abso rbed . Hallucinatory. internal excitement.

15-18

18

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mother. There was a sense of lack of recognition in his seeming not to notice when he was spoken to or approached. Tony was retarded in all parameters of motor and fine motor coordination , personal-social functioning, and adaptive functioning. The child guidance clinic that saw him found no evidence of organicity, suspected mental retardation, but did not rule out autism. When Ton y was 4 Y2, the famil y sought further evaluation. Tony was now having severe temper tantrums, in which he thrashed till exhausted , hit and scratched himself, and occasionally cried out "help, help," These tantrums might be provoked by frustrations or arise out of the blue. On intake, he was diagnosed as suffering from a psychosis of early childhood, of a form most closely resembling autism. Since that time, Tony has been in continuous treatment. Now, many years later, he is in his age-appropriate grade in a normal high school. His intellectual functioning is average, although he remains isolated from peers and is only now beginning to express affiliative feelings for classmates. Though the bizarre behavior of his early childhood is long past, he maintains rigid obsessive habits, and therapeutic content includes such borderline phenomena as occasional confusion of ego boundaries. There have never been hallucinations. At the time of intake , the parents revealed that they had been concerned about their child's lack of re sponsiveness when he was as young as 6 months. They had not mentioned their concern until he was 3 years for fear that they were worrying too much, and be cause the famil y pediatrician said that he was a health y child. Only in the second year were the parents convinced he recognized them. He was 2 before he said "mama" and "dada ," Further developmental history re vealed that the first 6 months of Tony's gestation were complicated by hyperemesis. At birth , the child was slightly cyanotic and icteric, and therefore was kept in an incubator for the first two days. Otherwise, his medical history has been negative, as have been EEG and appropriate neurological tests. The child is reported to have smiled at 3 weeks. He was switched from breast to bottle feeding at 4 months without observed reaction, the mother reported, because she had a sinus infection. In the first 6 to 12 months, the parents remarked that he "seemed to need no one," Sitting, crawling, standing, and walking took place normally. At 7 months, a stereotyped mannerism was noticed. When puzzled or when reaching for an object beyond his grasp, Tony squinted and then began rhythmicall y to clench and unclench a hand. When he began to walk at the end of his first year, the hand movements changed to a waving, Happing motion, accompanied by

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dancing, athetoticlike motions of his fingers, like those described in case I. At this same time, he frequently walked on tiptoe, as did Joan when she was excited. At other times he had a stiff, broadbased gait. These mannerisms persisted well into latency. When Tony was 16 months old and his brother was born, his mother weaned him from the bottle. She observed that he ignored his brother at first, but his vocalizations developed a very angry tone. When he was 21 months and the infant brother was moved to his room, the temper tantrums began. At 2 years, there appeared transient phobias of slides, swings, and rocking horses. With the birth of a second sibling, a sister, when he was 3 years, Tony developed periods of severe constipation. At the same time, he first began using the toilet for urination. His mother had been lackadaisically, and his father angrily, attempting to toilet train him since he had been 18 months. But at 3 Y2 years, when his parents divorced, Tony lost his urination training and began to urinate on the bed, sofa, and rugs. Ironically, however, he deposited his bowel movements for the first time in the toilet, although periods of constipation and soiling also continued. Tony's mother and father had met in graduate school. They married, and Tony was born two years later, while they were in their late 20s. The mother's looks and manner were plain and unassuming, and she was reserved, seclusive, and passive. She saw a likeness between herself and her father, whom she described with distaste as cool and distant. She "never knew what he felt," for he showed strong feelings only about abstractions like politics. She said she feared her son's anger, responding to it with rage or withdrawal. Her mother, she said, had a more outgoing veneer, but hid her feelings too. Her childhood family read much and interacted little, either among themselves or with people outside, a pattern she continued in her adult years. She said that she felt that all she liked was fantasy and didn't like real people around. Although trained as a teacher, she feared being unable to control a class. Tony's father, on the other hand, was more outgoing and very self-assured. He needed to be in charge. Early in the marriage, he had proved a better cook than his wife-a source of mutual irritation, and just one example of the many conflicts between husband and wife. Results

rif Film Analysis

Tony's family supplied approximately 1,400 feet of home movies of the child's life from 2 months to 3 years. Though analysis of these films reveals similarities between case I and case 2, there

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were significant differences between the course of Tony's physical and interactional development, on the one hand, and that of Joan or of normal controls, on the other. Analysis of the films demonstrated that: 1. Like Joan, Tony was born without gross neurological stigmata. 2. Tony did have a social smiling response within the first 3 months, but it was lifeless and placid. In later months, his smile never conveyed excitement or recognition in response to his mother's face or presence. Contrast this with the pleasure Joan showed, and the vigorous attempts she made to look at her mother in her first 5 months. 3. Eye movement, focus, and fixation were present at their expected times. 4. A notable delay in motor development appeared between 5 and 6 months. When pulled from a supine to sitting position, the child's head lagged backward; and even when sitting, he was unable to hold his head erect and steady. Similarly, between 3 and 6 months the child showed no anticipatory adjustment to being lifted by his parents. Otherwise, general body movement, head and torso control, and manipulation progressed within normal limits. In addition, later major motor milestones occurred normally. 5. From birth, the child had a flaccid body tonus. Throughout most of his first year he had less-than-normal activity, reaching, visual pursuit, and attention to and excitement at objects and people. These observations are like those made of Joan's infancy, but are more apparent in Tony's. 6. In the category of dyadic gaze behavior between mother and child, from 2 to 6 months of age there were numerous scenes in which Tony looked briefly (I to 5 seconds) at his mother, who did meet his gaze. Tony would then break eye contact by looking away. On the other hand, if the mother looked at Tony, he did not meet her gaze unless she was also physically stimulating him. He might then look at her face briefly before breaking eye contact. By 7 months, Tony made only rare, fleeting eye contact with his mother or father. By this time, mother and father had markedly stepped up their attempts to elicit a look or smile from their child by increased touching, holding, and looking. 7. Tony's mother was like Joan's in being stiff and self-contained. She did not spontaneously initiate cuddling, show playfulness, or mold herself to her child. At 5 months, an impressive interactional behavior appeared for the first time; it was to reappear frequently, characterizing Tony's relationship to his mother. While his mother held him, Tony tried to struggle away. Before this, the

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child had shown no sign of molding. After this , body contact aroused in him obvious displeasure and an attempt to create di stance, unless the child was intensely stimulated with motion, such as being swung aloft. Throughout his infancy and earl y childhood, Ton y showed no displeasure at loss of eye or body contact. ,At about 6 months, when the parents began actively to attempt social games, Tony would not play. 8. Mood and affect development were sim ilar to those of case I. During the first 3 months , the child's affect was mostl y placid and contented, the mother's placid and self-contained. Between 3 and 6 months, the child's pla cidity gave way to irritability and apparent depression. After that , Tony's affect constricted. After 6 months , he rarely showed pleasure or displeasure. At the same time, depression first appeared in the mother. The final mood change occurred when Tony gained locomotion. With crawling, and especially with walking, his mood improved tremendously and he showed great pleasure. Toward I year of age, his principal expression was one of great self-absorption. 9. Tony's first sign of childhood psychosis may have appeared at 3 months. He had a peculiar squint when he looked at people and objects. At the end of his first year, it be came so marked it could be called a habit disorder. As the squint got worse at about I year, a prominent hand-flapping stereotype developed and persisted. What may have been other earl y signs of childhood ps ychosis appeared between 3 and 6 months: lack of attentiveness to and excitement at objects and people; lack of molding to his mother; and lack of visual pursuit of or fixation on people or objects. By 6 months, clear symptoms of childhood ps ychosis of an autistic type were present-acti ve avoidance of ph ysical contact with his mother, absence of social interaction with his parents, and absence of affective contact with people. DISCUSSION

Much material has co m e from the film analyses, and a first order of business is to consider what value is such information. First, home movies have an intrinsic limitation as a source of longitudinal data because they are discontinuous, capturing odd moments in a famil y's life history. Nor do they include the dimension of speech. Nevertheless, observations of development should be as valid as similar observations made in a physician's office. A distinct limitation of hom e movies is that much valuable developmental and interactional material escapes documentation. For ex-

Table 2 Summary of Film Observations of Case 2 (Tony) Age in Months

0-3

3-6

6-9

9---12

Dyadic gaze between mother and infant

C. makes brief eye contact with M. who responds. C. breaks eye contact.

C. makes only rare, fleeting eye contact.

Mood of infant and mother

C. placid. content, has social smile.

C. irritable, depressed, but shows no displeasure at loss of contact with M.

C.'s affect constricted; rarely shows pleasure or displeasure. M. depressed.

M. placid, content. Initiation of activity and responsiveness of mother and infant

M. stiff, selfcontained; does not initiate cuddling or playfulness.

C. pulls away from M. and does not mold . M. can elicit look from C. only , with physical stimulus.

C. has no displeasure at loss of body or eye contact : does not engage in social games.

Signs and symptoms of childhood psychosis

Squints at lights and when looking at people or objects.

Lacks attention and excitement at objects and people. PulIs away from M., no molding.

No visual pursuit or fixation.

Atypical or delayed development

C . shows great pleasure with locomotion.

Head falls back when pulled to sitting. Lack of anticipatory posturing when lifted.

18-21

C. has self-absorbed smile .

C.'s facial expression strikingly pinched and determined with eyes squinted . M. and father not able to elicit look or smile from C. by touching, holding, or looking at C.

Self-absorption.

No response to people, Active avoidance pets and toys . of body contact with M. Stereotypic hand motions.

Flaccid body tonus. Diminished activity, reaching, and visual pursuit.

15-18

12-15

Prominent stereotypic hand Rapping and eye squinting.

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ample, though pathological hand motions were observed at 9 months in case 2, it is possible they were present earlier, but not cap tu red on film. There is also a margin of error in dating the child's age at a given point in the film, though parents' recall, film markings, and anniversaries allow an estimate to within a month of actual age in scenes in which the child's precise age is not evident. Probably most cr itical for the understanding of early childhood psychosis are the observations of social interaction in the mother and infant. The sequence in case I of aberrant dyadic gaze is the most gripping (Figs. 1-4). Generalizing from such sequences rai ses several questions. Doesn't the process of home movie-taking affect the mother's and child's behavior? How representative is a given sequence of behavior? Since scenes are not shot under standard conditions, can we compare interactional findings in different families? The conviction that these observations are important and permit generalization within and between cases derives from recent work in ethology, family studies, and kinesics-the study of nonverbal behavior. These disciplines have developed methodologies like the one this research uses, and a theory allowing fine observations of behavior. From experiment they have concluded that gestures, postures, facial movements-indeed the whole phenomena of body movement and use of space-are a rich vocabulary of meanings that can communicate ideas, attitudes, feelings, and intentions as precisely as words . ScheAen (1971) believes that nonverbal behavior is both culturall y determined and highl y individualized and is repetitively. predictabl y, and unavoidably embedded in one's responses to social situations. Therefore, the most characteristic kinesics are not materially affected by external events, like a ca mera recording a scene. This independence of kinesics is demonstrated in Kendon's (1967) and Ferber's (1972) analysis of greeting behavior with groups of subjects, some aware and some unaware of being filmed. Without this demonstration it would be hard to be co n fid e nt that behavior observed between a mother and a child while being filmed by a father "for posterity" does in fact illustrate important, fixed attributes of the relationship. Additional confidence comes from firsthand sessions with the families of the two pilot cases. When Joan's and Tony's families were seen clinically, months to years after the infancy-period movies had been made, they showed patterns of mother-child and familial interaction replicating much of the film behavior. Corollary to this inv estigation is the recent experiment of Stern ( 1971), who filmed pla y under standardized con-

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ditions between mothers and their normal infant twins. Through frame-by-frame analysis of the eye-gaze interaction of the mother with her twins, he was able to determine that each twin formed a relationship with the mother in which social contact was characterized by a fixed pattern of mutual eye and head movements, different from the pattern formed by the mother and the other twin. From such work it is possible to conclude that the observations of family interaction in the candid movies are representative of that family's interactions. Although such data are not numerical but descriptive and in the language of kinesics, these cases can be compared in much the same way as traditional case histories are compared, and for the same reason: to teach us about the development of dysfunction in a particular child and family. The data from case I reveal a child attentive, alert, and responsive in her first 3 to 5 months. In normal fashion, Joan tried to engage her mother in eye contact. In aberrant fashion, the mother did not respond to this instinctive cue from her child and meet the gaze of her infant. Instead, she gave a message impossible for the infant to follow (Figs. 1-4). It is a biological rule of attachment behavior (Bowlby, 1969) that infants and mothers seek eye contact which gives each evident mutual pleasure. Such eye contact is crucial to healthy, normal symbiosis. It lays the groundwork for the infant to form an object representation of his mother and then, in his second year, to individuate (Mahler, 1968). Unfortunately, Joan's mother subtly changed this rule so that the end of the interaction was not mutual gaze. Through gentle stimulation (patting her head and perhaps stimulating the rooting reflex), the mother did give the baby a paradoxical message, which might be translated, "Respond warmly to me, but do not look at me." The infant was in an impossible situation. The only way she could respond was her inborn, patterned way-by looking at her mother and smiling with pleasure at the sight of her face. But this was forbidden. How the infant felt in this impossible situation is reflected in the sequence of facial expressions, going from pleasure as she turns to her mother, to desperation when she is blocked, then to confusion and depression, and finally back to a smile as her mother pats her head with her hand and touches her cheek with her mouth. This sequence was repeated several times, the shifting expressions lasting only a fraction of a second, to I or 2 seconds each. The mother's actions recall the "double binding" that Bateson et at. (1956) observed in families of schizophrenic adolescents and young adults, and the "mystification" that Laing (1959) perceived in schizophrenic families. In such families, the vulnerable

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member is placed in a double bind: a position in which under the family rules there is no right way to act. There are only two ways out of the bind-change the rules of behavior or find a psychotic solution. Although neither a precise description nor a proven process, double bind serves as a reasonable characterization of Joan's plight. Spitz (1965) has observed that among infants in a foundling home, those who developed psychotic manifestations, like extensive coprophagia or hallucinations, were most likely to have had shatteringly inconsistent mothers, Underlying Spitz's holistic characterization may have been a single pattern of aberrant mother-infant interaction, like the one observed in case I, or perhaps different discrete patterns for different mother-child pairs, each with the same basic result-severe disruptions of the child's ego development. To return to Joan, by 6 months she no longer initiated eye contact with her mother; soon afterward, symptoms appeared. She avoided physical contact with her mother, responded only to inanimate objects, was more self-absorbed, and possibly hallucinated. Both from the history and from the films, the period between 4 and 6 months appears crucial to her development. At 4 months the child was weaned quickly, was moved from the parents' bedroom, and had less access to her mother, who was mourning the death of her grandparent. Possibly these separations ruptured what tenuous symbiosis had developed in spite of the aberrant mother-infant behavior. As a result of the abortive symbiosis, the child's primitive, crippled ego may have been unable to master the effects and tasks of turning outward to the world and of the individuation that begins in the second half of the first year. Perhaps the child developed autistic defenses and a psychotically regressed mode to deal with these affects and tasks. A sign of inner disorder and a harbinger of the psychosis may have been Joan's irritable mood from 4 to 6 months. It is interesting that Tony was irritable at the sarnc time. Before this time, hoth children had been mostly placid; after what appears to be a 6month turning point, both became affectively constricted and avoided their animate world. Finally, both became exuberant with locomotion at about 9 months. It will be important to see if a similar pattern emerges as other cases are studied. Even at this point, our knowledge of the cases permits speculations about this mood and symptomatology pattern. For example, in some prepsychotic children, irritability may be an affective concomitant of the symbiotic period, at its height, as

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Mahler (1968) has pointed out, between 3 and 6 months. We also know that this period is a maturational nodal point, signified by marked developmental changes in the EEG and neuromuscular coordination (Metcalf, 1971). All these phenomena indicate important synergistic processes occurring during this time between neurological and psychological structuralization. The second quarter of the first year, then, is probably a time of accentuated vulnerability, when either endogenous or exogenous factors may be highly disruptive. The affective constriction that then follows in the third quarter of the first year may signal a derailing or blunting of normal emotional and social development. Simply stated, when pleasure with eye contact is not allowed to Joan, she gives up eye contact and the accompanying satisfaction. The affective constriction may also signal the onset of regressive, defensive processes that become increasingly elaborated as the body matures and a now crippled psyche grows. Let us consider here the appearance in both cases of prominent stereotypic mannerisms. Both children had dancing-finger motions and hand-waving autisms when they began to walk. In both cases, these could be recognized much earlier in less developed and more transient forms which resembled similar phenomena that occur only briefly in normal children. In addition, they recall the blindisms described by Fraiberg and Freedman (1964) in their study of ego development in blind children. By noticing correspondences between autistic children and the developmental course of blind infants, whether or not they develop severe pathology, Fraiberg and Freedman have drawn our attention to the epigenetic role of vision for psychological development. The authors described the difficulties blind children have developing stable self and object representations, and pointed out that they have an increased liability to autistic or autistic-type psychosis. They described one child, who, like Joan, constantly sought oral stimulation and moved his hand in a repetitive dancing manner. A child cut off from external stimulation through vision may develop blindisms and oral stimulation as alternative and/or regressive modes of self-stimulation. The stereotypes of the autistic child may serve a bimodal purpose: they may be a discharge of affect and excitation that the organism cannot sustain, and they may be means of self-stimulation when autistic withdrawal has cut off ordinary external interpersonal input. Moreover, it is conceivable that the autistic dancing-finger and waving-hand motions are an atavism of early infancy situations such as nursing or self-defense, fending-off gestures. Close observation of the normal infant nursing at his mother's breast reveals

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that the child's fingers open and close aimlessly about the breast and occasionally approach his mouth. These phenomena may very well he part of the grasping and hand-mouth reflexes. They may also function as a release of excitation; and in turn, they may be phylogenetically linked to the need of neonatal precocial animals to use their limbs to stand at their mother's nipples in order to nurse. Furthermore, the overfed infant and the infant who is overstimulated in feeding and playing also waves his hands as if to ward off the offender, although with little structure to the movement at this early point in life. There has been significant clinical evidence to support the hypothesis that original reflex behavior can become the focus of a regressive component of later behavior. For instance, Spitz (1957), on the basis of infant observation, saw the genesis of the social "yes" and "no" head-nodding movements in original reflex behavior. Benjamin and Tennes (1958) reported a case of a child who at 6 months began to respond to the approach of strangers with a vigorous, abnormal, upward and downward head nodding. They felt that this unusual behavior was a regressive mode of dealing with interpersonal anxiety, and was linked to the child's earlier pathological feeding situation. The authors observed that the child had a weak horizontal rooting response, and that the mother was somewhat remote. She "held him low on her lap for feeding, sufficiently away from her body that essentially no facial contact with her was experienced in this situation. . . the mother held him and moved the bottle in such a way as to cause Sammy's head to bob up and down rhythmically, with each of her arm-wrist movements." The point of these illustrations and of the discussion of autisms in the two subject cases is that some of the earliest symptoms of psychosis and abnormal behavior may be traceable to normal neonatal phenomena as well as to abnormal interpersonal patterns. Underlying neonatal phenomena and abnormal interpersonal patterns is the substratum of the child's organismic givens. Up to this point, I have discussed primarily the social responses of mother and child. However, the film analysis of Joan and Tony during their preautistic period allows us to make some instructive inferences about their physical integrity. The data suggest that both children had a flaccid body tonus; that is, they did not show the degree of muscular tautness or limb tension that children in control films showed. Constitutionally, they were children with a low level of organismic excitement. They recall Brazelton's (1969) description of the quiet child, who neither provokes, invites, nor responds with any vigor to interaction with his world.

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Although this constitutional type is not abnormal, but falls at the end of the normal spectrum, Brazelton suggests that this kind of child needs more stimulation and empathic parenting than the average baby in order to nourish. Similar reasoning suggests that this kind of child is vulnerable to traumatic parenting and events, because the organismically patterned drives which eventuate in the drives toward motor competency and social behavior are weaker. However, it would be remiss not to question whether constitutional qualities cannot be fundamentally altered during the infant's birth and contact with the mother and environment in the first hours and days of life. The only specific deviations of physical development were Tony's lack of anticipatory posturing, and (at 5 months) his head lag when pulled from a supine to a sitting position. Along with flaccid body tonus, these are the types of neuromuscular deviations and evidences of uneven development that Fish and Hagin (1973) have found to have predictive value for the later development of psychosis in childhood. These deviations may indicate a basic integrative disorder in prepsychotic children. Although this may be true in some cases, I believe that children like Joan and Tony have an organismic vulnerability that may result in several kinds of outcomes. In a child more constitutionally vigorous than Joan, the disordered eye-gaze interaction between mother and child and the accompanying parental influences might not have crystallized into a psychotic disruption of ego development. Alternatively, given a vulnerability to developmental problems, if the two children had had mothering that was more supportive and more active, while being more empathically tied into their particular needs, they might not have become ill. On the basis of close film analysis of mother and infant interaction, it appears that each mother and child sets up a unique, reciprocal interaction, with a pattern in rhythm and space. Some of the experimental evidence for this conception has been cited earlier (Stern, 1971). In addition, clinical experience with many families with very young, psychotic children has given rise to the intuition that there is a dyssynchrony in the rhythm of interaction and attachment between mother and child. For example, I have observed the mother of a child who was beginning to emerge from autism respond to her son's affectionate gaze, while he stood about a foot away from her, by swooping him into her arms and bringing her face into contact with his. This appeared to be a violation of the child's intrinsic need for a less driven, slower pace, and greater space. Hardly an isolated example, it characterized the disjointed choreograph between this mother and her child.

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In this last example, the disorder of rh ythm and space was observed after the child's autism was diagnosed . Did the illness in fan give rise to it by disorganizing the mother's responses? The examination of the two films does not suggest this. In the case of Joan, the child's pleasurable behavior and her development of reflex and innate behaviors into social responsiveness were distorted by the mother's imposing h er personal rules upon the child, and not permitting health y, d yadic e ye contact. The mother was like a dancer stifH y and awkwardl y leading her partner about the floor. A most important finding in both cases was the placidity and lack of vigor of both infants. Neither mother accommodated herself to this tone in her baby . But in a dyssynchrouous manner the mothers stimulated the babies too stiffly at times; at other times, they matched their offsprings' placidity with their own self-absorption. This could only fail to encourage the reciprocity of interaction which an infant needs in order to develop. CONCLUSION

This paper has presented the detailed anal ysis of two cases of an autistic type of earl y ch ild h o od psychosis. This anal ysis has been based principall y upon a frame-by-frame examination of the childreu's infancy famil y films which predated the appearance of illness. From the data , it is possible to h ypothesize that the children were born constitutionally intact, but also (on the basis of their diminished activit y and uneven physical development) constitutionall y vulnerable to major disruptions of psy chological development. From the data it has also been possible to co nsid e r that the specific mechanism of the formation of gaze aversion, the major symptom in case 1, was the mother's abnormal d yadic gaze behavior with her child in the first months of life; and to hypothesize that this became an epigenetic nidus around which later symptoms and developmental disruptions OCCUlTed. Furthermore, the film analysis of mother-infant interaction supports the more general hypothesis that there was a dyssynchrony between the mother's maternal rhythmic and spatial patterns and her child's. This was at best not sl.lJ~portive of health y reciprocity and at worst grossly disorgaI11zmg. It must be remembered that h ypotheses drawn from the findings are speculations. The film findings themselves, having been taken from a small sample by a method that is inexact in some re spects, do not achieve sufficient validity to be considered representative of other cases, but may nonetheless help us understand other ca ses.

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As the study of additional films proceeds, subsequent findings may replicate the initial data and raise them to the level of general validity, as well as produce new information. Moreover, in this initial report, I have raised a great many questions and have used a variety of experimental and clinical knowledge for explanatory and speculative purposes. Neither space nor existing data have permitted a satisfyingly complete consideration of all these issues at this time. Nonetheless, it is important to report this work now, since it has significant application in the three areas of theory, treatment, and prevention. Though the paper has dealt primarily with theory, knowledge of the earliest signs of illness in psychotic children is of vital use in bringing them to psychiatric treatment as soon as possible. In the two cases reported here, illness was evident in the first year, yet sadly neither parents, relatives, nor physicians saw it until the third year. Clearly, there is a great deal of work to be done in educating professionals and nonprofessionals alike about the earliest signs of severe disturbance in young children. Clinical experience has shown that an incipient autistic syndrome can sometimes be aborted by timely therapeutic intervention, when the symptoms are recognized and child and mother are given appropriate corrective therapeutic support. A detailed knowledge of such factors as rhythmic dyssynchrony, disturbances in behavior patterns between mother and child, and the child's constitutional qualities and liabilities is essential in framing such a therapeutic intervention. Likewise, once the psychosis is crystallized beyond infancy, treatment efforts are likely to be futile if they do not take these factors into consideration.

REFERENCES BATESON, (;., JACKSON, D. D., HALEY . .J., & WEAKLAND,.J. (1956), Toward a theory of schizophrenia. Behau. Sci., 1:251-264. BENJAMtN, .J. & TENNES, K. (1958), A case of pathologic head nodding. Read at the Los Angeles Society for Child Psychiatry and at the American Psychoanalytic Association. Bmnwiusrrr.r., R. 1.. (1970), Kinesics and Context. Philadelphia: University of Pennsylvania Press. BOWLBY, .I. (1969), Attachment and Loss, Vol. I. New York: Basic Books. BRAZELTON, T. B. (l969),lnfanLI and Mothers. New York: Delarorte Press. CALL,.J. D. (1964), Newborn approach behaviour and early ego development. Int. j. PsychoA nal., 45:286--294. ESCALONA, S. K. (1963). Patterns of infantile experience and the developmental process. The Psychoanalytic Study of the Child, 18: 197-244. FERBER, A. (1972), Personal film demonstration and communication, at the Division of Family Studies, Albert Einstein College of Medicine, New York.

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FISH, B. & HAGIN. R. (1973). Visual-motor disorders in infants at risk for schizophrenia. Arch. Grn. Psychiat .• 28:900-904. FRAIB~:RG. S. & FREEDMAN, D. A. (1964), Studies in the ego development of the congenitally hlind child. Till" Psychoanalytic Study of the Child, 19: 113-169. KANNER. 1.. (1943). Autistic disturbances of affective contact. Nero. Child, 2:217-250. KENnoN, A. (1967), Some functions of gaze-direction in social interaction. Acta Psychol., 26:22-6:~.

KORNER. A. F. (1972), State as variable. as obstacle, and as mediator of stimulation in infant research. Merrill-Palmer QUflrt., 18(2):7H-!13. LAING. R. D. (1959), The Dioided Sel]. London: Tavistock Publications. MAHl.ER. M. S. (1968). On Human Symbiosis awl the Vicissitudes of Individuation. New York: International Universities Press. METCAl.F, D. R. (1971). SOllie critical points in normal EEG ontogenesis. (Abst. in:) Electroenceph. Clin. Nrurophysiol., 30: 16:~. SCHEFLEN. A. E. (1971), Personal demonstration and communication at the Division of Family Studies, Albert Einstein College of Medicine. New York. - - - ( 1972). Body Language and the Social Order. Englewood Cliffs, N..J.: Prentice-Hall. SPITz. R. A. (1957), No awl Yes. New York: International Universities Press. - - - (1965), The First Year ofLife. New York: International Universities Press. STERN. D. N. (1971), A micro-analysis of mother-infant interaction. This [oumal, 10:501-517.

The early natural history of childhood psychosis.

The Early Natural History of Childhood Psychosis Henry N. Massie, M .D. This paper reports on two cases of early ch ild hood psychosis, and on findin...
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