A comprehensive overview of autism and childhood psychosis—symptoms, causes, diagnosis, and treatment—by Jacques Didier Duché, professor of child and adolescent psychiatry and physician at the Salpêtrière Hospital in Paris.
Before we address early childhood psychosis, it helps to define the term "psychosis" itself. Classically, it refers to all mental illnesses. Today we use it more narrowly: it describes major mental illnesses that alter personality, damage self-awareness and sense of reality, eliminate critical judgment, and produce strange and incoherent behavior.
Early childhood psychosis appears before age six. This age limit, somewhat arbitrary, matters because it reflects clinical reality. In early childhood and through the first year of school, a child gradually becomes aware of his own autonomy and slowly distinguishes himself from others. We use the term "early psychosis" for children who fail to achieve this separation. Their personality, still forming, develops without proper structure—or with deeply disharmonious structure.
Severe mental illness is a screen that masks the other's depth and authenticity.
The dissociative process, working on a developing mind, overturns what has been learned and disrupts what is yet to come. These features set early psychosis apart from the schizophrenia of adolescents and young adults. That word—meaning "splitting-dissociation"—presupposes a structured personality on which dissolving contact with reality then breaks down. Given our ignorance of the causes of early psychosis, and the absence of perfectly objective diagnostic criteria, the term has expanded greatly. Some clinicians apply it to large numbers of psychologically disturbed children whom others would never classify as truly psychotic.Early infantile autism, described by Kanner in 1946, is the most characteristic form of early childhood psychosis.
It affects roughly 4 children in 10,000. It is marked by two pathognomonic elements—symptoms that help establish a diagnosis.
The Psychotic Child's Behavior
1. Self-Isolation—Autism Proper
Autism is the primary symptom. It consists of an absolute, very early inability to form a real, living bond with others. Parents describe these children as "self-sufficient," "in a shell," "happy when alone." They act without regard for anyone nearby; they ignore or reject what comes from the outside world. They refuse physical contact or seem to dread it, as if it were an intrusion.
The autistic child approaches people and uses them as tools. He may take an adult's hand to have a door opened, even though he is perfectly capable of doing it himself. He does not look at the adult, never addresses him as a person, and seems to recognize him by function rather than as an individual: "the one who washes," "the one who feeds." When his parents leave or return, he is unmoved.
He does not speak, perhaps because he is not interested, but he seems to understand what is said to him.
His gaze is evasive—peripheral or blank—avoiding the other's eye, which he experiences as dangerous.When you try to penetrate his closed world, he reacts with aggression: no words, no look, then he withdraws into isolation again. He does not join other children, does not play with them. He attacks violently if they try to approach.
Language disorders are typical. The absence of speech likely reflects total indifference on the child's part. Yet despite not speaking, he seems to understand everything said to him. He is often thought to be deaf—an opinion contradicted by audiometric testing (though difficult to interpret, since these children often do not react to noise, or react in paradoxical ways).
Acquiring language before age five is an important prognostic factor.
In worse cases, speech does appear but remains inadequate, distorted, and impoverished. It serves no communicative purpose: it consists of isolated words arranged by sound alone.
Echolalia—repeating the words spoken to the child with the same intonation, immediately or later—is common. Pronoun reversal is typical: using "he," "him," or "you" instead of "I" or "me." The child speaks to himself as to another, or uses phrases directed at him: "Push your arm, there's a good boy," "You'll see…" Or, very characteristically—suggesting he lacks true awareness of his own individuality—he uses the third person to speak of himself: "He will eat," or "Peter will eat." His voice tone is often bizarre, monotonous, or mechanical, a quality called phonographism.
The other's speech strikes him as intrusion, aggression. A psychotic child reacts with anxiety to a loud voice. If you speak to him indirectly—from offstage, so to speak—gently and impersonally, he shows sensitivity and responds more appropriately.
Stereotyped gestures—constant, unvarying repetition of certain movements—are common. They include drumming, upper-limb movements like wing-flapping, toe-walking, finger gestures of remarkable dexterity.
Self-injurious gestures are not rare. Locked in his silence, the child cannot, as infants do, express distress except through screams and violent movement. So he bangs his head against wall or floor with extreme force; he scratches, bites, tears at his hair. There seems to be relative insensitivity to pain in these children. Sometimes a protective helmet is necessary, or even restraint to prevent serious injury. This self-injury is not random: it answers frustration, or signals an appeal—redirecting at himself aggression meant for others—or serves as self-stimulation.
This behavior cannot be viewed as automatic. Rather, it is conduct laden with relational meaning.
2. An Obsessive Need for Sameness
The child obsessively and anxiously refuses any change in his surroundings. It is a form of retreat to safe, defensible positions. The psychotic child clings to it; he screams and protests the moment he sees anything new.
His memory for the arrangement of objects, sometimes after days have passed, is extraordinary. It can explain surprising abilities in specific domains: fitting puzzles together, which some children pursue for long stretches, swaying rhythmically from foot to foot and chanting a kind of monotone melody.
Autism appears in all races, in every people, in all social classes.
This urgent need shows itself too in the rhythm of daily activities. Any change in schedule triggers panic. The child should be prepared for these changes, insofar as possible, so he can bear them.Clothing works similarly—it is protection for the child, a defense against contact with others. The smallest tear causes enormous distress.
What Do We Know About Causes?
In his early publications, Kanner considered peculiarities of the family environment as the third hallmark of this syndrome. The disorder would arise from early disruption in the child's relationship with his parents—people from highly intellectual backgrounds, cold, perfectionist, without humor, more at ease in the realm of abstractions than among human beings. This "affective coldness" played an important role in the child's early development.
Later, Kanner reconsidered this hypothesis. Autism, in fact, appears in all races, in every people, in all social classes.
In the remote history of nearly half of psychotic children, we find organic traumas that may be the origin of encephalopathy.
A child does not, we believe, become psychotic without at least constitutional factors that predispose him to it.
Some authors think the child's "organic structure"—his "equipment"—does not allow him to adapt to the demands and requirements of the external environment.A child does not become psychotic, we believe, without at least constitutional factors predisposing him to it. Moreover, the birth of a child who "disappoints" wounds parents deeply, and this wound shapes the particular relations between child and parent.
In any case, facing our ignorance of what causes early psychosis, we cannot crush already-suffering parents with completely unjustified guilt.
How to Establish a Diagnosis
These children often strike observers by their beauty: regular, delicate features and an intelligent expression. Intellectual insufficiency does not appear at the start of illness and may in some cases be above average, explaining certain exceptional but sterile abilities—like those of prodigy calendar calculators.
Projective tests—techniques that ask the child to interpret a series of images—are possible only if the child can express himself. Dominant themes include "tearing," "devouring," "catastrophe," "dismantling." Differential diagnosis in young children must rule out deafness or hearing loss. Deaf children often show isolation that resembles autism in the autistic child. It is therefore a difficult diagnosis. The same applies to deaf-mutism and congenital verbal deafness.
Some children, victims of prolonged maternal deprivation and long hospitalizations, may appear to be authentic psychotics. Recovered in good conditions of care and affection, the psychotic traits disappear. Other children, more vulnerable and deprived, will develop entrenched psychosis.
The course of early childhood psychosis is, on the whole, rather grave. Except in rare cases—some studies mention spontaneous, complete recoveries—the possibility of cure appears very slight. Even in cases of dramatic improvement, language difficulties and strange behaviors persist. Yet these children can adapt to normal life and access protected workshop activities.
How to Help These Children
The variety of proposed therapies shows that none can be considered a cure-all. Drug therapy is indicated for anxiety crises, agitation, and rage, calibrated to the tolerance of the surrounding environment. Administered cautiously and under strict medical supervision, it allows better contact with the child and can facilitate psychotherapy.
It must never become a kind of chemical straitjacket.
Psychotherapies of various schools, along with environmental restructuring and reorganization of daily life, are more often employed.
—"Reparative" techniques aim to spare the child frustration and help him live through the stages of the mother-child bond he may have missed, in a harmonious and satisfying way.
—"Interpretive" techniques rest on the psychoanalytic model.
—"Behavioral" techniques aim to eliminate the most troublesome symptoms. Attempts at schooling offer valuable contact and happily overlap with psychotherapy: the autistic child is always capable of progress, at his own pace, with longer or shorter periods of regression.
The psychotic child can be treated at a day center, which he attends daily. There he benefits from the techniques above without being cut off from his family. Full-time centers address needs more social than medical in nature: they should be used in particularly difficult family situations.
Placement in specialized settings can help with "deconditioning" certain behaviors and give parents some relief. How much they need help and support! The marriage of parents and the lives of siblings are deeply affected by an autistic child. Some parents meet this unspeakable trial admirably: they even help and guide other parents.
Early diagnosis and early therapeutic intervention with the child and family would be a source of hope.
To conclude: research into the causes of early childhood psychosis follows two directions. One, biological, tries to identify a possible defect in functioning—innate or acquired early—in the neurobiological structure. The other, psychogenetic, emphasizes possible distortions in the mother-infant relationship.These two viewpoints need not exclude better recognition of warning signs as harbingers of psychotic development.
Early diagnosis and early therapeutic intervention with the child and his family would be a source of hope. It would allow us to be more optimistic about the course of this illness.
—by Jacques Didier Duché, 1984, from Ombres et lumière No. 61