The Early Natural History of Childhood Psychosis Ten Cases Studied by Analysis of Family Home Movies of t h e Infancies of t h e Children

Henry N . Massie, M.D.

Abstract. Family-made home movies of the infancies of 10 children suffering from an early childhood psychosis were studied as a kind of prospective documentation of their earliest months of life. Brief case histories are given along with the findings from the detailed analysis of the infancy movies. T h e movies provide data about the constitutional qualities of the children, neuromuscular pathology, initial signs of psychosis, and maternal-infant interaction. T h e focus is on the patterns and presence or absence of the infant’s attachment to the mother and the mother’s to the infant via eye gaze, holding, touching, feeding, and smiling from the first weeks of life. T h e finding of disturbances in attachment-sometimes on the infant’s part and sometimes on the parent’s part-suggests a connection with subsequent psychopathology.

In 1971, frame-by-frame study of the infancy home movies of a child later diagnosed as suffering from autism revealed scenes in which the mother repeatedly frustrated the infant’s vigorous attempts at eye contact by blocking the infant’s head-turning with her own body or by forcibly turning the infant’s head away. These observations sparked a project to gather such home movies and make systematic observations. This report summaiizes the history and findings of our first 10 cases. At least 800 feet of movies of the first year of life, with at least half of the footage in the first 6 months are reviewed. T h e methodology is detailed in a prior report (Massie, 1973) and can be summarized. Movie sequences are analyzed frame-by-frame to resolve subtleties of movement. Three classes of information are Dr Massae ts Associate Medical Lhrector and Director of Research, Adolescent Day Treatment Program, Department $ Psychzatry, Children’s Hospztal Medical Center (?700 Calafornia Street, San Fiancuco, CA, 941 18),where repnntc may be requested Very special thanks for their help are extended to Tim tnghant and Kathy Bacon, research assatants, and to Joel Saldanger, Mirzam Gross, Sue Salter, Sara Mathews, Frankie Lemon, Joe Afterman, Maleta Boatman, Mary Main, Eleanor Gale?~YO?l,Dan Feinberg, Justan Call, and Helene Veltfort Thzr investzgation ha, been supported bv grants from the Skaggs Faundataon, Mt Zion Hospatnl, Sun Francrsco, and the East Bay Activaty Center, Oakland 0002-7 l38/78/1701-0O~9$0144 @ 1978 American Academy of Child Psychiatry

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sought: ( 1 ) the nature of social interaction between mother and infant; (2) the initial signs of illness and their development; ( 3 ) and assessment of the infant’s constitutional qualities, with particular attention to any signs of motor development or neurological abnormality. T h e films of children who later became psychotic are compared to an equal number of films of control children with no psychiatric diagnosis. All observations are made against the background of normative patterns in the controls. T h e subject films come from parents whc) read of the project in newsletters of associations for parents of disturbed children, from contacts with treatment facilities, and by word of mouth among therapists. We have obtained our control films similarly by announcements in newsletters of nonpsychiatric institutions and by word of mouth. Control and index cases were matched in numbers of first- and secondborn children, but we were unable to control other demographic and film-content variables. Behind this methodology is the theory that people’s actionstheir patterns and rhythms-comprise a rich nonverbal vocabulary with meanings as specific as those of words. They are not significantly affected by external circumstances (such as the act of filming), since the patterns of behavior are deeply embedded in each person’s character and in each dyad’s relationship (Scheflen, 1972; Ferber, 1972). However, because the film data are discontinuous, most of our formulations must be considered hypotheses and speculations. All the children were diagnosed as psychotic before their 6th birthday, with the diagnosis encompassing the range of psychotic diagnoses of early childhood-autism, symbiotic psychosis, childhood psychosis, childhood schizophrenia, and the mixed forms (Goldfarb, 1970). T h e reason for this inclusiveness is twofold. T h e diagnostic distinctions tnade by therapists and institutions are often unclear, and we d o not know whether the different diagnoses represent different illnesses, different syndromes o f one illness, or a continuum of severity of one illness. Cases 1 and 2 have been discussed more extensively in a previous report (Massie, 1975) and case 4 is the subject of a detailed analysis that explores developmental and psychopathological theoretical aspects of the research findings (Massie, 1977). Case 9 was the subject of Erikson’s discussion of “early ego failure” in chapter 5 of ’Childhood and Society (1950). T o his report we have added our analysis of her infancy movies and a firsthand follow-up of the patient, now in her 40s. Because sources of data vary from firsthand contact with family and patient and extensive histories to only films

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and brief histories, each case should be read for its positive findings. Case I Joan L. was firstborn and diagnosed as autistic at 3% years after a nursery teacher noted lack of speech and isolation. Her symptoms were repetitive wheel-spinning and block-dropping, cruising around the room touching objects, hand-flapping mannerisms, and avoidance of eye contact. Gestational, medical, and neurological history were normal. T h e mother was wooden with her child, avoided eye contact with child and adults, and was rhythmically too swift for the child’s movements. Joan, at 9 years, has made little progress in day treatment. Film Analysis. Movie footage showed no specific deviations in neuromuscular development. However, in the first 3 months, the baby seemed to have less-than-normal activity, visual pursuit and reaching, as well as a flaccid body tone. In the second 3 months, there seemed to be a lack of excitement at people and objects. T h e child showed strong attachment behaviors-smiling, eye gaze, sucking, clinging, and touching-until the 6th month. But her mother repeatedly avoided making eye contact with her infant when in close contact, although she did look at her from a distance. One such disturbing episode occurred at 4 months arid is illustrated by sequential drawings of movie frames in the detailed report of Joan’s case (Massie, 197.5). I n this episode, Mrs. L. is holding Joan and both appear relaxed. Smiling, Joan turns her head and eyes toward her mother’s face. Mrs. L’s expression becomes tense; and as Mrs. L. tenses instead of smiling and turning to her child, Joan loses her smile. Mrs. L. then inclines her head backwards and to the side of Joan’s face so that the child’s head is blocked from turning. Joan cannot turn her head further to bring herself face to face with her mother; her eyes are as far to the right as she can look, but she cannot see her mother’s face or eyes. Joan’s affect in quick succession becomes tense, then desperate, then dejected. Finally, she gives u p trying to turn to her mother; the mother herself is more relaxed, the evasive actions having been successful. Mrs. L. and Joan then resume the same postures as in the beginning of the sequence, although Joan’s affect is depressed. Mrs. L. then begins to caress her daughter’s head; Joan smiles and drools. Then the whole interactional sequence repeats itself as Joan again attempts unsuccessfully to look at her mother. Initial Signs of Illness. A t 6 months, Joan n o longer initiates eye contact with her mother. At 7-8 months, she is increasingly self-ab-

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sorbed and her affect more constricted, showing little or no pleasure or displeasure. At 9 months there appears to be hallucinatory excitement. Joan is responsive not to people but looking only at objects, and shows autisms such as peculiar shaking and rotating movements of her hands and dancing movements of her fingers as if playing a piano. Comparison of the mother’s behavior with the next-born child, a brother who at 6 years is developing normally, revealed a marked difference. T h e mother made good eye contact with this infant and was patient and gentle in holding and feeding. Case 2

Tony C. was first evaluated psychiatrically at 3 years because of severe aggressiveness toward his infant brother. Tony had little relatedness, eye contact, or speech. Neurological work-up was negative and pregnancy history revealed hyperemesis and slight perinatal jaundice. T h e mother was withdrawn. Diagnosis was early childhood psychosis of a form most closely resembling autism. After 7 years of treatment with the same therapist, Tony attends a normal high school. N o longer bizarre, he is rigid but far less isolated. Film Analysis. Smiling was present at 3 months, but it was lifeless, placid, and never conveyed excitement or recognition in response to his mother’s face or presence. Eye gaze was unremarkable, but a delay in motor development appeared between 3 and 6 months: Tony’s head lagged backward on being pulled to a sitting position; even when sitting supported, he could not hold his head erect and steady. Likewise, between 3 and 6 months Tony showed no anticipatory adjustment to being lifted by his parents. He seemed to have a flaccid body tonus and less-than-normal activity, reaching, and attention to, and excitement at, objects and people. With respect to dyadic behavior in the first 6 months, Tony gave brief looks at his mother to which she responded. T h e mother initiated looks that Tony did not respond to unless at the same time she physically stimulated him. By 7 months Tony made only rare eye contact with his parents. Mrs. C. was strikingly stiff and selfcontained; she did not initiate cuddling, show playfulness or mold herself to the baby. At 5 months Tony began frequently to struggle away from being held by his mother. Before this h e had not molded. Affectively, for the first 3 months Tony was placid and contented; the mother, placid and self-contained. Between 3 and 6 months Tony’s placidity gave way to irritability and apparent depression. Depression first appeared on his mother’s face after 6 months. After this time Tony’s expression constricted and never matured into firm communicative expressions, although he most

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often appeared self-absorbed and did show pleasure in physical motion. Initial Signs of Illness. Unresponsiveness and lack of molding in the first 6 months; struggling away from his mother after 3 months; a peculiar squint when Tony looked at people and objects as early as 3 months, and a hand-waving autism at the end of the 1st year. Case 3

Edward P., firstborn, was suspected ill at 3 years because of sudden onset of speech deterioration, hyperactivity, negativism, and anxious rages on entering nursery school. Prior medical history was negative. Therapists’ notes suggest that the mother was controlling of and intrusive into the child’s behavior, and that the father was meek. After a year of treatment and just as the child was beginning to progress, Mrs. P. withdrew him from treatment. Initially diagnosed as a symbiotic psychosis, Edward is now a teen-ager and believed to be schizophrenic. Film Analysis. His motor development was unremarkable in the 1st year. Attachment indicators of molding, lively smiling, looking, and clinging were intact. Edward was a vigorous, but somewhat affectively impassive baby. His mother was very brusque and did not mold to him. She was rhythmically too brisk for the baby, repeatedly breaking eye contact by turning away from him to other activities or turning him away. Edward’s attempts to cling and make eye contact were not reciprocated. In his 2nd year, episodes of rough, perfunctory treatment of him by his mother were apparent. In contrast, his father was gentle, synchronized with him, and showed good molding. At 21 months the following sequence occurred which embodies the earlier interactions. Both parents are in a swimming pool. Mrs. P. brusquely pulls Edward off the edge of the pool. Mr. P. then makes eye contact with him and holds out his hands. Edward responds by coming to his father. Mrs. P. interrupts and competes with Mr. P. for Edward, taking him from Mr. P. while the boy grimaces and tries to look at his father. His mother returns him to his father, and Edward relaxes. Initial Signs $Illness. T h e films ended at 2 years. There had been increasing impassivity, irritability, and gloomy affect from 6 months onward.

Case 4 Firstborn Ann S. was diagnosed as autistic with symbiotic features at 4 years when she could not separate from her mother on entering nursery school. Additional symptoms were periods of mute-

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ness, multiple fears of objects, and hand and finger mannerisms. Both parents appeared to experience pathological helplessness and repressed rage, which led to clinging t o the children, fear of limit setting, and periods of unresponsiveness. Medical history was negative. Ann, now 10 years, remains in day treatment, slightly improved. Film Analysis. There were no specific motor developmental deviations. T h e child was felt to be moderately more somnolent, to have a lower level of activity and attentiveness, and to be more flaccid than controls in the first 3 months. Attachment behaviors-smiling and gazing, sucking, clinging, touching-were all strongly present and initiated by the baby. In contrast, Ann’s mother responded at times in a highly aberrant fashion, an enduring patterned interaction whose structure in space and time was characteristic for this mother-child dyad. For example, at 4 weeks and throughout the first 6 months, the mother’s arm straps Ann firmly against her with the baby’s back to her chest. T h e holding is so tight that there can be neither free movement of the baby’s torso nor adequate support of it to provide muscular tone to the limbs (fig. 1). T h e closeness does not allow reciprocal interaction or modification by mother o r child. In this scene, as in feeding scenes, and in figure 2 at 2 months, and figure 3 at 6 months, the mother lacks segmental thoracic movements (reciprocal molding to the baby’s movements toward her). Mrs. S. looks as if she were ensconced in armor. She is deanimated, recalling the wire-frame surrogate mothers which the Harlows (1965) used for the experimental production of maternal deprivation and subsequent psychosis in monkeys. At 15 months (fig. 4), Ann is sitting on the floor and begins to cry. Mrs. S. lifts her, places her on the couch without holding her, and sits down a few feet away. When Ann continues crying, Mrs. S. places Ann on her knees, still 2 feet away, still without initiating comforting body closeness. After a moment Ann throws herself against her mother’s chest and Mrs. S.’s hands limply encircle the child’s shoulders. Initial Signs .f Illness. Generally somber mood in the first 3 months; 12 to 1.5 months: somber; frequent tearfulness, fretfulness, and easy frustration; 15 months on: increasing anger; affect and expression generally constricted and wan with rare slight, brief smiles; 3 years: Ann’s expression is immature in its shallowness and flatness; little involvement in or attentiveness to activities, and little affect used for communication; affect appears “plastic” because of its easy mutability.

The Early Natural Hzstory of Childhood Psychosis Figures 1-4.

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DRAWINGS OF MOVIE FRAMES FROM CASE 4

Figure I Mother holds child (at 1 month) with chest turned away, and rigidly immobilizes baby’s torso to her by strapping her right arm around baby‘s midsection. Baby is not supported from below and hangs limply and apathetically.

Figure 2 In ventral-ventral position, baby (I! months) attempts to cling to mother’s blouse, but mother does not maintain chest-chest contact 01- nuzzle baby. T h e child falls away, unsupported at mother‘s chest, her irritability heightened.

Figure 3 Supported in an infant seat, the baby ( 6 months) arches her chest toward mother, sniiles broadly at mother’s face, and places hand on mother’s bouse. Mother returns smile, but her torso remains inHexible.

Figure 4 Distressed, the child (18 months) is placed o n the mother’s knees, but not brought into chest-chest contact. T h e child’s distress heightens until she throws herself against mother’s chest. Note the symmetry of the mother’s and child’s right hand ane l a t i o n and gesture.

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Case 5 Firstborn and first of an identical twinship, Martha N . was seen initially at 13 months because of the parents’ concern about her clunisiness. Symptoms were mannerisms, terrors, toe-walking, lack of relatedness, and speech failure. There was a history of a threatened miscarriage at 0 months and mild toxemia in pregnancy; the child’s medical history was negative except for intermittent bilateral strabismus. Diagnosed as autistic, she is now a teen-ager in an institution for the retarded. Her twin sister, Madge, has no reported illness. Film Analysis. Both babies appeared more flaccid and less vigorous than normal controls, with Martha more deviant. In the first 6 months, Martha lacked eye pursuit and exploration of her environment; her sister appeared normal. I n the 1st year, Martha’s torso often moved in an unusually fragmented manner that did not correspond to any known neurological sign or pathology. In the first half year Martha had only fleeting half smiles. T h e twin sister’s primary mood, like Martha’s, was irritability, but Madge in her 1st year showed a full range of well-formed expressions, with a strong smile for her mother. T h e mother with both children was physically brusque and coercive and apparently insensitive to the children’s mood or actions. An example occurs at 8 months in the bath. Madge puts hand in mouth and mother removes it; Madge puts washcloth in mouth and mother yanks it away; Madge attempts to put her mouth on the rim of tub and mother pulls her away. After each removal Madge looks dejected, while the mother’s expression remains inflexibly serious. A scene at 10 months shows the mother’s brusque, dysrhythmic quality. T h e mother’s hand reaches to smooth Martha’s hair, but instead hits the child’s head, causing her to grimace and lose her balance. Father, like mother, was very stiff and treated the twins as though they were dolls. Initial Signs .f Illness. At 8% months: bizarre, hyperactive, discoordinated, fragmented movements. Martha’s floppiness and inactivity would shift suddenly to flailing, purposeless hyperactivity; plastic mutability and lack of structure of expression; 9 months: hand-waving autisms; struggling away from being held by parents; 2 years: Martha attends to Christmas presents, though mechanically and tentatively, more like a 1-year-old, with an unmodulated excess of energy. She does approach her mother tentatively when the mother extends her arm to her. By contrast, the sister molds to her stiff parents nicely throughout. While both sisters are treated

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equally brusquely and insensitively by the parents, it is Martha who develops aberrantly.

Case 6 Firstborn Ethan C. was evaluated at 4 years because of undeveloped speech and echolalia. H e related to people only as needsatisfying objects. There was marked hypertrophy of reading ability. Medical history indicated slight bleeding and vomiting in gestation, and a Caesarian delivery. In his 3rd year Ethan had a tonsillectomy and bilateral myringotomy. Neurological was negative. He was diagnosed schizophrenic with autistic features, and continues in day treatment at 8 years. There had been severe marital strife, including a suicide attempt by the father in Ethan’s infancy. T h e mother recalled her depression, and on viewing herself in the movies years later, she spoke of “not being real then-just like a doll.” Film Analysis. T h e baby appeared physically normal. Ethan smiled strongly at his parents by 4 weeks, but was a subdued, attentive child who rarely showed spontaneous pleasure. In his first 3 years, he was largely curious, but gloomy and irritable. This film scene at 3 weeks is typical of several from the first 2 months: Ethan’s mother is holding him supine across her lap, angled to her so that his cheek slightly touches her blouse. Inadequately supported, his head slips away. He returns it himself to his mother’s blouse. Mrs. C. is rocking and cooing, but her torso is planar and boardlike. She moves her face close to the baby’s, and he responds, shifting from drowsiness to an alert smile. Neither breaks eye contact for about 10 seconds; then Ethan looks away. Mrs. C.’s smile has been tense and only half-formed. Tentatively she touches his hands and chin through the blankets. When Ethan shifts his head and body toward her, she does not move her body or hands to reciprocate. In feeding at 2 weeks, Ethan is supine alone in the middle of his parents’ bed, while his mother sits on the edge of the bed extending the bottle to him from arm’s length. These and later scenes show parenting that is appropriate, but marked by much maternal constraint and seeming perplexity. I n contrast, his father molded to Ethan in a manner similar to that of control parents. Initial Signs of Illness. From birth, a generally somber, irritable mien; 9 months: striking self-absorption and absence of gaze at people; 11 months: when his mother rolls him a ball, Ethan looks at it, but does not respond to her; his self-absorption mirrors his mother’s manner apparent in the earliest weeks; 10 to 12 months: beginning of a labile expression-fleeting alternations of pleasure

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arid displeasure-similar to the “plasticity” of expression seen in other cases but less intense; 12 months: Ethan is somberly content to be held by his mother, but does not look at, and seems unaware of, her; sensitive to his distance, Ethan’s mother looks at him quizzically, but does not engage him with her eyes, her voice, play, or body stimulation; 16 months: active avoidance of mother’s and father’s attempts to engage him by eye and toys. Both parents appear dejected. In their frustrations, they use inappropriate toys as a vehicle for interaction. There are no scenes of slowly paced, simple body and toy play.

Case 7 Bert C. was the second child of wartime concentration camp survivors. T h e mother was concerned with Bert’s unresponsiveness at 6 months, but the pediatrician temporized. By 3 years there were compulsive rituals, multiple fears, and clinging to the mother. Later there was eye contact avoidance. Speech appeared at 5 years. Medical history and neurological Fvere negative except for a Caesarian delivery for pelvic dystocia. T h e father’s angry physical and verbal outbursts against Bert, his controlling behavior, and denial of his own feelings were noted, as were the mother’s somatization of anxiety. Diagnosed as suffering from early childhood psychosis, Bert is now a teen-ager in a group home. H e is believed to be schizophrenic because of delusions and rigidity, but is capable of considerable affectionate interaction with peers. Film Analysis. In infancy the right corner of the baby’s mouth did not go down in smiling or crying: a paralysis or congenital hypoplasia or absence of the right depressor angulz orzs muscle (Yearbook .f Pediatrics, 1974). This anomaly was less evident and ultimately almost inapparent after the 1st year. There was also a slight right ptosis in the first 6 months; it too became inapparent later. Parents or physicians had not previously noted these neuromuscular findings. Otherwise in the first 6 months Bert had good muscle tone. At 3 months he had a full social smile, good head and posture control, and was attentive to his mother. Other motor milestones were unremarkable. T h e mother was attentive, responsive, and rhythmically attuned to Bert. Of the first 10 cases, only Mrs. C.’s behavior was indistinguishable from that of control mothers. In a typical interaction at 4 months, she holds and molds to Bert while he molds to her. They look intently at each other. After a few moments, Mrs. C. looks away, and Bert then immediately turns away. A moment later, Mrs. C. returns her gaze to Bert, who follows suit by looking at his mother. Mrs. C.’s expression is content and smil-

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ing without being stiff. T h e father, however, repeatedly teases and rebuffs mother and children. H e is seen throwing snowballs at the family, taking a ball away from the older brother, unaware of the boy’s tears, and pinching, rather than kissing, his wife. He shows great stiffness and controlled anger. Initial Signs of Illness. At 3 months: Bert is wan with little pleasure or excitement, although social smiling is present; he is vacant and does not fix his eyes on people and things, although he does respond to his brother’s excitement when they are together; 8 months: plastic fleeting expressions that do not communicate appear; 9 months: the unfocused, apathetic look is prominent; so are autoerotic, repetitive rocking and periods of aimless flailing of the whole body; 12 months: Bert’s body movements decompose, just as his facial expression had; he moves his whole body in an unmodulated way, with jerky, athetoticlike dancing movements of his fingers. Case 8

Firstborn, Steven 0.was diagnosed as autistic at 3% years because of speech failure, periods of frenetic overactivity, unresponsiveness, and hand-flapping. There was a striking reading precocity. T h e mother recalled feeding difficulty and unresponsiveness in the 1st year. During gestation Mrs. 0. suffered a flulike illness and later headaches and edema. T h e child’s neurological examination was normal. Now at 10 years, Steven is less isolated, but h e is rigid and has begun hearing voices, leading to a diagnosis of schizophrenia. One institution correlated the parents’ insistence on cleanliness with the child’s emotional and physical constriction. Film Analysis. Steven’s motor development appeared normal, and attachment responses to his mother were present in the first 3 months. Mrs. 0. appeared stiff, self-conscious and often grooming herself. Throughout Steven’s first 6 months, she does not mold to him, her thorax is planar rather than segmental in movement, and she fusses with the infant’s clothes without holding him close or touching him. Her face is tense and fixed in a somewhat angry smile. Steven is somewhat more irritable than normal. I n feeding scenes at 3 and 3 months, a battle is apparent. T h e mother forcefully, if not angrily, pushes Steven’s head into position to receive the spoon. Steven is angry and does not make eye contact with her. By this time he is in a somber mood and rarely shows pleasure. There are no scenes in which the parents face their child while playing with him. A dramatic representative scene occurs at about

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5 months. Mrs. O., seated behind Steven and partially supporting him as he sits, bounces a teddy bear in his lap. Just as the boy begins to show pleasure (which seems to be in response to the masturbatory stimulation), his mother leaves. Steven’s expression turns to bewilderment, then confusion, then somber wanness. He falls from the sitting position and lies limp and depressed. This sequence is repeated twice, his mother stopping each time a smile begins to form on Steven’s face. Mrs. O.’s rhythm throughout is too rapid for her baby. T h e rare scenes of father and child mirror the mother’s tenseness, lack of reciprocity with the baby, and lack of awareness of the boy’s mood or rhythm. Znitial Signs of Illness. Somberness and avoidance of eye contact as early as 3 months; 12 months: aimless hand-opening and closing movements, as well as plasticity of expression in the form of fleeting near-smiles arising without apparent external stimuli: 2nd year: plasticity continues in aimless, formless, and uncommunicative expressions; less attention to people, with occasional response to his parents’ instructions; hand-flapping.

Case 9 Jean’s case was first richly described by Erik Erikson in Childhood and Society (1950) in the chapter on “Early Ego Failure.” Secondborn, Jean suffered severe oral thrush in infancy, was treated roughly and impatiently by nursemaids from infancy, and was separated from her mother from 9 to 13 months because of the mother’s tuberculosis. When reunited with her mother, Jean developed engulfing fears of people and objects as well as mannerisms. Diagnosed a childhood schizophrenic, she had a series of inpatient and outpatient therapies. Followed u p for the project, she is now in her 40s and lives with her mother. Many of her childhood behaviors appear now in Jean’s middle life like the qualities of a severely eccentric adult. She is alternately subdued and impulsive, with some posturing. Although her speech is fragmented and parroting, she sometimes speaks perceptively and empathically. Largely alone, Jean does some housework and goes on outings with groups for the handicapped. Further review of institutional records revealed that the pregnancy was complicated by first trimester bleeding. T h e father was dominating and compulsively fearful of dirt; and the mother was subservient to him as well as to the autocratic women to whom Jean was entrusted in her early years. Film Analysis. From birth the baby appears alert with good body tone, eye contact, strong cardinal points and rooting reflexes, smil-

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ing, and strong clinging and molding when held by her mother or nurse. Jean’s gross and fine motor development appears normal throughout early childhood. There was but one observation of the mother with Jean in the 1st year, for the mother was the principal photographer, capturing the child with others. At about 7 months while bathing Jean, the mother twice removes Jean’s hands from the child’s mouth. Then Jean raises her left hand and stares at it blankly, seemingly not noticing her mother. T h e mother tries to turn the child’s head around to create eye contact with her. I n the first week in several scenes the nurse handles the baby brusquely; she takes Jean’s hands out of her mouth and ignores the baby’s heightening irritation. In one scene the nurse holds the irritable child up for the camera and her left hand inadvertently brushes the right side of the child’s mouth (one of the cardinal reflex points). Jean’s mouth opens wide and she turns her head toward the nurse’s chest; the nurse remains immobile, offering no ventralventral contact, and Jean’s head falls away, her limbs flailing. Initial Signs of Illness. Jean’s vacant, unfocused look at about 5 months, and her preferring to look at her hand rather than her mother’s face at 7 months; 11 months: repetitive rocking back and forth with vacant expression; 12 months: aimless flailing; striking unawareness of her mother when mother smiles at her; up-anddown finger- and hand-waving autisms; face aversion from mother and father; lack of maturation of her expression, which increasingly has a lost or quizzical look that shifts in a plastic and uncommunicative manner into fleeting smiles, grimaces, coy glances, and confusion.

Case 10 Ken Y. firstborn, was referred at 3 years by his pediatrician for speech deterioration, restlessness, attention to objects rather than people, and jumping mannerisms. T h e child had had an abrupt weaning and a 1-week separation from his mother at 4 months, after which the parents felt there was gaze aversion. Bowel training was started at 1 year; he had painful ear infections with head banging in the 2nd year. A diagnosis of autism was later revised to childhood schizophrenia. After 10 years of intensive (mostly residential) treatment for child and parents, Ken is now largely obsessive-compulsive, has returned home, and is in a normal high school. Both parents had severe paranoid character disorders. Love for their children was mixed with angry demands for achievement, most harshly directed at Ken. When the children could not reflect favorably on their parents, they were criticized and rejected.

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Film Analysis. This baby appeared vigorous, intact, and attentive. Scenes in the first 3 months showed normal grasping and touching. T h e parents’ actions appeared malignant. Both mother and father were awkward and stiff holding the child. Looking uncomfortable, they overstiniulated Ken and controlled all maintenance and termination of activity between themselves and their son, unaware of the child’s mood. There was no reciprocal play. In a scene at 6 months that is repeated at other times, his mother brings Ken into close chest-chest contact with her. Quickly and frenetically she then stimulates the boy by jiggling, rocking, and swaying him with no pause to observe, or share in, Ken’s response. T h e child’s expression shifts between fragmented smiles and distress. Initial Signs of Illness. From 3 to 6 months: Ken was self-engaged with his rattle and teething t o y while his mother was active with him; 18 months: intense autoerotic bouncing, and increasing bodily rigidity; affect largely a constricted partial smile that often breaks down into distress; 3 years: stereotypic sway to walk at times, with arms held in a rigid disjointed manner; little response to other children. Nonetheless, instances of affective contact with and response to parents continue.

D I SC:Uss I ON I n 9 of 1 0 cases, the parents’ behavior with their child was inappropriate from the earliest weeks of life. Though the ways in which it was inappropriate differ from case to case, the parents’ traumatic omissions and commissions do fall within generic disorders of attachment behavior (Bowlby, 1969). Normatively, niothers and infants attach to each other via eye contact, smiling, touching, holding or clinging, and vocalizing. We saw in 9 of 10 cases (all except case 7) that some parents did not allow their children to attach with one or. more modality (e.g., eye gaze in case 1; chest-chest contact in case 4); and other parents did not reciprocate their child’s attachment to them, by dint of the parents’ stiffness, lack of body molding in holding, rhythmic dyssynchrony of movements, and frequent inattention to their child’s intention, activity, mood, or affect (cases 2-5, 8-10). Constitutionally, the babies in cases 1-6 & 8 were sotnewhat more atonic and apathetic than normal infants. If this reflects an organic diathesis toward ego failure and psychosis, these children would require optimum support from their parents to compensate for this vulnerability, support which they did not appear to receive. Additionally, there is evidence that a child within the first days is

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Childhood Psychosis

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organismically influenced by, and interacting with, the parenting figure. Condon and Sander ( 1974) demonstrated the significant linkage between neonatal movements arid human speech; and Sander et al. ( 1 972) showed that newborns with a single caretaker differentiate the EEG into day and night patterns more quickly than newborns with multiple caretakers. Thus, atony in an infant may possibly be an environmentally induced factor as well as a congenital liability. With respect to parenting observations, the fathers are relatively absent. When seen, their behaviors generally parallel the mothers’ (cases, 4, 5, 8, lo), though there are exceptions. I n case 3 the father was agreeably attuned to his son, but from history and observation we know that the mother battled him for control of the boy and won. Conversely, in case 7 (the only child with a discrete neuromuscular finding), the mother was highly supportive, whereas the father was strikingly insensitive. Case 5 was of special interest because the parents apparently treated twin sisters alike. That only one developed psychosis suggests that a constitutional factor was also operative in this child. Families (case 1) that appeared to treat a normal sibling much more sensitively than the child who became sick also were of interest. Table 1 lists signs of atypical development observed in the 10 cases. T h e left column lists atypical findings, grouped according to the approxiinate period of life during which they were first and most frequently observed (birth to 6 months, 6-12 months, 12-24 months). T h e columns at the right of the table indicate the month that each of the findings observed in a given case first appeared. After they first appeared, many of the signs continued on into childhood. Time-limited findings that disappeared in the films were flaccid body tone, less-than-normal activity, specific motor and neuromuscular deviations, and somnolence. Interestingly, many children who develop no psychiatric illness have these same time-limited findings in their early childhood. On the other hand, the remainder of the signs seems especially malignant, since they are so striking in their intensity and omnipresence when compared to films of the infancies of normal children. Although normal children may show any of these other atypical findings, if a normal child shows one of the self-involved behaviors (such as hand-flapping), it is transient, not fully developed, and does not recur over a period of time. Occasionally a normal child shows one of the object-directed behaviors (such as avoidance of body contact or irritable moods), but it is fleeting and does not characterize the child. Although this report is neither statistical nor controlled in a

H e w y N . Massie

44 Table 1

Atypical Signs in the Infancy Home Movies of 10 Cases of Early Childhood Psychosis Signs of Atypical Development

Case

1. Flaccid body tone 2. Lacks attentiveness or response to people or things 3. Lacks excitement in presence of parents 4. Lacks anticipatory posturing to being picked u p 5. Vacant, unfocused gaze 6. Less than normal activity (e.g., reaching) 7. Specific motor deviations: a. Developmental head lag on being pulled to sitting b. Submental palsy c. Ptosis 8. Doesn’t mold to mother’s body 9. Eye-squint mannerism 10. Predominantly somber or irritable mood; little smiling 11. More somnolent than normal 12. Seeming hallucinatory excitement 13. Appears self-absorbed 14. N o visual pursuit of people 15. Looks away from people repeatedly 16. Avoids mother’s gaze 17. Resists being held; arches torso away from parents on being held 18. Autisms: a. Hand-flapping b. Finger-dancing movements c. Rocking 19. Plastic expressions-fleeting, unstructured, not communicating affect o r intention: labile shifts from grimaces to squints 20. Fragmented, uncoordinated body movements 2 1. Episodes of flailing, aimless, unmodulated hyperactivity 22. Doesn’t approach parents 23. Keeps distance from parents 24. Constricted or flattened affect 25. Little or no purposeful activity

1

2

1

3

2 4

3 3

3

4 2

4

5.

6

7

8

9

9 9

3 1 2 24

6 6

16

3 24

6

10

3 3

3

9 2

3

2

?I

3

6 3 3 5 3

,9

51‘L 3 4

3 2

3

1

3

9 9

8

3

9

7

7

6

7

2 4 6 7

7 6

7

5

9

9 12

9

12 12 12 9

9

12 12 11

9 10 8 12 18 12 9 12 18 12

12

9

9

9 9 12 9 7 15

12 12

16

18 12

16 16

I3

24

24 18 18 12

Left-hand column indicates findings in period of life that they were frequently first observed (signs 1-11: birth to 6 months; 12-21: 6-12 months; 22-24: 12-24 months). Righthand columns indicate the month of life that each finding was first seen in a given case (ages are sometimes approximate since subject to clinical judgment).

double-blind manner, the information should not be too quickly discarded, even though it is liable to subjective distortion. We are not going to be able to ascertain whether a mother who is never seen to initiate comforting chest-chest contact on film (as in case 4) may act positively off-camera, or whether parents with normal children may not behave badly off-camera. But it is clear in case 4 and

The Early Natural History of Childhood Psychosis

45

in repeated instances in 9 of the 10 cases that the infant initiates an action by hand, touch, or body inclination toward the mother which is not consummated because the mother does not reciprocate. This is followed by a shift of the infant’s affect to distress and depression. Almost certainly this experience will inhibit the infant’s attachment, intensify and not reduce the tension, and probably lead to an accentuation of aggressive impulses, with their potential for further disruption of the normal development of object relations. Versions of these developmental problems-subsequently demonstrated as failures to relate to people, outbursts of aggression, intense impulses that need immediate gratification, and severe anxiety-are among the primary manifestations of psychosis in the children. One such lack of consummation is painful for a child, even though it may occur occasionally in normal motherchild dyads. We would expect repeated lacks of consummation to have profound psychological consequences for a child.

REFERENCES BOWLBY, J. (1969), Attachment and Loss, Vol. 1. New York: Basic Books. CONDON. W. & SANDLR, L. (1974), Neonate niovenient is synchronized with adult speech. Science, 83:99-101. ERIKSON, E. H . (1950), ChildJiood and SocieQ. New York: Norton, pp. 196-197. FERBER, A. (1973, Personal communication and film demonstration, Albert Einstein College of Medicine, New York. GOLDFARB. W. (1970), Childhood psychosis. In: Manuul of Child Psychology, ed. P. Mussen. New York: Wiley, pp. 770-830. HARLOW. H . 8c HARLOW, M. (1965), Effects of various mother-infant relationships on Rhesus monkey behaviors. In: Determinants of Infant Behavior, ed. B . M. Foss. London: Methuen, 4: 15-36. MASSIE,H . (197.3). The early natural history of childhood psychosis. This Journal, 14583-707. (1977), Patterns of mother-infant behavior and subsequent childhood psychosis. Child Psychiat? and Human Development, 7:211-230. SANDER, L., STECHLER, G., B’JRNS,P., 8c J U L I AH. , (I%’?), Continuous 24-hour interactional monitoring in infants reared in two caretaking environments. Psychosom. Med., 34:270-2#2. SCHEFLEN, 4 . (1972), Body Language arid the Social Order. Englewood Cliffs, N.J.: PrenticeHall. STERN,D. (1971). A micro-analysis of mother-infant interaction. This Journal, l0:501-517. Yearbook of Pedzahzrs (1974), ed. S. Gellis. Chicago: Yearbook Medical Publishers, pp. 313-3 15.

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