“Of what’s to come, the wise perceive things about to happen.” -Constantine Cavafy
A portrait of Leo Kanner, M.D., by Nicholas Pavloff. Oil on canvas.
Courtesy of the Alan Mason Chesney Medical Archives of the Johns Hopkins Medical Institutions
In October 1938, Leo Kanner, M.D., the leading child psychiatrist at Johns Hopkins University School of Medicine, evaluated “Donald T.,” a 5-year-old boy from Mississippi.
“He has no apparent affection when petted,” his concerned parents had written in an earlier 33-page letter to Kanner. “He almost seems to withdraw into his shell and live within himself.”
Curious, Kanner invited the couple and their child to Baltimore. “I saw a behavior pattern not known to me or anyone else,” Kanner said in 1978 in a video recorded at Hopkins.
Children with this syndrome displayed “extreme autistic aloneness. . .an inability to relate themselves in the ordinary way to people and situations from the beginning of life,” Kanner wrote afterward.
They also had “an anxiously obsessive desire for the maintenance of sameness” that brooked no disruption. They displayed “excellent rote memory,” but little ability to use “language as a tool for receiving and imparting meaningful messages.” They related to objects well but had very limited affective engagement with human beings.
“Kanner was puzzled, having seen nothing like this before, but over the next five years, he saw 10 similar children,” said neuropsychiatrist James Harris, M.D., a professor of psychiatry and behavioral sciences and pediatrics at Hopkins, in an interview with Psychiatric News. “Because he was a skilled and careful clinician, he not only observed the child but also listened to the parents’ description of the child’s history and took them seriously. He began to synthesize the common features these children displayed.”
Kanner described those 11 children in a now-classic paper—“Autistic Disturbances of Affective Contact”—published in 1943 in a short-lived journal, The Nervous Child.
Kanner had taken a long and winding road to that moment. He was born in 1894 in Klekotow, a Jewish village in Galicia, near the border between Russia and the Austro-Hungarian Empire. He trained in medicine and cardiology in Berlin, where he taught electrocardiography to an American doctor, Louis Holzt, M.D., from Aberdeen, S.D. That led to an invitation in 1924 to serve as an assistant physician at the state psychiatric hospital in Yankton, S.D.
His experience there produced a few papers on psychiatry, soon noticed by Adolph Meyer, M.D., chief of psychiatry at Hopkins. Meyer encouraged Kanner to apply for a Commonwealth Foundation Fellowship at Johns Hopkins to train psychiatrists and psychologists for work in juvenile courts and child guidance centers. Once at Hopkins, Kanner initiated the first pediatric psychiatric consultation service in a university setting and in 1935 published the first American textbook on child psychiatry.
His office stood at the boundary of the Henry Phipps Psychiatric Clinic and the Harriet Lane Home for Invalid Children. The location was both symbolic and appropriate, given that until the early 1980s, child psychiatry was administratively a division of the pediatrics department, and the director’s salary was evenly split between pediatrics and psychiatry.
It was a fortuitous appointment. He had a natural affinity for children, recalled his son, Albert Kanner, M.D., now a retired professor of ophthalmology at the University of Wisconsin. Sometimes when Kanner saw patients at his home, young Albert played with the children while his father talked with their parents. “He just had a way of interviewing children.”
Young psychiatrists who trained under Kanner also stood in awe at his “capacity for entering the world of the child,” as the late Leon Eisenberg, M.D., put it in a memorial in the American Journal of Psychiatry after Kanner’s death in 1981.
“I joined Kanner’s staff when I finished my fellowship,” recalled Eisenberg in a 2009 interview. “The most valuable experience I had as his student was being what he called ‘his baby sitter’—being with him for the history-taking and examination. I was so impressed with what he elicited from a child, establishing rapport.”
Perhaps Kanner’s most prescient conclusion from those first 11 cases was about the origin of autism, which he had diagnosed as appearing as early as at age 2.
“The children’s aloneness from the beginning of life makes it difficult to attribute the whole picture exclusively to the type of early parental relations with our patients,” he wrote in his 1943 paper. “We must, then, assume that these children have come into the world with innate inability to form the usual, biologically provided affective contact with people, just as other children come into the world with innate physical or intellectual handicaps.”
During a time when psychoanalysis was flourishing, Kanner’s formulation of an explicitly biological, and likely genetic, explanation was quite distinct, an aspect that was ignored until the 1970s, said Daniel Geschwind, M.D., Ph.D., a professor of neurology, psychiatry, and behavioral sciences at the David Geffen School of Medicine at the University of California, Los Angeles.
In his small group of patients, Kanner also noted in his 1943 paper that there “were very few really warmhearted fathers and mothers.”
“The parents may not have been autistic, but Kanner’s observations suggested a broader phenotype,” Geschwind told Psychiatric News.
If his conclusions presaged the rise of a more biologically oriented psychiatry decades later, few appeared interested at the time. Kanner’s paper was cited by others only 34 times between 1943 and 1954. However, citations rose to 2,400 by 2009, reflecting increased interest and research.
Originally, Kanner used “autistic” as an adjective. He employed “autism” for the first time as a noun in 1944, in the paper “Early Infantile Autism,” published in the Journal of Pediatrics. In the paper, he added observations from nine more children.
“More attention was paid when it was published in a pediatrics journal because pediatricians were curious about kids with developmental disabilities, but psychiatrists did not routinely evaluate those children,” said Harris.
Today, when the word “autism” is a part of everyday speech, it is hard to imagine a time when the diagnosis did not exist. Before Kanner, children like these usually were diagnosed with “childhood schizophrenia” or “feeble-mindedness.”
Also, pediatricians and parents had other, more immediate health concerns for children a century ago—such as acute infectious diseases.
“Conditions like autism became more visible as diseases with higher morbidity and mortality were increasingly controlled during the course of the 20th century,” said Howard Markel, M.D., Ph.D., a professor of pediatrics and communicable diseases, psychiatry, and the history of medicine at the University of Michigan.
“As medicine grew better at diagnosing and treating infectious diseases, pediatricians began to see more low-morbidity, low-mortality conditions that doctors ignored when they had more deadly things to deal with,” said Markel in an interview. “Lots of behavioral problems are observed and treated today that were not part of the field then.”
Some cautionary notes should be applied to Kanner’s two early papers, say historians of medicine.
“Most of these children came from families of higher socioeconomic status who could afford to have their child seen at Hopkins,” said Markel. Ultimately, autism was diagnosed across the socioeconomic spectrum once children had greater access to services.
Then there was the association of autism and intellectual disability.
“Kanner firmly believed that autism was incompatible with mental retardation based on the lack of dysmorphic features in his patients, the remarkable feats of memory demonstrated by so many, and his belief that cognitive testing did not indicate their true abilities,” wrote Jeffrey Baker, M.D., Ph.D., a professor of pediatrics and director of the Program in the History of Medicine at Duke University, in the September 19, 2013, New England Journal of Medicine. “More sophisticated testing would eventually show that children with autism had scattered intellectual functioning, marked by islets of ability as well as deficits.”
Kanner continued his research into autism, and in a follow-up paper in 1971, he reported on what became of those first 11 children. Even with similar initial presentations, they showed heterogeneous outcomes.
Donald T., who had good family and social support, would go on to earn a college degree and work in a bank, said Harris. “He didn’t make eye contact or understand the feelings of others, but he was the best person the bank had to count out money.”
Others led productive lives as well, one running copying machines in an office and another working first on a farm and then as an assistant to elderly nursing-home residents. Among the others, two were lost to follow-up and several were institutionalized.
Kanner saw little concrete progress in 1971 toward understanding or treating autism, but he was not without hope. “[A] 30- or 20-year follow-up of other groups of autistic children will be able to present a report of newly obtained factual knowledge and material for a more hopeful prognosis than the present chronicle has proved to be,” he concluded. ■