EARLY I N F A N T I L E AUTISM LEO KANNER,
M.D
BALTIMORE, MD.
URING the past six years, I have become increasingly interested
D in a number of children, twenty by now, whose behavior differs uniquely and markedly from anything reported so far. Among the individual patients there are great variations in the degree of the disturbance, in the manifestation of specific features, and in the stepby-step development in the course of time. Yet in spite of this seeming divergence they all present essential common characteristics to such an extent that they cannot but be considered as fundamentally alike from the point of view of psychopathology. Many of these children were brought to us primarily with the assumption that they were severely feeble-minded or with the question of auditory impairment. Psychometric test performances yielded indeed very low quotients, and often enough absent or inadequate responses to sounds of any kind g a v e good reason for the suspicion of deafness. But careful examination showed very soon that the children's cognitive potentialities were only masked by the basic affeetive disorder; in fact, a few of the children had started out by amazing their parents with phenomenal feats of rote repetition. In all instances it could be established that hearing as such was not defective. The common denominator in all ,-these patients is their disability to relate themselves in the ordinary way to peopie and situations from the beginning of life. Their parents referred to them as always having been "self-sufficient," " l i k e in a shell," "happiest when left alone," " a c t i n g as if people weren't there," "giving the impression of silent wisdom." The ease histories indicate invariably the presence from the start of extreme autistic aloneness which, wherever possible, disregards, ignores, Shuts out anything that comes to the child from the outside. Almost every mother recalled her astonishment at the child's failure to assume at any time the usual anticipatory posture preparatory to being picked' up. According to Gesell this kind of adjustment occurs universally at 4 months of age. Two case histories may serve to illustrate the principal features: CASE 1 . - - P a u l G. was referred in March, 1941, at the age of 5 years for psychometric assessment of what was thought to be a severe intellectual defect. He had a t t e n d e d a nursery school where his ~ncoherent speech, inability to conform, and temper outbursts created the impression of feeble-mindedness. Paul, an only child, when nearly 2 years of age, had come to this country from England with his mother. The father, a mining engineer, had left his wife a f t e r several years of an unhappy marriage. The mother, a restless, unstable, excitable woman, gave a vague and b l a t a n t l y conflicting history of the family background 211
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and the child's development. 8he spent much lime emphasizing and illustrating her efforts to make Paul elever by teaching hlm to memorize poems and songs. At 3 years, he knew the words of not less than 37 songs and various and sundry nursery rhymes. He was born normally. He vomited a great deal during his first year and feeding formulas were changed frequently with little success. Ke cut his teeth, held up his head, sat up~ walked, and established bowel aud bladder control at the usual age. He had measles, chicken pox, and pertussis without complications. On physical examination, phimosis was found to be the only deviation from.otherwise good health. Paul was a slender, well-built, a t t r a c t i v e child, whose f a c e looked intelligent and animated. H e had good manual dexterity. He rarely responded to any form of address, even to the calling of his name. At one time he picked up a block from the floor on request. Once he copied a .circle immediately a f t e r it had been drawn before him. Sometimes an energetic ~ ' D o n ' t ! " caused him to i n t e r r u p t his activity of the moment. But usually, when spoken to, be w e n t on with whatever he was doing as 'if notMng had been said. Yet one n e v e r had the feeling t h a t he was willingly disobedient or contrary. ~tte was obviously so remote t h a t the remarks did not reach him. He was always vivaciously occupied with something and seemed t o be highly satisfied unless someone made a persistent a t t e m p t to interfere with. his self-chosen actions. Then he first tried i m p a t i e n t l y t o get out of t h e way and, when this m,et with uo success, screamed and kicked in a full-fledged tantrum. T h e r e was a marked contrast between his relations to people and tO objects. Upon entering the room he ~nstantly went a f t e r objects and used them correctly. He was not destructive and t r e a t e d the objects with care and even affection. He picked up a pencil and scribbled on paper t h a t he found on the table. H e opened a box, took out a toy telephone, singing again and again: " H e w a n t s the te!epho!le," and went around the room with the mouthpiece and receiver in proper position. H e got hold of a pair of scissors and p a t i e n t l y had skilfully cut a slieet of paper into small bits, singing the phrase, " C u t t i n g - p a p e r , " many times. He helped himself to a t o y engine and ran around the room holding it up h i g h and singing over and over again~ ~'The engine is f l y i n g . " While these utterances, made always with the same inflection, were clearly connected with his actions, he ejaculated others that could not be linked up with immediate situations. T h e s e are a few examples: " T h e people in the h o t e l , " " D i d you hurt your l e g ? " " C a n d y is all gone, candy is e m p t y , " ~ Y o u ' l l fall off the bicycle and b u m p your h e a d . " H o w e v e r , some of those exelamatious could be definitely traced to pre. v~ous experiences. He was in the habit of saying almost every day~ " D o n ' t throw the dog off the b a l c o n y . " His mother recalled t h a t she had said those words to him about a toy dog while they were still in England. None of these remarks was m e a n t to have communicative value, l i e behaved as if people, as such, did not m a t t e r Or even exist. I t made no difference whether one spot~e to him in a f r i e n d l y or a harsh way. He never looked up at people's faces. When he had any dealings with persons at all, he t r e a t e d them, or rather parts of them, as ~if t h e y were objects; He would use a hand to lead h i m . He would, in playing, b u t t his head against his mother as at other times he did against a pillow. He allowed h i s boarding m o t h e r ' s hands to d r e s s h i m , paying not the slightest attention to her. When with other children he ignored t h e m . a n d went a f t e r their toys. His enunciation was clear and he had a good vocabulary. His sentenee::con: struetlon was Satisfactory with one significant exception, fie ileve~' us~ett'the pronoun of the first person, nor did he refer to hlmse]f as Paul. ~AzlIs,tNteme~ts p e r t a i n i n g to himself were made in the second person, as litei'al 'repe'titibns ~af things t h a t had been said to him before. He Would express his desire'@o~:':eandy
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b y s a y i n g , " Y o u w a n t c a n d y . " Hie would pull his h a n d a w a y f r o m a h o t r a d i a t o r a n d say, ' ' Y o u g e t h u r t . ' ' F o r m a l t e s t i n g could not: be c a r r i e d out, b u t he c e r t a i n l y could n o t b e r e g a r d e d as f e e b l e - m i n d e d in t h e o r d i n a r y sense. A f t e r h e a r i n g h i s b o a r d i n g m o t h e r s a y g r a c e t h r e e t i m e s , he r e p e a t e d it w i t h o u t a flaw a n d h a s r e t a i n e d i t s i n c e t h e n . H e could c o u n t a n d n a m e colors. H e l e a r n e d q u i c k l y to i d e n t i f y h i s f a v o r i t e v i c t r o l a r e c o r d s f r o m a l a r g e s t a c k a n d k n e w h o w to m o u n t a n d p l a y t h e m . H i s b o a r d i n g m o t h e r r e p o r t e d a n u m b e r of o b s e r v a t i o n s t h a t i n d i c a t e d comp u l s i v e b e h a v i o r . H e o f t e n m a s t u r b a t e d w i t h c o m p l e t e a b a n d o n . H e rat/ a r o u n d in circles e m i t t i n g p h r a s e s i n a n e c s t a t i c - l i k e f a s h i o n . H e could c o n t i n u e i n t h i s m a n n e r for a l o n g t i m e a n d s h o w e d g r e a t i r r i t a t i o n w h e n he w a s i n t e r f e r e d w i t h . All t h e s e a n d m a n y o t h e r t h i n g s w e r e n o t o n l y r e p e t i t i o n s b u t r e c u r r e d d a y a f t e r day with almost photographic sameness. CASE 2 . - - C h a r l e s 2f. w a s b r o u g h t b y his m o t h e r on F e b r u a r y 2, 1963, a t 4 y e a r s of age, w i t h t h e c h i e f c o m p l a i n t , " T h e t h i n g t h a t u p s e t s me m o s t is t h a t I c a n ' t reach my baby." A s a b a b y t h e b o y h a d b e e n inactive~ " s l o w a n d p h l e g m a t i c . " t i e w o u l d lie in t h e crib, j u s t s t a r i n g . H e w o u l d a c t a l m o s t as if h y p n o t i z e d . H e s e e m e d to c o n c e n t r a t e on d o i n g one t h i n g a t a t i m e . H y p o t h y r o i d i s m w a s suspeeted~ a n d he w a s g i v e n t h y r o i d e x t r a c t , w i t h o u t a n y c h a n g e of t h e g e n e r a l c o n d i t i o n . H i s m o t h e r r e p o r t e d : ~<When he w a s 11~ y e a r s old, h e could d l s e r i m i n a t e bet w e e n 18 s y m p h o n i e s , l i e r e c o g n i z e d t h e c o m p o s e r as s o o n as t h e first m o v e m e n t s t a r t e d , l i e w o u l d say, ' B e e t h o v e n . ' A t a b o u t t h e s a m e age, he b e g a n to spin t o y s a n d lids of b o t t l e s a n d j a r s b y t h e h o u r . l i e h a d a lot of m a n u a l d e x t e r i t y in a b i l i t y to s p i n c y l i n d e r s . He w o u l d w a t c h t h e m a n d g e t s e v e r e l y e x c i t e d a n d j u m p u p a n d d o w n in e c s t a s y . N o w he is i n t e r e s t e d in r e f l e c t i n g l i g h t f r o m m i r : rors a n d c a t c h i n g reflections. W h e n he is i n t e r e s t e d in a t h i n g , y o u c a n n o t c h a n g e it. l i e w o u l d p a y no a t t e n t i o n to m e a n d s h o w no r e c o g n i t i o n o f me i f I e n t e r e d t h e room. " T h e m o s t i m p r e s s i v e t h i n g is his d e t a c h m e n t a n d his i n a c c e s s i b i l i t y . He w a l k s as i f he is in a s h a d o w , l i v e s in a w o r l d o f his o w n w h e r e he c a n n o t be r e a c h e d . N o s e n s e of r e l a t i o n s h i p to p e r s o n s . H e w e n t t h r o u g h a p e r i o d o f - q u o t i n g a n o t h e r p e r s o n ; he n e v e r offers a n y t h i n g h i m s e l f . H i s e n t i r e c o n v e r s a t i o n is a r e p l i c a of w h a t e v e r h a s b e e n s a i d to h i m . H e u s e d to s p e a k of h i m s e l f in t h e s e c o n d p e r s o n ; n o w he u s e s t h e t h i r d p e r s o n a t t i m e s . " H e is d e s t r u c t i v e ; t h e f u r n i t u r e in h i s r o o m looks like it h a s h u n k s o u t o f it. H e will b r e a k a p u r p l e c r a y o n into two p a r t s a n d say, ' Y o u h a d a b e a u t i f u l p u r p l e c r a y o n a n d now i t ' s two pieces. Look w h a t y o v d i d . ' " W h e n h e is w i t h o t h e r people, he d o e s n ' t look up at t h e m . L a s t J u l y we h a d a g r o u p o f people. W h e n C h a r l e s c a m e in, h e w a s j u s t like a f o a l w h o h a d b e e n l e t o u t o f a n e n c l o s u r e . H e d i d n o t p a y a t t e n t i o n to t h e m b u t t h e i r p r e s e n c e w a s felt. ]~Ie will m i m i c a voiae a n d he s i n g s a n d s o m e people w o u l d n o t n o t i c e a n y a b n o r m a l i t y in t h e child. A t school he n e v e r e n v e l o p s h i m s e l f i n a g r o u p ; he is d e t a c h e d f r o n t t h e r e s t of t h e c h i l d r e n e x c e p t w h e n he is in t h e a s s e m b ] y ; if t h e r e is m u s i c , he will go to t h e f r o n t r o w a n d sing. "He h a s a w o n d e r f u l m e m o r y f o r words. V o c a b u l a r y is good, e x c e p t f o r pron o u n s . H e n e v e r i n i t i a t e s c o n v e r s a t i o n a n d h i s c o n v e r s a t i o n is l i m i t e d ; it is e x t e n s i v e o n l y as f a r as o b j e c t s go. ' ' C h a r l e s w a s b o r n n o r m a l l y , a p l a n n e d a n d w a n t e d child, t i e s a t up a t 6 m o n t h s of a g e a n d w a l k e d a t less t h a n 15 m o n t h s . ' ~ l i e j u s t s t o o d u p a n d w a l k e d one d a y , no p r e l i m i n a r y c r e e p i n g . " H e h a s h a d n o n e of t h e u s u a l c h i l d r e n ' s diseases. C h a r l e s is t h e oldest of t h r e e children. T h e f a t h e r , a h i g h school g r a d u a t e a n d a c l o t h i n g m e r c h a n t , is d e s c r i b e d as a " s e l f - m a d e , g e n t l e , calm, a n d p l a c i d person." T h e m S t h e r h a s " a s u c c e s s f u l b u s i n e s s record, a t h e a t r i c a l b o o k i n g ofllee
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in New York; she is of remarkable e q u a n i m i t y . " The other two children were 28 and 14 months old a t the time of Charles's visit to the Clinic. The materna! g'randmother, ,every dynamic, forceful, hyperactive, almost h y p o m a n i e , " has done some w r i t i n g and composing. A m a t e r n a l aunt, " p s y c h o n e u r o t i c , v e r y brilliant, given to h y s t e r l c s j " has w r i t t e n poems and songs. A n o t h e r aunt was r e f e r r e d to as " t h e amazon of the f a m i l y . " A m a t e r n a l uncle, a psychiatrist, has considerable musical talent. The p a t e r n a l relatives were described as " o r d i n a r y simple people. ' ' Charles was a well-developed, intelligent-looking boy, who was in good physical health. He wore glasses. When he entered the office, he paid not the slightest a t t e n t i o n to the people present (three physicians, his mother, and his uncle). W i t h o u t looking at anyone, he said, ! ' G i v e me a p e n c i ! ! " Then he took a piece of paper from the desk and wrote something resembling a figure two (a large desk calendar p r o m i n e n t l y displayed a i~gure 2; the day was F e b r u a r y 2). He had b r o u g h t w i t h him a copy of l~eader's Digest and was f a s c i n a t e d by a picture of a baby. t i c said, " L o o k at the f u n n y b a b y , " i n n u m e r a b l e times, occasionally a d d i n g i ' ' I s h e not f u n n y ? Is he not s w e e t ? " When the book was t a k e n away from him, he struggled w i t h the hand t h a t held it, w i t h o u t looking at the person who had t a k e n the book. When he was pricked w i t h a pin, he said, " W h a t ' s this.~" and answered his own question: " I t is a n e e d l e . " He looked timidly at the pin, s h r a n k from f u r t h e r pricks, but at no time did he seem to connect the pricking w i t h the persoq~ who held the pin. When the Reader's Digest was t a k e n from him and t h r o w n on the floor and a foot placed over it, he tried to remove the foot as if it were another detached and i n t e r f e r i n g object, again with no concern for the person to whom the foot belonged, g e once turned to his mother and excitedly said, " G i v e it to y o u / " W h e n confronted w i t h the Seguin form board, he was m a i n l y interested in the names of the formst before p u t t i n g them into t h e i r appropriate holes. Ite often spun the forms around, jumping up and down excitedly while they were in motion. The whole performance was very repetitions, l i e rarely used language as a means of communicating" w i t h people, l i e remembered names, such as " o c t a gon, '~ " d i a m o n d , ~' " o b l o n g b l o c k , " b u t nevertheless kept asking, " W h a t is this ? ' ' l i e did not respond to being called and did not look at his mother when she spoke to him. W h e n the blocks were removed, he screamed, stamped his feet, and cried, " I ' l l give i t to you! " (meaning, " Y o u give it to m e " ) . l i e was very skilful in his movements. In spite of great individual differences, the twenty children* of the group (sixteen boys and four girls) presented the same basic features of extreme autistic aloneness. Thirteen children acquired the ability t o s p e a k , w h i l e s e v e n h a v e r e m a i n e d m u t e so f a r . B u t l a n g u a g e , e v e n when present, did not, over a periqd of years, serve to convey meaning to others. Naming presented no difficulty; even long and unusual words were retained with remarkable facility. An excellent rote memo r y , r e t a i n i n g m a n y p o e m s , s o n g s , l i s t s of p r e s i d e n t s , a n d t h e like, m a d e the parents at first think of the ehildi~ p r o u d l y as c h i l d p r o d i g i e s . As far as the communicative functions of speech are concerned, there is n o e s s e n t i a l d i f f e r e n c e b e t w e e n t h e s p e a k i n g a n d t h e m u t e c h i l d r e n . Even some of the "mute" children were reliably reported to have surprised the observers on occasions by uttering single words. One clearly *Eleven of the twenty eases have been reported 217, 1943.
by me
in the Nervous Child 2:
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once said, " g o o d n i g h t , " another said, " o v e r a l l s , " and one said, "ma~ ma," "baby," "chocolate," and"marshmallow." W h e n sentences are finally formed, they are for a long time mostly parrotlike: repetitions of h e a r d w o r d combinations. They are sometimes, echoed immediately, b u t they are j u s t as often " s t o r e d " b y tile child and u t t e r e d at a l a t e r date. One may, if one wishes, speak of delayed echolalia. Affirmation is indicated b y literal repetition of a question. " Y e s " is a concept t h a t it t a k e s the children m a n y y e a r s to acquire. T h e y are incapable of using it as a general symbol of assent. One child learned to say " y e s " w h e n his f a t h e r told him t h a t he would p u t him on his shoulders if he said " y e s . " This w o r d then came to " m e a n " only the desire to be p u t on his f a t h e r ' s shoulders. I t t o o k m a n y months before he could detach the word " y e s " f r o m this specific situation, and it took m u c h longer before he was able to use it as a general t e r m of affirmation. The same type of literalness exists also with r e g a r d to prepositions. Alfred, w h e n asked, " W h a t is this picture a b o u t ? " replied: " P e o p l e are m o v i n g about." J o h n P. eorreeted his f a t h e r ' s s t a t e m e n t about pictures on tile wall; the p i c t u r e s were "near the w a l l . " Donald T., requested to put something, down, p r o m p t l y p u t it on the floor. A p p a r e n t l y the m e a n i n g of a w o r d becomes inflexible and cannot be used with a n y but the origin a l l y acquired connotation. There is no difficulty with plurals and tenses. B u t the absence of spontaneous sentence f o r m a t i o n and the eeh01alia t y p e r e p r o d u c t i o n h a s , ' i n e v e r y one of the s p e a k i n g children, given rise to a peculiar g r a m m a t i c a l phenomenon. Personal pronouns are repeated just as heaed, with no change to suit the altered situation. The child, once told b y his mother, " N o w I wilt give you y o u r m i l k , " expresses the desire for milk in exactly the same words. Consequently, he comes to s p e a k of himself always as " y o u , " and of the person addressed as " I . " Not onl?~ the words, but even the in%nation is retMned. I f the m o t h e r ' s original r e m a r k has been m a d e in the f o r m of a question, it is reprodueed w i t h the g r a m m a t i c a l f o r m and the inflection of a question. The p r o n o m i n a l fixation remains until about the sixth y e a r of life, when the child g r a d u a l l y learns to speak of himself in the first person, and of the individual addressed in the second person. I n the transitional period, he sometimes still r e v e r t s to the earlier form or at times refers to himself in the t h i r d person. The child's b e h a v i o r is governed by an anxiously obsessive desire for the maintenance of sameness that nobody but the child himself m a y disr u p t on r a r e occasions. Changes of routine, of f u r n i t u r e a r r a n g e m e n t , of a pattern, of the order in which e v e r y d a y t/cts are carried out can drive him to despair. W h e n J o h n ' s p a r e n t s were r e a d y to move to a new home, the child was frantic when he saw the moving men roll up the r u g in his room. He was acutely upset until the m o m e n t when in
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tile new home he saw his f u r n i t m ' e a r r a n g e d in tile same m a n n e r as before. He looked pleased, all a n x i e t y was suddenly gone, and he went a r o u n d affectionately p a t t i n g each piece. Once blocks, beads, sticks have been put t o g e t h e r in a certain way, t h e y ' a r e always regrouped in exactly the same way, even though there was no definite design. The children's m e m o r y was p h e n o m e n a l in this respect. A f t e r the lapse of s e v e r a l ' d a y s a m u l t i t u d e of blocks could be r e a r r a n g e d in precisely the same u n o r g a n i z e d pattern, with the same color of each block t u r n e d up, with eaeh picture or letter on the u p p e r surface of each block facing in the same direction as before. The absence of a bloek or the presence of a supernumeraE'y block was noticed immediately, and there was an i m p e r a t i v e d e m a n d for the r e s t o r a t i o n of the. missing piece. I f someone r e m o v e d a block, the child would struggle to get it back, going into a panic t a n t r u m until he r e g a i n e d it, and then p r o m p t l y and with sudden calm a f t e r the s t o r m would r e t u r n to the design and replace the block. E v e r y one of the t w e n t y ehildre~_ has a good relation to objects; he is interested in t h e m ; he ean p l a y with them h a p p i l y for hours. He can b e v e r y fond of them, or get a n g r y at t h e m if, for instance, he cannot fit them into a certain space. W h e n with t h e m he has a gratifying, sense of u n d i s p u t e d p o w e r and control. Donald and Charles b e g a n in the second y e a r of life to exereise this p o w e r b y spinning e v e r y t h i n g t h a t possibly could be spun and j u m p i n g up and down in eestasy when they watched the objects whirl about. Frederick " j u m p e d up and down in great g l e e " w h e n he bowled and saw the pins go down. The children sensed and exercised the same p o w e r over their own bodies b y rolling and other r h y t h m i e movements. These aetions and the a c c o m p a n y i n g eestatic f e r v o r s t r o n g l y indicate the p r e s e n c e of
masturbatory gratification. The children's relation to people is a l t o g e t h e r different.
E v e r y one of the children upon entering the office i m m e d i a t e l y w e n t a f t e r bloeks, toys, or other objects w i t h o u t p a y i n g the least attention to the persons present. I t would he w r o n g to say t h a t t h e y were not a w a r e of the presence of persons. But the people, as long as they ]eft the child alone, figured in about the same m a n n e r as did the desk, the bookshelf, or the filing cabinet. W h e n the child was addressed, he was not bothered. IIe h a d the choice between not r e s p o n d i n g at all or, if a question was r e p e a t e d too insistently, "getting it over w i t h " and continuing with w h a t e v e r he h a d been doing. Comings and goings, even of the mother, did not seem to register. Conversation going on in the room elicited no interest. I f the adults did not t r y to enter the child's domain, he would at times while n m v i n g between t h e m gently touch a hand or a knee as on other occasions he p a t t e d the desk or the couch. But he n e v e r looked into a n y o n e ' s face. I f an adult forcibly i n t r u d e d himself by t a k i n g a block a w a y or stepping on an object t h a t the child needed, the child s t r u g g l e d and became a n g r y
t,2ANNER :
EARLY
INI~ANTI[~F AUTISM
~17
with tile hand or the foot, which was dealt with pel' se and not as a part of a person, t i e never addressed a word or a look to the owner of the hand or foot. W h e n the object was 'retrieved, the child's mood changed a b r u p t l y to one of placidity. W h e n pricked he showed feat' of the pin but not of the person who pricked him. Even t h o u g h most of these children were at one time or another looked upon as feeble-minded, they are all Unquestionably endowed with good cognitive potentialities. They all have strikingly intelligent physiognomies. Their faces at the same time give the impression of serious-mindedness and, in the presence of others, an anxious tenseness, probably because of the uneasy anticipation of possible interference. W h e n alone with objects there is often a placid smile and an expression of beatitude sometimes accompanied b y happ~r though monotonous humming and singing. The astounding vocabulary of the speaking children, the excellent m e m o r y for events of several years before, the phenomenal rote m e m o r y for poems and names, and the precise recollection of eomplex p a t t e r n s and sequences, bespeak good intelligence in the Sense in which this word is commonly Used. Binet or similar testing could not be carried out l~ecause of limited accessibility. But all the ehildren did well with the Seguin form board. There is one other v e r y interesting common denominator in the backgrounds of these children. Among the parents, grandparents, and collaterals there are m a n y physicians, scientists, writers, journalists, and students of art. Nine of the t w e n t y families are repi'esented either in Who's Who in America or in American Men o/Scienc.e, or in both. It is not easy to evaluate the fact that all of our patients have come of highly intelligent parents. This much is certain, that there is a great deal of obsessiveness in the family background. The very detailed diaries and reports and the frequent remembrance, after several years, that the children had learned to recite 25 questions and answers of the Presbyterian Catechism, to sing 37 n u r s e r y songs, or to discriminate between 18 symphonies, furnish a telling illustration of parental obsessiveness. One other fact stands out prominently. In the whole group there are v e r y few really w a r m h f a r t e d fathers and mothers. F o r the most part the parents, grandparents, and collaterals are persons strongly preoccupied with abstractions of a scientific, literary, or artistic n a t u r e and are limited in genuine interest in people. E v e n some of the happiest m a r r i a g e s are r a t h e r cold and formal affairs. The question arises whether or to what exte~t this ~aet has contributed to the condition of the children. The children's aloneness from the beginning of life makes it difficult to attribute the whole picture exclusively to the type of the early parental relations with our patients.