Leo Kanner: Mixed Decision part 1

Dr. Coplan (far left) during his Fellowship in Child Development at Johns Hopkins (1977-79)

Dr. Coplan continues his review and commentary of Steve Silberman’s NeuroTribes.

Last time we reviewed Hans Asperger’s need to downplay the existence of “lower functioning” children at his clinic, lest those children (and perhaps Asperger himself) be hauled off to Nazi death camps, under the auspices of the T4 program. As a result, the term “Asperger Syndrome” (coined by Lorna Wing in 1981) has been used to encompass children with mild, high-functioning autism, plus hyperverbal behavior – i.e., just the upper end of the range of Asperger’s own patients.

While Asperger and his patients lived in the shadow of Nazi death squads, Leo Kanner was enjoying his own ascendance to the pinnacle of fame and influence within the American psychiatric community, from his perch at Johns Hopkins. Much of Kanner’s fame is well-deserved. Sadly, however, Kanner’s story is more complex and in some ways darker than I had supposed. We have already mentioned that Kanner was the beneficiary of the thinking and diagnostic acumen of two of Asperger’s co-workers, who had fled Nazi Germany and wound up working for Kanner: Georg Fankl and Anni Weiss. Silberman’s discovery of this heretofore “missing link” is nothing short of astounding, and invites speculation that Kanner might never have gained prominence as the grand old man of autism, without the insights of these two Jewish refugees – one a psychiatrist, the other a psychologist – transplanted from Asperger’s clinic to Kanner’s. Kanner made only the scantest mention of Frankl or Asperger in his own writings. An innocent sin of omission, or a pre-meditated attempt to reserve all credit for himself? Hard to say, but certainly disquieting.

(Full Disclosure: I spent 2 years at Johns Hopkins myself, and experienced the academic cutthroat environment there firsthand. As a Fellow in Child Development at Hopkins’ Kennedy Krieger Institute , I was asked to consult on a little girl next door at the Phipps Psychiatric Clinic, the very place were Kanner himself had practiced. I diagnosed the child with fetal alcohol syndrome (FAS) – the first case of FAS ever diagnosed at Phipps. The psychiatry Fellow who had consulted me wrote up my results, and published them as a case report, but did not offer me the opportunity to be a co-author. (As sole author rather than co-author, he would get more credit on his own CV.) The first I knew of it was when I received a copy of the journal article in the mail – a fait accompli. Such is the nature of academic treachery.)

In addition to failing to give credit where it was due – which, although ignoble, didn’t do any widespread damage – Kanner was involved in two more acts of malfeasance, which did produce widespread fallout: his adoption (albeit transitory) of the psychogenic theory of causation of autism, and his insistence that autism was a rare disorder.

On the subject of causation, Kanner’s original 1943 paper leaves no doubt as to where he stood initially:

We must, then, assume that these children have come into the word 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. If this assumption is correct, a further study of our children may help to furnish concrete criteria regarding the still diffuse notions about constitutional components of emotional reactivity. For here we seem to have pure-culture examples of inborn autistic disturbances of affective contact. (Italics in the original)

However, the mid-40s and early 50’s marked an era during which analytic psychiatry was in ascendancy within the profession of psychiatry, and Kanner embraced (or, at least, acquiesced to) to the psychoanalytic school – apparently for the sake of his own career. If autism were “inborn” (as Kanner had clearly asserted in 1943), then analytic psychiatry would not hold the answer to ameliorating the features of autism. On the other hand, ascribing autism to maladaptive parenting not only held out hope for a cure, but also promised job security for analytic psychiatrists. For example, in 1948 Kanner gave an interview to Time Magazine (for an article that ran under the header “Frosted Children: Diaper-Age Schizoids”), during which he attributed the children’s autism to having been “kept neatly in a refrigerator which didn’t defrost.” And he went on from there; in 1956 co-authoring a paper attributing children’s autism to having been reared in a setting where the child’s “physical needs were met mechanically and on schedule, according to the rigid precepts of naïve behaviorism applied with a vengeance.”

Ultimately, Bruno Bettelheim carried theories of “toxic parenting” and “refrigerator mothers” to their logical conclusion, asserting in his own book (The Empty Fortress; 1967): “The precipitating factor in infantile autism is the parents’ wish that his child did not exist.” By then, however, analytic psychiatry had reached its peak, and the pendulum was about to swing the other way. In 1968 Rutter and Folstein’s landmark book on autism, re-establishing the biological basis of autism, was published. In 1970, The Journal of Autism and Childhood Schizophrenia would rename itself the Journal of Autism and Developmental Disabilities. At this point, Kanner did a second about-face, returning to his original formulation of ASD as a biological disorder, while letting Bettelheim take the blame for the toxic parent model (In 1969, Kanner referred to Bettelheim’s “The Empty Fortress” as “the empty book,” while telling attendees at the first annual gathering of the National Society for Autistic Children “I hereby acquit you as parents”), despite the fact that Bettelheim had simply been “parroting” Kanner himself. I have long admired Kanner’s 1943 paper. Now, I find myself among those who swallowed Kanner’s protestations of innocence and blame-shifting onto Bettelheim. So count me as “sadder and wiser.”

The final harm done by Kanner (it pains me to use the word “harm” but I can’t think of any other) was his insistence that autism was “rare,” and severe. This mirror-image of Asperger’s story deserves its own post – stay tuned.

James Coplan, MD is an Internationally recognized clinician, author, and public speakerin the fields of early child development, early language development and autistic spectrum disorders. Join Dr. Coplan on Facebook and Twitter. Have a question for Dr. Coplan? Ask the doctor.