The lonely children
Bewildered and frightened, thousands of Canadian children are walled off from reality by the most terrible of mental illnesses, schizophrenia. Here is a report on what science is doing to lead them from their bleak secret world
THE MOST HEART - RENDING situation any parent can face is the spectacle of a child walled off from reality by the bewildering disease called schizophrenia. So little has been known about this ailment — the most disturbing and severe of all mental illnessesthat until very recently nobody realized that juveniles suffered from it at all. But it has lately been discovered that there are perhaps ten thousand of these children in Canada living in a mysterious and often frightening world of their own making.
Today, thanks to the research of men such as Ray Keeler, a psychiatrist with Toronto’s famous Hospital for Sick Children, science is beginning to understand something about these lonely children. Keeler has spent two years of research on the subject and has diagnosed one hundred and fifteen cases of child schizophrenia. But he knows that thousands of other cases will go unrecognized. These will be described as being “emotionally disturbed,” mentally retarded, defective in speech, deaf, brain injury cases, oras psychopathic personalities. Through his research Keeler hopes to make the detection of ihe disease easier. He’s also searching for the answers to two baffling questions: what causes childhood schizophrenia, and what can be done about it?
Adult schizophrenia has been studied for the last sixty years. It is sometimes called dementia praecox or, popularly, “split personality.” The schizophrenic withdraws from the world as we know it and lives in a fantasy world of his own. His thinking, mood and behavior are affected. Frequently, he has delusions and hallucinations. In response to them, he may resort to violence and suicide. It is the most stubborn of all mental illnesses to treat: almost half the sixty thousand patients in Canada’s mental hospitals are schizophrenic.
Although juvenile and adult schizophrenics differ in many respects, they have one thing in common: an inability to derive warmth and enjoyment from the companionship of others. I spent a few days recently in the gaily furnished daytreatment centre of the Montreal Children’s Hospital, watching a group of schizophrenic children at play. They ranged in age from four to seven. They were frightened bewildered children, each living in his own private world They paid no attention to their teacher-therapists, the other children nor to me. They made none of the happy noises of children at play. An attractive girl with long brown hair sat at a table, rolling out an endless procession of plasticine balls and quietly smiling to herself. A curly-headed boy faced the wall and rocked back and forth on his feet. He would frequently bring his hands close to his eyes and examine them. Another small boy went about the room exploring everything by taste, touch and smell. A chubby red-haired girl frequently burst out into a piercing shriek. Greta Fischer, the teacher-therapist, explained, “We don’t know whether they’re cries of anguish or delight. It’s her own secret.”
Speech was a problem. One child spoke rapidly and explosively. A few of the children didn’t talk but expressed their feelings by a series of grunts and cries. Some uttered only an occasional few words. This speech weakness is not due to any inability to talk; the children simply don’t feel the need to communicate with anybody. On occasion, some schizophrenic children surprise even their parents by showing that they possess extensive vocabularies. One five-year-old, previously mute, suddenly explained, “Mother, I want to inform you that I left the frying pan outside.”
Because of their strange speech and strange silences there has been a tendency to consider schizophrenic children mentally retarded. Yet they frequently possess high intelligence; indeed, some of their accomplishments suggest genius. One five-year-old girl mastered English, French and Dutch. Another, aged two-and-a-half memorized thirty - seven nursery rhymes. Some schizophrenic boys can draw complicated pieces of machinery from memory. Many juvenile schizophrenics prefer classical to popular music and can hum whole sections from difficult compositions. Others have a talent for painting.
“I can’t love my child”
To a parent, childhood schizophrenia can be the most painful and bewildering of all afflictions. The child is apparently physically healthy and intelligent, yet his behavior is bizarre and unpredictable. By the time he is seven or eight, the parents are sometimes themselves on the verge of breakdown —as many mothers have testified to Dr. Taylor Statten, the chief of the psychiatric service at the Montreal Children’s Hospital. “I’m exhausted. 1 sometimes feel that I just * can’t love my child any more,” is a familiar complaint.
The symptoms vary with the individual child and with his age. In infancy the child may have a history of disturbed feeding, eating and sleeping. He may be a chronic head-banger. Past crib age he may bang his head against the wall so vigoi-ously and continuously that he makes holes in the plaster. He won’t do as he’s told and any attempt to divert him from his own private world is met with loud angry cries of frustration. He may go on shrieking jags, wander miles away from home or jump off the roof in an effort to fly.
Because so little is known about the disease, psychiatrists can do relatively little to help the schizophrenic child and his parents. “It is a dangerously uncharted field,” says Dr. D. G. McKerracher, a University of Saskatchewan psychiatrist. Definite knowledge is lacking about practically every phase of the disease. Is it inherited? Is it due to the faulty development of the infant during pregnancy? Can an unhappy home environment bring it on? How prevalent is the disease? What course does it follow? To what extent can the sufferer be helped?
It was to find the answers to these and other questions that Ray Keeler, of Toronto, began the first systematic study in Canada of childhood schizophrenia. His study involves parents and relatives as well as the child. The parents are interviewed about their marriage relationship and their home life. They are given psychological tests to determine their personality pattern. But the child himself, of course, is the main focus of the study.
Keeler sets down all the details of his behavior and attitude. Every six months the doctor takes a sample of the child’s speech on a tape recorder. One of the theories now being tested is that schizophrenia reflects, among other things, faulty development during the fetal period—that the trouble may be dated to the embryonic stage. In effect, this theory suggests that the child is born physically and emotionally underdeveloped.
One of the children recently studied was a four-year-old named Alaria. I spent the better part of a day with the child, her mother and Ray Keeler.
Alaria was the picture of health, her weight well above average, her skin clear and transparent. Up to the age of one and a half she had appeared to be developing normally. Then her mother noticed an abrupt change. She cried a great deal and refused to eat solid food. (Even at four, she still eats only milk, porridge, soft-boiled eggs and soup—refusing meat, fish or vegetables..) She liked to be alone. When called or told to do anything, she flew into a rage that sometimes lasted for hours. She seemed to understand people but she didn’t talk to them. She was neither deaf, mute, nor mentally retarded.
in tier stomach, said a schizophrenic girl, “bad Indians" told lier what to do
Our first stop in reviewing Maria’s history was at the hospital’s motionpicture studio where film studies are made of the child’s movements. “If the child is irregular in her movements, it reflects improper development of the central nervous system,” Keeler explained. While waiting for the cameraman to get ready, Maria became absorbed in a swivel chair and swirled it back and forth several hundred times, as though hypnotized by the motion. When Keeler called to her, she paid no attention at first. Then she burst out into a shriek that sounded like “go-go-go-go,” rushed to her mother and clung to her. Maria began shouting again when her shoes were being removed by her mother, on instructions from the doctor.
The camera started rolling. The child walked around barefooted with a peculiar duck-like gait, gesturing with her arms and fingers, and touching the floors and walls with her feet and hands. She bit smaller objects such as door knobs and ash trays. “Like many other schizophrenic children, she’s exploring,” said Keeler. “She’s not sure where her body leaves off and where the rest of the world begins.”
We went to the genetics department where prints are taken by placing the hand and foot on pieces of chemically treated paper. By studying the lines on the palm of the hand and the sole of the foot, the geneticist can tell if the development of the embryo during the first three months was normal. Ordinarily, the prints can be taken in a minute or so. But Maria vigorously objected to the technician touching her. “Go-go-go-go,” she shrieked, and clung to her mother’s neck.
In the X-ray room Maria was fascinated by an idle fan, and twirled the blades slowly with her finger. When the time came to sit in the X-ray chair, she balked. Finally, the radiologist, assisted by two other people, held her still while pictures were taken of her skull, hands and feet. (Keeler is trying to find out whether the bone structure of the schizophrenic child is fully developed.)
The last stop made was in the hemotology department where samples of Maria’s blood were taken. The aim of this test is to determine the proportion of fetal hemoglobin in the blood. A large amount of this type of hemoglobin is found in the normal infant at birth but, by the time he is one year old, it normally comprises only one percent. If a higher proportion is found in an older child, this is an indication of incomplete growth. Taking the blood sample led to another violent outburst by Maria. By now her mother was at the point of tears.
Keeler’s findings will add to the present meager knowledge about childhood schizophrenia. Before 1933, the disease was seldom diagnosed. From his clinical observations has come a graphic close-up of the secret world of the lonely children. One of the commonest features is the victim’s lack of awareness about the boundaries of his own body. Asked to draw a selfportrait, he draws his fingers as though they were tapering roots of a plant. Arms are shown coming off the head, hands are depicted as being directly attached to the body.
He spends much time examining the world about him. This he does primitively, by taste, touch and smell. One child smelled everything: he sniffed
at the clothing and body of any new person who entered the house. Another tasted everything; a third explored the wallpaper continuously with his tongue. For the same reason some will often bite other children or even animals.
Gravity either terrifies him or preoccupies him. One eight-year-old told Keeler, “I have the feeling that I’m going to fly off the earth.” Others reflect a feeling of anxiety by showing a fear of exploding, disintegrating or burning up. Some five-year-olds refuse to climb stairs or get on a tricycle, and often seek relief from this fear by clinging to somebody close to them. The schizophrenic child clings so tenaciously “his body seems to melt into yours,” Keeler reports. “It’s as though he is finding his own centre of gravitation by identifying with your own.” When gravity doesn’t terrify him, it fascinates him. Some patients occasionally jump off roof tops, like the seven - year - old who explained, “1 wanted to fly like a pigeon.”
“It tells me to be bad”
Of all the things that torment the child schizophrenic perhaps the strangest are what psychiatrists call “introjected objects.” Keeler has found that ninety percent of his patients between the ages of six and twelve are bothered by these “objects,” which they describe as being two things, or persons, within their bodies. These objects speak to him, usually in a man’s voice, the child will explain. One of the objects is bad and urges him to do bad things—set a fire, molest a baby, run away from home or kill a cat. The other is good and valiantly tries to dissuade him from his evil doing. “I’ve seldom had a patient who wasn’t harassed by bitter conflicts within him between good and evil,” says Keeler.
The young patient is usually reluctant to talk about these things. But, with skilful interviewing, the information can be elicited. After several preliminary questions, for example, Keeler asked one eight-year-old boy, “Are you a good or bad boy?”
He tapped the patient’s stomac . “What’s in there?”
The normal child usually answer. . “Blood and bones.” The patient answered, “Something.”
“What kind of thing?”
“It talks to me.”
“What does it say?”
“It tells me to be bad — to yell and scream and hit anyone who makes me mad.”
“Does anybody tell you to be good?” “Yes. God. He’s up here, inside my shoulder.”
Other investigators have noted that the introjected objects assume different forms in different children. One spoke of “bad Indians in my stomach.” A ten-year-old girl said there was a “bad witch” just below her heart, and that it entered and left her body through her mouth.
The introjected objects seem to follow a certain pattern of develop ment. The bad ones are usually lo cated by the patient on the left side of his body; the good ones on the right. In the sixand seven-year-old, the bad ones are located in the lower parts of the body, moving up as the child grows older. With the onset of puberty, they emerge from within his body and are now perched on his shoulder, whispering into his ear. As time goes by, the “devils” are replaced by people known to the patient. He blames them directly for leading him into trouble and persecuting him. Thus is developed a full-blown paranoid state, or “persecution complex.”
There are two opposing schools of thought as to the underlying cause of childhood schizophrenia. One maintains that the disease stems primarily from a biological defect in the body, starting from birth. Keeler’s study is not yet complete but, to date, there is strong evidence to suggest that the schizophrenic child carries with him, from the date of conception, the potential to develop schizophrenia.
This coincides with the concept of the disease held by Dr. Lauretta Bender, the New York authority. According to Dr. Bender, the child is improperly developed in the womb. He starts life with a “biological lag” and he never quite catches up. His mind and body fail to acquire—both physically and mentally—the wisdom necessary to cope with the world. Dr. Bender doesn’t rule out the importance of environment. The amount of love—or lack of it—will influence the pattern and severity of the illness. “No child,” she emphasizes, “can develop schizophrenia unless he is predisposed to it by heredity. But it can be aggravated and precipitated by adverse psychological experiences.”
The information that Keeler has so far gathered on the family background of his patients tends to support the theory that childhood schizophrenia is largely inherited. Among the relatives of twenty-seven children examined, there was an absence of mental illness in only twelve cases. This finding coincides with Lauretta Bender’s conclusions after studying one hundred and forty-three patients: forty percent of them had one parent with a definite or suggested diagnosis of schizophrenia.
Keeler is also giving careful attention to the possible influence of home environment on his patients. He has noted one surprising thing: in one large group of parents studied, half were university graduates. (Only one percent of the Canadian population possesses a university degree.) Many of them were successful physicians, lawyers, business executives and artists, deeply interested in cultural activities. On the surface they were sociable people, but, searching deeper, Keeler found they were cool, withdrawn, unemotional personalities who failed to give much warmth to their children.
The marriage of these parents was usually contracted relatively late in life. There was a minimum of glamour and romance during the courtship, the selection being made primarily on the sharing of intellectual interests. Keeler is exploring the possibility that the children of such parents, failing to find warm emotional acceptance, tend to withdraw into themselves and thus development of the schizophrenic state is encouraged.
Dr. Leo Kanner, of Johns Hopkins University, flatly concludes, after studying fifty-five sets of parents, that schizophrenic children are reared in “an emotional refrigerator.”
“On visits to the clinic,” says Kanner, “I have noticed a lack of warmth between mother and child . . . When the mother is asked to take the child in her lap, she does so in a stilted manner. I have seen only one mother embrace her child warmly and bring her face close to his. It’s as though the mother can’t bear the physical proximity of the child.
“I believe that most of my parents were emotionally and gave a mechanical type of attention to material needs only. The child’s act of withdrawal seemed to be an act of turning away from such a situation to seek comfort in solitude.”
Not all psychiatrists, of course, agree with Kanner and Kanner himself points to a weakness in his argument. “One is entitled to know,” he says, “why it is that such parents can rear other children who are not schizophrenic.” Kanner’s theory is further minimized by scores of case histories gathered by Keeler. It appears that the behavior of the schizophrenic child is different even before he is born.
In a large number of cases the child was extremely quiet during pregnancy. One mother, for example, recalled, “I went to the doctor after being pregnant for seven months, to find out if the child was dead or alive.” Another mother said, “I never felt anything until a week before he was born, and even then only a slight amount of movement.”
The parents recalled that, as infants their children were “different.” They were apathetic and appeared to be happiest when alone. They were “lazy and indifferent,” even to breast feeding. One mother described her child as “an inanimate object, like a small wooden log,” when she held it in her arms. Their choice of toys tended to be mechanical objects with moving parts. They didn’t like soft cuddly things like teddy bears.
In other groups of children, Keeler noted that, instead of being apathetic and quiet, many of the infants were excessively noisy, and there were serious problems in eating and sleeping. All of which, says Keeler, suggests the presence of a good deal of anxiety.
Keeler has noted other features commonly found in the early years of some schizophrenics. These are to be found, to some extent, in all children, but in the schizophrenic they are more intense and they persist longer. There is a ritualistic, obsessional behavior, for example. Some children spend hours tearing paper, turning light switches on and off, screwing and unscrewing a nut and bolt. Then too, schizophrenics tend to have morbid fears of a great many objects, including old people, tall buildings, trees and colored dishes.
To what extent can such confused, anxious and disturbed children be helped by science? This question may be in the process of being partially answered at the Montreal Children’s Hospital. Each child under study there spends one hour a week with a psychiatrist or clinical psychologist. In groups of six, they spend three halfdays a week at the day-treatment centre. Finally, the mothers and fathers meet in groups, once a week, with psychiatrists and psychiatric social workers, to learn how they can best cope with the problem at home.
In the hour-long patient-doctor sessions, the doctor does all he can to establish a relationship with the child. “If the youngster can learn to get along with one person, he’s got a chance of getting along with others,” says Dr. Brian Hunt, of the hospital staff. The doctor tries to meet the child at his own level. If the patient can’t talk, the doctor will grunt, yell and shriek along with him as a sign of willingness to share his activity. If the child can talk, the doctor will encourage him to discuss his fears. Often the doctor will take the child in his arms and rock with him—a favorite activity of most schizophrenic patients. As he holds him, the doctor will point out to the child the various parts of his body. Even after several months there may be little overt sign of improvement. “But if you switch therapists,” says
Hunt, “it has a disturbing effect on the child.”
At the day-treatment centre—gaily painted and full of toys—there are two teacher-therapists for each group of six children. The main purpose of these sessions is to help the child play and work with other people, as well as to make the most use of his abilities.
Speech is encouraged. A little girl pointed to a plastic toy on a high shelf, indicating that she wanted it. Greta Fischer, the senior teacher-therapist, refused her obvious request, asking over and over again, “What do you want?” After a few minutes, the child replied, “I want that toy.” Miss Fischer explained that this child, like others, is able to talk but will refuse to do so without encouragement.
When one child struck another, Miss Fischer ran over and comforted the attacker. “It’s usually the aggressor who needs help,” she explained. “He’s more frightened and anxious than the other child.”
Parents discover themselves
Perhaps the most important part of the treatment program is the weekly group sessions attended by the mothers and fathers of the schizophrenic children. For years they have grappled with their problem alone. With a group of other parents who have the same problem, the feeling of loneliness and helplessness vanishes.
At the group meetings the parents are not given any neat formula for handling their children. It is an experience of self-discovery. Each is helped to examine his own feelings toward the child and to adjust to the situation. Discussions usually centre on the parents themselves and their own reactions and attitudes.
What does the future hold for the schizophrenic child? Taylor Statten, chief of psychiatric service at the Montreal hospital, says, “We don’t know how many will grow up to be reasonably normal adults or how many will have to spend the rest of their lives in mental institutions.” It is true that as they grow older, some patients show surprising improvement. There are some former juvenile schizophrenics who are now attending university. At the Children’s Centre, in Boston, officials claim that one third of their graduates show marked improvement, but how long the improvement will last is not known. One third, it appears, require at least partial supervision in the community; the final third have to be committed to mental institutions.
Statistics gathered by other authorities are less cheerful. Lauretta Bender did a follow-up study of one hundred and forty-three adults she had treated as children: over eighty percent of
them were in mental hospitals. When Leo Kanner, of Johns Hopkins University, traced his juvenile schizophrenic patients after sixteen years, he found that seventy percent of them were hospitalized. Dr. Bender and other investigators were also gloomy about the long-term benefits of such treatments as electric shock and prefontal lobotomy. The patient who has undergone such treatment, they report, shows some temporary improvement, then lapses into his accustomed style of behavior.
Authorities such as Keeler say that, if the outlook for the schizophrenic child is to grow brighter, we must embark on a vigorous program of treatment and research. Placing these children in institutions for the rest of their lives is a costly solution both in human and economic terms.
Present facilities for the schizophrenic child in Canada are practically non-existent. His condition is seldom detected; instead, he is classified in a mixed diagnostic grab bag along with mental retardation, deafness, muteness, and psychopathic personality.
Ray Keeler, of Toronto’s Sick Children’s Hospital, says, “The problem of the schizophrenic child is like the problem of old age. Although our treatment methods are not yet fully effective, we can learn new techniques of managing it.” Keeler suggests a variety of services—day-treatment centres for preschool children; small, residential cottage-type institutions for school-age children; special hospital wards for “incurable” patients; and observation centres in our main cities where youthful patients can be diagnosed and sent to the appropriate place for treatment or care.
In all these places, our best medical brains should be studying the children and conducting research, says Keeler. For if our scientists can enter the bewildering inner world of the child schizophrenic and successfully explore it, thousands of wasted lives may be salvaged and millions of dollars may be saved. ^