Harry Breuer

Klinefelter's Syndrome in a Three-Year Old Severely Disturbed Child.

A case study of a 3-year-old boy, said to be the youngest known Klinefelter patient (47 XXY) with severe psychopathology, mental retardation, and speech disorder is presented and discussed. The possibility of childhood schizophrenia was raised and a diagnosis of “emotional disturbance” formulated by other specialists on the basis of the childs stressful home environment. Pertinent psychiatric observations and laboratory findings are detailed and the interplay of environmental and biological factors related to the final diagnosis of Klinefelters syndrome with borderline to mild retardation, dysarthria and a superimposed withdrawing reaction of childhood. The importance of complete diagnostic work-up, including cytogenetic studies, for retarded and/or severely disturbed children of preschool age is emphasized. Such studies showed sex chromosome anomalies in 2 out of 25 patients consecutively admitted to a psychiatric hospital nursery.

Childhood Psychosis in Perspective: A Follow-up of 10 Children

Abstract This pilot study of 10 subjects showing manifestations of illness in infancy and diagnosed as psychotic between 2:1 to 6:8 years is a report on their revaluation 3:6 to 12 years later. Multiple behavioral assessments by independent raters and psychological testings were carried out on follow-up, revealing a shift in the distribution of symptoms and a relatively stable IQ. Those who initially had some verbal skills and were able to perform at higher intellectual levels had better future prospects. The results indicate that the form of behavioral pathology depends on the organizational-maturational level each individual has reached.

Introduction: Disease, Disability, and Psychodiagnostic Concepts in Childhood

Webster’s Dictionary defines disease as “an aberration of a living body that impairs its function.” By this definition, the concept of disease is easily applicable to physical illnesses where the optimal functioning of an organ or a system is known, and direct links can be traced between a damaged or pathological organ and various symptomatic manifestations of its deviant functioning. Thus, one can speak with relatively high levels of assurance about physical disease-entities, their distinguishing characteristics and, in most instances, their defined etiologies. When one enters the realm of aberrant psychological states and behaviors, however, the disease-concept is applied problematically at best. Behavioral abnormalities and psychiatric conditions do not have simple linear relationships with the brain and its malfunctioning. Furthermore, even though the state of physical well-being is almost universally recognizable, behavioral or psychological normalcy is a value-laden concept, varying broadly in its application from community to community and subject to changes in interpretation in different times. Psychological disorders are more aptly defined and better understood when they are conceptualized as disabilities rather than diseases. By disability, we mean failure to perform as expected in a psychological task or function that is considered essential at a given point in life by a particular cultural community.

Specific Language Dysfunctioning in Children: A Historical Overview

The origins and growth of awareness of specific impairments in the linguistic functioning of children may be looked at in terms of three roughly chronological but overlapping and ongoing aspects: clinical recognition, conceptualization, and classification. The first aspect is characterized by the discovery, mainly during the first third of this century, that a population of children existed in facilities for the mentally deficient or the deaf who were neither imbecilic nor hard of hearing. Rather, these children displayed what appeared as circumscribed aberrations in the development and use of their native language, but they were relatively normal in other respects. On the basis of the paucity of published studies, the occurrence of such cases was thought to be something of a rarity. Gradually, an increasing number of writers reported such cases, and detailed accounts of directly observable symptoms grew. As more probing questions were posed, more thorough examinations appeared in the literature, and inferences were made regarding the specific nature of the linguistic defects and their etiology. Thus emerged the second aspect—theoretical conceptualization.

Childhood Psychosis: A Historical Review

The official glossary of the American Psychiatric Association defines psychosis as “a major mental disorder of organic or emotional origin in which the individual’s ability to think, respond emotionally, remember, communicate, interpret reality and behave appropriately is sufficiently impaired so as to interfere grossly with his capacity to meet the ordinary demands of life.” According to this definition, the severity and pervasiveness of the impairment are the two key features of the clinical diagnosis. However, it must be noted that in order to designate any function as deviant or impaired the range and fluctuation of its normal operation must be clearly defined. Also, “the ordinary demands of life,” against which the individual’s shortcomings are to be judged, need to have identifiable criteria. The official classificatory scheme is silent on both of these accounts. Diagnosticians differ in their assessment of the degree of impairment due to their sociocultural expectations of the normative behavior, professional training, philosophical bent or their personal life history.

The Psychological Testing of Dysphasic and Psychotic Children

The distinctions and similarities between dysphasic and psychotic behavior that we have discussed thus far extend to the children’s reactions and responses to psychological testing. The use of standard tests in making differential judgments about these children is, however, fraught with misconception and open to serious misinterpretation when test results and responses are accepted at face value and when preconceived categorical notions of test interpretation are applied.

Deviant and Normal Social Development

The child’s adaptation and development of various aspects of his personality are dependent upon the availability of a group of well-tested coping mechanisms and viable strategies provided in the social network. Their need for social survival makes it necessary for parents to help induct the child into the social milieu through encouragement, direct teaching, and even coercion. The innate impetus for socialization compels the child to accept what is offered, learn what is exhibited, and actively select from what is present. Gradually the child’s unique personality is shaped, and a complex psychological being is created. On the other hand, incorporating each new individual into the social network confronts the system with a new challenge. As the social system shapes the child’s personality, it is in turn modified by him. This reciprocal interaction prevents the fossilization of the social network, and assures the guided development of each individual’s psychology.

Psycholinguistic Development: Functioning and Dysfunctioning

Language, viewed as it must be for the practical evaluation of problems in human communication, consists of holistic acts that involve complex, interconnected operations and determinants— physical, perceptual, cognitive, emotional and social, as well as linguistic. They are subjective acts to the extent that their meanings derive from the individual’s interpretations of inner and outer experience and from their communal validity which is a matter of degree from person to person and situation to situation. They are objective acts in that they utilize a code with conventional referents and rules of grammar. Thus, in making judgments about aberrations of human communication, their primary and secondary components and systemic effects, one must consider all of their aspects interactively, from both the standpoint of the patient’s phenomenological world and the standpoint of the congruence or incongruence of his acts with the shared rules and practice of communication in his particular community. When the patient is a child, one must consider one other, highly complicating factor—the patient is somewhere along the road of developing the mechanisms of communication and of learning its conventions from his immediate and extended community.

Normal Social Development

Every human infant is born in a social milieu and his survival, both biological and psychological, is dependent on such an environment. It may therefore be assumed that the capacity to respond to interpersonal cues and to develop social ties is among the important biological endowments of human beings. Although we do not have the necessary genetic information as yet to support such a hypothesis, we may observe seemingly innate tendencies on the part of the infant, which, if not directly causative, can be said to encourage and set the stage for socialization. We do not and cannot know how a human infant might have developed under a radically different set of circumstances, but we do know that even in vastly different forms of societies and with various philosophies of child rearing, the task of socialization of a child begins with the earliest interactions between him and his human environment. These interactions require social receptivity and reciprocity and are dependent on the presence of certain factors in the individual as well as in his surroundings.

Diagnosis and Evaluation of Disordered Thought and Language

By definition, dysphasic behavior originates in the processing of the formal components of language—in a child’s perception, decoding, comprehension, storage, retrieval, or encoding of words and syntactical arrangements of words that he hears in his environment. Defects in any one or more of these operations result in abnormalities of communication, either in what the child does and does not do in response to the communication of others, or in expressing himself, or in both. Although dysphasic defects secondarily bring about or contribute to difficulties in the way the child conceives of and reacts emotionally to himself and the world about him, they are not caused by such difficulties. Psychotic behavior also is comprised of aberrations in the child’s communicative functioning, both receptive and expressive, and may affect the formal components of his developing language as well. However, psychotic disability originates in the child’s conceptualization of and emotional reactivity to self and environment. In short, both dysphasic and psychotic functioning have systemically interactive consequences for the development of communication and for the child’s psychological and social adaptation and survival, but for fundamentally different reasons. Although at times the behavioral manifestations of each are quite similar, and mixed cases are not unheard of, the distinction in primary dysfunctioning bears directly upon one’s approach to planning and treatment and is vitally significant to those who must understand daily the child’s actions and look to his needs.