A review of Mental Defectives, Childhood Psychotics and the Origins of Autism Research at the Maudsley Hospital, 1913-1983, by Bonnie Evans.
Bonnie Evans’ excellent dissertation maps out the formation of child psychiatry in the twentieth century while simultaneously exploring the origins and construction of the autistic child in British society. Tracing evolving political standards, upheavals in local and national legislation, changing roles for medical and educational institutions, as well as new trends in psychiatric theory and treatment, Evans’ story captures the ways that the classification and experiences of socially impaired children dramatically changed over the British twentieth century.
Evans begins and ends her story in the 1980s, arguably the period when the most famous of these classifications of children, the autistic child, had come to acquire its public, political, and medical prominence. In that decade many observers called attention to the fact that autistic children seemed increasingly prevalent in Western societies. Evans asks her readers to consider why and how that happened, and in an empirically and theoretically rich two-hundred pages, answers the question with a brilliant archaeology of the economic, institutional, and conceptual underpinnings of child psychiatry. Along the way she revises our contemporary historical understanding of the Maudsley Hospital, an institution Evans rightly claims as having “a central role in the establishment and development of child psychiatry in the United Kingdom” (Appendix, p.3).
Using legal, institutional, intellectual sources, as well as patient records from the Maudsley to excavate her story, Evans convincingly demonstrates that transformations and formations outside and inside the strata of professional psychiatry and psychology ultimately made and unmade child patients, categorizing them in various generations as “backwards,” “mental defectives,” “subnormals,” “ineducables,” “psychotics,” “schizophrenics,” “autistics,” and “socially impaired,” She concludes that the increasing prominence of the autistic child derived from a confluence of epidemiological understandings about the social and mental abnormalities of children and laws concerned with those children’s protection and education. It was this meeting between law and epidemiology that ultimately constructed the autistic child into a demographic reality and made that child a prevalent, persistent subject.
Changing Legislative Standards, 1910-1950
In interwar Britain the types of child patients that found their way to the Maudsley Hospital changed dramatically. Changes in legislation — the 1913 Mental Deficiency Act, the 1914 Education (Defective and Epileptic Children) Act, and the 1929 Local Government Act — meant that children were ever-more often referred to the Maudsley. The children that found their way there suffered from “malnutrition, neglect [and] poverty” and moreover physicians increasingly found themselves operating a great “sorting ground for human types,” a mission beyond their role as a research centre (p. 58).
Although it had long been recognized that legal and medical categories into which many of these children fell were inadequate, physicians at the Maudsley soon recognized that many children simply did not fit given psychiatric classifications, and they quickly began creating new means of distinguishing children in need of medical treatment (even as they sent many to mental deficiency institutions scattered across Britain). At the Maudsley, medical treatments were few and of questionable efficacy. Moreover, with numerous theories of childhood disorder, wholly different therapeutic regimens were commonplace and sat alongside difficult questions. Could, for example, infants experience hallucinations?
Such problems, Evans argues, meant that: “Psychologists were in desperate need of new forms of evidence which could convincingly support the clinical work that they were being asked to conduct on increasing numbers of children… There was a critical need for a new science of child development and its pathological manifestations” (p. 52). Unavoidably the already fragmented methodological imperatives of psychology and psychiatry dissolved into deeper debates about the normal psychic development of children. Fundamentally these problems were theoretical, a fact that would lead figures at the Maudsley to re-conceive their knowledge and practice.
Contested Knowledge, Practice, and Therapy, 1930-1960
Debates and controversies in the provision of care for mentally impaired children did not imply that the British government maintained adequate, up-to-date classifications systems. In the early 1950s, children diagnosed with “psychosis and schizophrenia… had no legal rights to long-term treatment or education.” Aware of this administrative conundrum, physicians and psychologists at the Maudsley sought to get “‘childhood psychosis’ recognized as a legal category” (p. 58). The lack of government recognition, however, conferred certain creative advantages to the researchers responding to the conceptual problems of childhood development, and this fact Evans argues dominated but also limited the Maudsley approach.
Among the advantages was that researchers at the Maudsley were able to unmake the categories that had placed the children into their institutional keeping. Imagining new categories, Kenneth Cameron and Elwyn James Anthony, the founders of the first psychotic clinic for children there, drew upon concepts pioneered by Ernst von Feuchtersleben (who coined the word “psychosis”), Pierre Janet, Sigmund Freud, Eugen Bleuler, Jean Piaget, and Emil Kraepelin “in order to comprehend and analyze psychotic children” (p. 15). It was Bleuler who first coined the word “autism” in 1911, which he claimed designated “in a positive way the same concept that Pierre Janet formulated negatively as “the loss of the sense of reality” (p. 62). The word “psychotic,” however, was preferred in the 1950s, despite recognition by figures like Cameron and Anthony that the designation covered too broad a group.
Cameron and Anthony saw it their duty to clear up that diagnostic ambiguity and etiological ignorance; in so doing, they established child psychiatry. Central in their efforts were broad, almost Baconian-like observations. Nurses and other workers kept detailed records of psychotic children’s vocalizations, phrases, and social relations. Their media for these observations were standardized notepads and case-notes. Interestingly behaviorist assumptions also became commonplace in the observations about these children. Evans describes how Anthony and Cameron’s interests in language and their behaviorist assumptions merged into a theory that words were only windows “onto psychotic states of mind” and thus originated what she terms “a language of autism” (p. 75).
Another curious effect of the behaviorist approach was that wholly new therapeutic approaches became commonplace, including “occupational therapy,” “socialization,” (p. 84) and even mainstreaming away from institutionalization. Eventually Anthony and Cameron concluded that psychotic children “were children in whom normal identifications processes had failed” (p. 92). Although desiring to take these observations to develop new theories about the psychological development of children, researchers at the Maudsley found themselves with a limited population of children to examine, a consequence of inadequate legislation which placed many of this population beyond the researchers’ reach.
From Psychotic to Autistic, 1940-1970
The Maudsley Hospital Psychotic Clinic for Children would eventually unmake psychotic children and establish autism as a field of research. Central to this transformation was the rise of population psychology there. This paradigm of psychological research, which harkened back to the work of Karl Pearson or Francis Galton, pointed towards new methods and procedures for unraveling the psychological development of children statistically. The underlying cause of this turn to epidemiology and statistics was that children previously designated as “mentally deficient” or “psychotic” had been placed by the 1959 Mental Health Act into a broader category termed “in need of care” (p. 99).
Evans notes that there were two major consequences of this signature legislation that brought about this shift in categories: 1) whole populations of children suddenly came to the attention of local authorities through the schools or social workers, and 2) parents suddenly found they had new agency in determining where their children ended up institutionally. Workers at the Maudsley suddenly found themselves in the middle of a vast certification process that often dictated whether or not subnormal children found their way into special schools, which often showed some success in socializing and treating them.
After the passage of 1959 Mental Health Act, numerous definitional and classificatory ambiguities emerged with immediate implications in terms of cost, access, treatment, and long-term care. At issue were also concerns about individual autonomy. Designations of “subnormality” or “psychopathy” brought with them implications of guardianship. Such designations, which replaced “feeble-minded” and “moral defective,” soon acquired rather rigorous legal limitations. A further effect of these changes was that the numbers housed in asylums and other long-term care facilities decreased rather rapidly; government training centers and special schools rapidly sprang-up in consequence (p. 99).
For workers at the Maudsley, however, these changes brought them a new, deeper and wider population for statistical examination, which began influencing their theories of mind and individual development. Interested in the mentally defective population, they began speculating that this population might be useful for characterizing myriad psychological conditions. As Evans recognizes:
It was ironic that the “mentally defective” were precisely the section of the population which the bureaucratic systems of the previous era of psychology had hidden inside large institutions and eventually disregarded. The influence of the Eugenics Society in establishing Mental Deficiency Law had a long-term effect which had diverted attention and interest away from the mental life of this section of the population (p. 102).
Prevalence rate studies on this population proved doubling illuminating. Such studies could aid NHS planning while also identifying new psychological conditions, which could in turn be studied biochemically or immunologically. It was in this way that “autism” became regarded as an “exemplary mental state” (p. 118). Evans writes: “Instead of focusing on individual cases, Maudsley researchers of the 1960s focused on the study of total populations of autistic individuals… [the move away from] the study of unconscious drives [to] measurable behavioristic reflexes, enabled the study of autistic and psychotic phenomena using the model of statistical psychiatry” (p. 118). Child psychological theory was slowly remade to reflect these statistical collections; statistics offered “new possibilities for the analysis of children’s developmental and psychological problems…” (p. 125).
Did Autism Increase? 1960-1985
The first patient advocacy groups for autism formed in the 1960s. The rise of such new groups complemented a further destabilization of the child psychiatry and psychology paradigms. In turn, the autism diagnosis spread both through efforts by researchers at the Maudsley and in wider administrative application. The children, who were at the heart of this transformation, lost many of their previous designations as “subnormals” or “defectives” and were reintegrated under a penumbra of new classifications that carried the mark of the new socio-psychiatric epidemiological paradigm of autism. They also experienced new treatment interventions that emphasized educating around the various handicaps of the children in precise, logical ways.
Increasingly many researchers argued that: “language and cognitive defect constitutes the primary handicap in autism” (p. 144). Lorna Wing, one of the most prominent researchers on autism in the late twentieth century, argued that autism was “characterized by a deficit in certain aspects of thought” (p. 145). Evans shrewdly notes that one important context for this new centrality of language in autism research was the wider linguistic turn then influencing the humanities and social sciences. But was this turn to language the cause of the alleged rising incidence of autism?
By the 1970s, the autism category or its features were being applied to increasing numbers of children. Partly to blame was the unmaking of obsessions and fantasies as aspects of the autism condition and the remaking of those symptoms into forms of autism behavior. This change came to be reflected in the International Classifications of Diseases and it was used to differentiate autism from conditions like schizophrenia (p. 163). Following the publication of the Diagnostic and Statistical Manual of Mental Disorders in 1980 and the passage of the 1981 Education Act, the numbers of autistic children who were integrated into classrooms increased further. Evans concludes that this phenomenon transpired as a result of psychiatrists moving from group descriptions of autism to specific diagnostic statements about individual children. Thus it was that “a new psychiatric profession” succeeded in integrating “‘mentally defective’ populations” into popular consciousness (p. 183). It was not the case that autism had increased; it was that a new political standard backed by new legislation had once again changed the roles of medical and educational institutions. So much so, in fact, psychiatric and psychological theories of autism once again lagged behind.
Evans has revised and refined much scholarly understanding of the history of psychiatry, neurology, and clinical neuroscience. Through her empirical rigor and theoretical determination, Evans showcases the value of ceasing to ponder the possibility of critical historiography; instead she simply adopts it and writes a powerful, compelling, and evocative narrative. Her study makes great strides towards helping historians understand why it is that increasingly the whole notion of discipline and specialty became meaningless in proximity to nervous disease, disorder, and normality concepts. There is, of course, still some distance to travel for all of us. Evans notes in her appendices that the Maudsley was but one institution — admittedly an important one — among many in Britain and across the world constructing autism. As I have suggested elsewhere, there is sometimes great value to be added by refocusing such local socio-historical reconstructions of disease-things into wider explorations of global encounters. I suspect that similar strides towards unearthing autism as a thing made through encounters and exchanges will help scholars further refine and understand Evans’ magnificent work (Casper 2011, 160-166). But Evans has started us on that road. And in so doing, she has opened and advanced the history of psychiatry in a surprising, forceful, and meaningful way. She has shown us where an archeology of knowledge might take us if we feel inspired to keep digging.
Stephen T. Casper
Humanities and Social Sciences
Stephen T. Casper, “Essay Review of The Collectors of Lost Souls: Turning Kuru Scientists into Whitemen by Warwick Anderson and The Social Construction of Disease: From Scrapie to Prion by Kiheung Kim” in Journal of the History of the Neurosciences 20 (2011), 160-166.
Selected Primary Sources
Bethlem Royal Hospital Archives
Institute of Psychiatry — Social, Genetic and Developmental Psychiatry Centre Archives
King’s College London Archives
Institute of Psychiatry Archives
Psychoanalytic Electronic Publishing Archive
University of Cambridge. 2010. 230pp. Principal Advisor: John Forrester.