Revisiting the history of autism before Kanner and Asperger: a tribute to Grunya Sukhareva

Abstract

Almost two decades before Kanner's and Asperger's works, the original paper by child psychiatrist Grunya Efimovna Sukhareva had already been written. It was published in 1926 by Sukhareva in a German scientific journal of psychiatry and neurology, with a detailed description of children who presented clinical conditions whose characteristics and evolution closely resemble autism, according to current criteria. In the present historical note, we intend to present Sukhareva's pioneering work and retrieve the meaning of her original contribution.

Resumo

Quase duas décadas antes dos trabalhos de Kanner e Asperger, o artigo original da psiquiatra infantil Grunya Efimovna Sukhareva já havia sido escrito. Foi publicado por Sukhareva em 1926, em uma revista científica alemã de psiquiatria e neurologia, com uma descrição detalhada de crianças que apresentavam quadro clínico cujas características e evolução em muito se assemelham ao autismo, segundo os critérios atuais. Nesta nota histórica, pretende-se apresentar o trabalho pioneiro de Sukhareva e resgatar o significado da sua contribuição original.

Keywords

Autistic Disorder - Psychiatry - Asperger Syndrome

Palavras-chave

Transtorno Autístico - Psiquiatria - Síndrome de Asperger

THE UNTOLD HISTORY

Whenever the historical review of autism is presented, it begins with Kanner and Asperger. According to the official story, in 1943, Kanner, an American child psychiatrist of Austro-Hungarian origin, described a clinical picture in 11 children that was later considered classic early infantile autism.[1] In 1944, Hans Asperger, an Austrian pediatrician, described “autistic psychopathy” in four boys, which, many years later, took the name Asperger syndrome.[2] However, there is an author who is little explored in this story, whose role has not been given due importance: Grunya Efimovna Sukhareva (1891–1981), a Jewish psychiatrist and researcher born in Kiev.[3] [4] [5]

In 1921, Sukhareva founded a therapeutic school for children with psychiatric problems in Moscow. She was head of the Department of Psychiatry of the Kharkov Psychoneurological Institute in 1933 and, between 1938 and 1969, she was head of the Psychosis Pediatric Clinic at the Institute of Psychiatry of the Union of Soviet Socialist Republics.[3]

In 1926, Sukhareva published part one of a detailed description of autistic traits in 6 boys, in the Monatsschrift für Psychiatrie und Neurologie, a German scientific journal of psychiatry and neurology.[6] In 1996, Sula Wolff[7] translated this article into English, originally published in Russian in 1925 and in German the following year, entitled “Die Schizoiden Psychopathien im Kindesalter”. Sukhareva initially used the term schizoid (eccentric) psychopathy and later replaced it with autistic psychopathy (pathological avoidance) to report the clinical picture of what is now described as autism. Her original paper was available almost two decades before the studies by Kanner[1] and Asperger.[2] However, Sukhareva's pioneering work is rarely even cited.

In 1927 she published “Die Besonderheiten der Schizoiden Psychopathien bei den Mädchen” in the same journal as a follow-up to the first article, presenting 5 cases of girls and a discussion of the differences between the sexes in the presentation of schizoid psychopathy, potentially being considered part of the autistic spectrum now. This study was translated and published in 2020 by Charlotte Simmonds.[8]

In the report of her first six patients, Sukhareva[6] [7] presents the entire family history of parents, grandparents and uncles, the detailed neurological and psychological clinical examination as well as the evolution observed during their stay in the therapeutic school. Her final impressions involved a clinical opinion, course, and diagnosis that resembled classical features of autism. At the end of the descriptions, Sukhareva pointed out that despite the individual differences in the clinical picture of the cases, of what she initially called schizoid personality disorder, it was possible to define common characteristics to all children. These included:

• A strange kind of thinking: a tendency toward abstraction and schematization. This trait of thought was often combined with a tendency towards rationalization and absurd rumination, and the latter feature often marked the personality as strange.

• An autistic attitude: all affected children kept aloof from their peers, had difficulty adapting, and were never fully themselves among other children. They also manifested a tendency to loneliness and withdrawal from other people since early childhood. They kept themselves isolated, avoided community games, and preferred fantastical stories and fairy tales.

• Emotional life: there was a certain flatness and superficiality of emotions. This mixture of insensitive and supersensitive elements was observed in all cases, from affective slowness and exaggerated sensitivity, to increased irritability, resulting in emotional outbursts, according to Bleuler's description of spasms and paralysis of emotions. Still, a generally calm and at the same time passionately tender mood towards some of the people close to them was noted.

• Other characteristics: tendency towards automatism, manifesting itself as adherence to initiated tasks and psychical inflexibility with difficulty in adapting to new situations; impulsive and strange behavior; tendency to stereotyped neologisms; tendency to obsessive-compulsive behavior and increased suggestibility; motor alterations: clumsiness, awkwardness, sudden and superfluous movements, synkinesis. Lack of facial expressiveness and expressive movements; decreased postural tone; lack of speech modulation.

Recovering contribution

The precision and detail in the description of these cases is surprising, since Sukhareva evidenced the presence of sensory abnormalities, which only recently regained their proper relevance in the description of autism spectrum disorder (ASD) in DSM-5.[9]

Manouilenko and Bejerot[3] presented a comparative analysis between the clinical description highlighted by Sukhareva in her original article and the similarity with the description of ASD in DSM-5. They also discussed her anonymity and trajectory and asked if Kanner and Asperger really knew about her early work. Interestingly, these three pioneers who began to describe the clinical picture of autism were all German-speaking and born in Ukraine and Austria, but died as citizens of the United States, Austria, and the Soviet Union. Being Jewish, a citizen of the Soviet Union, and publishing in German and Russian, as well as being a woman, may not have been a successful formula for achieving international acclaim at that time.

Sukhareva and Asperger studied Kretschmer's early work on schizoid personality in adults and cited different editions of the book Körperbau und Character.[3] Sula Wolff, who introduced the English translation of Sukhareva's original article in 1996,[7] speculated that Hans Asperger should have known about Sukhareva's article, but this cannot be confirmed in contemporary times.

It is understandable that the ASD is more heterogeneous and complex than the original description given by Sukhareva, but to deny the originality and accuracy of her descriptions, almost 100 years after her publications, would be a historical error, which we hope to repair.

Conflict of Interest

The authors have no conflict of interest to declare.

Authors' Contributions

Conceptualization or design of the work, data acquisition, analysis or interpretation, writing or reviewing the manuscript. All authors approved the final version of the manuscript and agree to be responsible for all aspects of the work.

Editor-in-Chief

Hélio A. G. Teive.

Associate Editor

Ylmar Correa Neto.

• References

• 1 Kanner L. Autistic disturbances of affective contact. Nerv Child 1943; 2: 217-250
• 2 Asperger H. Die Autistischen Psychopathen im Kindesalter. Arch Psychiatr Nervenkr 1944; 117: 76-136
• 3 Manouilenko I, Bejerot S. Sukhareva–Prior to Asperger and Kanner. Nord J Psychiatry 2015; 69 (06) 479-482
• 4 Goldschmied AZ, Zumpalov LG, Holyoake DD. Two psychiatrists, three boat builders and a million gap hunters: the choices we make in literature reviews. J Health Soc Care Improv. 2021; 4: 55-62
• 5 Posar A, Visconti P. Tribute to Grunya Efimovna Sukhareva, the woman who first described infantile autism. J Pediatr Neurosci 2017; 12 (03) 300-301 . Doi: 10.4103%2Fjpn.JPN_46_17
• 6 Ssucharewa GE. Die schizoiden Psychopathien im Kindesalter. (Part 1 of 2). Monatsschr Psychiatr Neurol 1926; 60 (3–4): 235-247
• 7 Wolff S. The first account of the syndrome Asperger described?. Eur Child Adolesc Psychiatry 1996; 5 (03) 119-132
• 8 Simmonds C, Sukhareva GE. The first account of the syndrome Asperger described? Part 2: the girls. Eur Child Adolesc Psychiatry 2020; 29 (04) 549-564
• 9 American Psychiatric Association, Manual Diagnóstico e Estatístico de Transtornos Mentais DSM-5. Porto Alegre: Artmed; 2014: 355-360

Publication History

Received: 11 March 2024

Accepted: 06 May 2024

Article published online:
08 August 2024