The very terms in the official classification for the mentally retarded offend today’s sensibilities. The terms ran from feebleminded to moron to imbecile to idiot. Down syndrome was still known as Mongolian idiocy, a label reflecting Langdon-Down’s belief that it was an atavistic throwback to a more primitive “Mongolian race” (6). We did know that risk increased with the mother’s age, but trisomy 21 was not identified until the late 1950s (7,8). That is hardly surprising, given that the correct human chromosome number was not established until 1948! Whatever the terminology and whatever the ignorance about pathophysiology, what remains distressing is that most child guidance clinics of the ’50s and ’60s screened out retarded children as if retardation excluded treatable psychiatric disorders. A recent study of an epidemiological cohort of almost 600 children with intellectual disability has provided documentation of the substantial and persistent level of psychopathology and the need for effective interventions (9).

Few things epitomize Kanner’s personal commitment to the rights of all children more than his concern for the “feebleminded” at a time when most psychiatrists assiduously excluded them from their clinics and offices. The Superintendent of the Maryland State Training School for the Retarded, knowing of Kanner’s concern for such patients, appealed to Leo Kanner for help in controlling an appalling problem. Female patients were being removed from the training school by court orders and were being exploited in the community for cheap domestic labor. The superintendent was at his wits’ end; he simply didn’t know what to do. With the assistance of Miss Mabel F. Kraus, a social worker, Kanner (10) did a followup study on 166 patients who had been released from the school via habeas corpus writs secured by lawyers over the previous two decades. Three-quarters of these releases had been obtained by enterprising attorneys who, for a fee, secured what were essentially indentured domestic servants for affluent Baltimore households; others had been claimed by relatives who suddenly appeared to manipulate estates that had been left them; a few were demanded by parents who, after years of neglect, asserted their “natural rights.”

Kanner was able to follow 102, of whom only 13 were making even a modestly satisfactory adjustment in the community at the time of the study; 11 had died of illness and neglect before they reached 30; 17 had tuberculosis, syphilis, or gonorrhea; 29 were prostitutes; 8 had been committed to mental hospitals; and 6 were in prison. In total, these released patients had given birth to 165 offspring, 18 of whom had died from neglect, 30 of whom had been committed to orphanages, and 108 of whom tested at a “feebleminded level” when examined. The customary sequence had been a period of domestic servitude, followed by peremptory release when the young women proved to be inadequate as maids, and then a mournful hegira through the whorehouses and flophouses of the Baltimore slums. Few now remember Kanner’s paper in the American Journal of Psychiatry, but in 1938, the study had a dramatic impact. The release of the information produced a double row of inch-high headlines across the front page of the April 8th edition of the Baltimore Sun and provided the impetus to end an evil practice that had arisen from the collusion of attorneys and judges against the valiant but unsuccessful opposition of the superintendent of the Training School. It is a study worth remembering (10). Clinical precision joined with social conscience in a clinical project with immediate benefit for the lives of a despised minority.

In 1942, amid the war against the Nazis, Foster Kennedy, a well known neurologist, published a paper in the American Journal of Psychiatry entitled: “The problem of social control of the congenital defective: Education, sterilization, euthanasia” (11). In it, he proposed that defective children with no future or hope of a worthwhile life “should be relieved of the agony of living,” language remarkably similar to the Nazi policy to end life unworthy of life. In a vigorous response to Kennedy, Kanner (12) wrote: “Let us try to recall one single instance in the history of mankind when a feeble-minded individual or group of individuals was responsible for the retardation or persecution of humaneness and sciences. They who caused Galileo to be jailed were not feeble-minded. They who instituted the Inquisition were not mental defectives. The great man-made catastrophes resulting in wholesale slaughter and destruction were not started by idiots, imbeciles, morons, or borderlines. The one man, Schicklgruber, whose IQ is probably not below normal, has in a few years brought infinitely more disaster and suffering to this world than have all of the innumerable mental defectives of all countries and all generations combined.”

Kanner’s revulsion against euthanasia for the severely retarded was not universal; in the same issue of the Journal an unsigned editorial argued that the role of psychiatrists should be to persuade parents to agree to release their defective children from “the burden of living” (13). Euthanasia never became official policy, but sterilization was widespread in U.S. institutions for the mentally retarded.

When Leo Kanner (4) first identified infantile autism as a diagnostic entity, he concluded that his patients had:

Kanner believed that his emphasis on an “inborn” disturbance delayed the acceptance of early infantile autism as a clinical entity. Recognition of the impact of severe maternal deprivation on child development had brought psychogenesis to the fore (14,15,16). Psychiatry was dominated by Don Jackson’s “schizophrenogenic mother” and Gregory Bateson’s “double-bind” (17). When Kanner coined the term “refrigerator mother,” the diagnosis of autism became more fashionable; it suggested that a “refrigerator mother” produced a “frozen child” (something he later regretted). Kanner was aware of the frequency of obsessional and schizoid traits among the parents and even suggested that the parents might be “successfully autistic adults.” Indeed, in my paper on the fathers of autistic children I suggested that the severe obsessional traits and relative social isolation some displayed might represent a forme fruste of the complete entity (18). Thirty years later, Sula Wolff and her colleagues (19) compared the parents of autistic patients with the parents of other child psychiatric patients and confirmed Kanner’s observations on the predominance of schizoid and socially gauche characteristics. But neither he nor I seriously pursued the genetic hypothesis. At Kanner’s invitation, I reviewed the charts of his first 100 patients and found 131 siblings, of whom 3 were autistic (20). I did not have a clue about the significance of what I had found. All I knew of genetics was Mendelian; it was clear that Mendelian laws were not operative in autism. Autism, I concluded, was not inherited because it was not Mendelian. No one called attention to my error.

In the 1950s, there were no published data on the prevalence of autism; but assuredly we knew it was rare. It was not until 10 years later that modern child psychiatric epidemiology began with the Isle of Wight study by Rutter and his colleagues (21,22). In a total population of 2,200 children, they found only one autistic child, a prevalence similar to the estimate of 4 to 5 per 10,000 published in the same year by Lotter (23). But I didn’t understand what finding three autistic children among 131 sibs implied. The rate I observed among siblings was two orders of magnitude greater than expected and established a genetic risk. Not until the mid-1970s did Folstein and Rutter (24) provide unequivocal proof of inheritance by comparing the identical and fraternal cotwins of autistic probands in a total population sample. I call attention to my failure to understand the data I analyzed to remind readers that the prevalent concepts, ideas, and methods of any given era act as blinders to all but the very gifted.

When my professional career began, what is now known as ADHD had not yet been recognized as a diagnostic entity. Symptoms of overactivity and inattentiveness existed, of course, but were allocated to such categories as “behavioral disorder,” “minimal brain damage,” “minimal brain dysfunction,” or “post-encephalitic syndrome” (even though an episode of encephalitis had never been documented). The patients were not of much interest to most child guidance clinics because of the supposition of “organicity.” The one symptomatic treatment that seemed to be as effective was dextroamphetamine. It was not in wide use and had never been put to an exacting test. Indeed, when the Psychopharmacology Service Center of the NIMH convened a conference in 1958 on Child Research in Psychopharmacology (25), “there was essentially no research on drugs in children” (26). Randomized controlled trials were being introduced into psychiatry in the late 1950s. Our research group at Hopkins received the first NIMH grant for RCTs on tranquilizers and stimulants for treating hyperkinesis in children (27). Tranquilizers proved to be worse than placebos (28), but stimulants were clearly effective (29), a finding that has been repeatedly confirmed.