The greatest challenge is stating the problem in a way that will allow a solution.

Wednesday, June 29, 2011

Book Review

The Kaspar Hauser Syndrome of ”Psychosocial Dwarfism”: 
Deficient Statural, Intellectual, and Social Growth Induced by Child Abuse

New England  Journal of  Medicine 1994; 331:1031 October 13, 1994 Article

The Kaspar Hauser Syndrome of ”Psychosocial Dwarfism”: Deficient Statural, Intellectual, and Social Growth Induced by Child Abuse By John Money. 290 pp. Buffalo, N.Y., Prometheus Books, 1994. $25.95. ISBN: 0-87975-754-X

In 1828 Kaspar Hauser, a foundling, physically and intellectually stunted by abuse and neglect, was abandoned at the Haller Gate of the wall of the city of Nuremberg. The facts of his story tore a hole through another wall, the wall of denial of the severe abuse to which many children were being subjected. Much controversy resulted from that breach in the wall and the writings of those who studied it. This study and the alternating outrage and incredulity that it provoked are the subtext of this book, whose main subject is the syndrome of reversible hyposomatotropism due to abuse, here christened the Kaspar Hauser syndrome by John Money.

That the story is told by a researcher who has walked the path made by the breach gives the book an urgency that belies the precise, scholarly language in which it is written. One never forgets while reading this book that this is a personal account, that of a man angered by what has been done to children by their abusive parents and by the indifference or incompetence of “decent folk.” Yet it is also the account of a scientist excited about the perspective the case of Kaspar Hauser brings to the connections between the soul and the soma.

Kaspar Hauser was found with a note identifying him as a 16-year-old foundling. He was 4 feet 8 inches tall, with a beard and mustache just beginning to show. His vocabulary was limited to a few reiterated words; his speech was telegraphic and deficient in syntax. After being tutored for three years, he was able to write in the style of a beginning student of German. He was thus able to write his own story. He wrote that he had always lived in a small dark room with only two toy horses. It was only shortly before being taken to Nuremberg that he was taught a few words. Despite his progress in learning language, he remained socially inept. At the time of his murder at the age of 21 years, he was only 4 feet 11 inches tall.

John Money uses the case of Kaspar Hauser to introduce the syndrome he proposes be named after that unfortunate boy. In the 22 chapters of parts I and II, he takes the reader from the gradual awakening of our awareness of its characteristics in children with failure to thrive in institutional settings to the scientific documentation of the many levels on which the effects of the abuse continue even after the children are rescued. No detail is spared, nor is there any bowing to current fads or political correctness as the author describes the biologic manifestations (the partially reversible stunting of somatic and cognitive development and pain agnosia), the children's psychological adaptations and social development, the accompanying systemic abnormalities in the families, and the short- and long-term sequelae for the children and those who care for them. In doing so, he quotes extensively from the writings of investigators who described different aspects of the syndrome.

This valuable method shows the process of scientific discovery in a clinical setting and gives the reader a perspective on the times that shaped this process. Extensive quotations from case reports allow the reader to make independent conclusions.

Two chapters deserve special mention. The one on grooming deprivation summarizes data implicating the quality of early care-giving in the development of the neuroendocrine system and subsequent physical and intellectual growth. This short chapter may be prophetic in drawing attention to the links between abnormalities in the neuroendocrine axis and major depression (and other affective syndromes) or cognitive deficits. The chapter on “lovemaps” reports on the sexual and erotic functioning of 16 children who were given a diagnosis of abuse dwarfism in childhood. The findings shed profound light on the confusion surrounding the sexual development of these children and clarify the development of sexuality and the vicissitudes of love in general. This chapter is particularly illustrative of the power of Money's method of inquiry: the longitudinal follow-up study with information collected through in-depth interviews over the years.

Professor emeritus of medical psychology and pediatrics at Johns Hopkins University Medical School, Money is known throughout the world for his contributions to the understanding of sexuality and its development. He was the first to describe the effects of child abuse and neglect on physical, intellectual, and social growth. One of the hallmarks of his work is its independence from prevailing academic fashion. Thus, some readers will note (and disagree with) the conspicuous absence in this book of detailed discussion of the newer psychoanalytic formulations of the effects of childhood abuse, but no one familiar with Money's work will be surprised. In the epilogue he offers his views on the historical role that psychoanalytic thinking had in developing our understanding of the effects of child abuse. Over the years, Money has grounded his own hypotheses in detailed longitudinal observation. As a result, much of his work continues to be cited as definitive in human psychology, though four decades have passed since some of it was first published.

The first two parts of this book document medical and scientific attempts to understand child abuse. The third part, written by Joshua Kendall, M.A., is a review and commentary on the century and a half of literary reaction to the story of Kaspar Hauser. It completes the design of this important study by documenting society's reaction. It reviews the portrayal of Kaspar Hauser in poetry, drama, and novels, and nicely documents how he became both a symbol and a metaphor.

I believe this book has much to offer to students and researchers alike. It places an important area of psychological inquiry in a historical context, summarizes the salient findings, and provides ready access to many important references. Beyond this it demonstrates what can be accomplished through the dedication of a career in clinical work if care is taken to document findings and conduct a follow-up over the long term. Lastly, it makes manifest both the power and the limitations of genius in formulating -- beyond its historical era -- observations that cut to the very essence of our tools of understanding.

Joseph Gonzalez-Heydrich, M.D. Children's Hospital, Boston, MA 02115