The Work of Grunya Efimovna Sukhareva in the Field of Autism Spectrum Disorder One Hundred Years After Her Original Description

Abstract

Despite several articles that in recent years have highlighted the work of the Russian child psychiatrist and researcher Grunya Efimovna Sukhareva (Kiev, 1891 - Moscow, 1981), even today the prevailing opinion, at least in the Western world, does not attribute to this author the merit of the original clinical description of autism spectrum disorder. In fact, this credit is still attributed today first to Leo Kanner and second to Hans Asperger, who in 1943 and 1944 respectively described some cases of children who today would certainly be diagnosed with autism spectrum disorder. In reality, almost 20 years earlier than Kanner and Asperger, that is in 1925, Sukhareva published a paper in which she described with great accuracy and in a modern way the cases of 6 children affected, using current terminology, by autism spectrum disorder, that today would be defined as “high-functioning.” Later, in 1927, Sukhareva described 5 girls affected, emphasizing the sex-related differences in autistic features, which today represent a very current and still debated topic. Over the next few decades, her work remained largely unknown to most of the Western scientific world. In this paper, the intention is to pay tribute to Sukhareva’s work in particular (but not only) in the field of autism and discuss some possible hypotheses as to why it has been ignored by most for decades.

What is already known on this topic?

• Even today the prevailing opinion, at least in the Western world, attributes the merit of the original clinical description of autism spectrum disorder first to Leo Kanner (1943) and second to Hans Asperger (1944).

What this study adds on this topic?

• Almost 20 years earlier than Kanner and Asperger, that is in 1925, Grunya Efimovna Sukhareva, a Russian child psychiatrist, published a paper in which she described with great accuracy and in a modern way 6 children affected by autism spectrum disorder, that today would be defined as “high-functioning.” But Sukhareva’s merits go beyond this original description and do not concern only the field of autism spectrum disorder.

Introduction

Despite several articles that in recent years have highlighted the work of the Russian child psychiatrist and researcher Grunya Efimovna Sukhareva (Figure 1), even today the prevailing opinion, at least in the Western world, does not attribute to this author the merit of the original clinical description of autism spectrum disorder (ASD), leading to a historical mistake.^1-6 In fact, this credit is still attributed today first to Leo Kanner and second to Hans Asperger, who in 1943⁷ and 1944⁸ respectively described some cases of children who today would certainly be diagnosed with ASD according to the current clinical criteria.⁹ In reality, almost 20 years earlier than Kanner and Asperger, that is in 1925, Sukhareva published a paper, whose title translated into English is “Schizoid psychopathy in childhood,” in the Russian-language journal whose name translated into English is: “Questions of Pedology and Child Psychoneurology.”¹⁰ The German translation of this paper was published in 1926 in the journal “Monatsschrift für Psychiatrie und Neurologie.”¹¹ In this paper the author described with great accuracy and in a modern way the cases of 6 children (all males, aged 10½-13 years) affected, using current terminology, by ASD, that today would be defined as “high-functioning,” that is, with a normal intellectual level and well-developed verbal language. Later, in 1927, Sukhareva described 5 girls affected, emphasizing the sex-related differences in autistic features, which today represent a very current and still debated topic. Over the next few decades, her work remained largely unknown to most of the Western scientific world. In this paper the intention is to pay tribute to Sukhareva’s work in particular (but not only) in the field of autism and discuss some possible hypotheses as to why it has been ignored by most for decades.

Figure 1.

Grunya Efimovna Sukhareva in 1928.

Biographical Notes About Grunya Efimovna Sukhareva

Sukhareva was born in 1891 to a family of Jewish origin in the current capital of Ukraine, namely Kiev (at the time located in Tsarist Russia), where she graduated in medicine in 1915 and then specialized in psychiatry.⁴ Later, child psychiatry became her main field of interest and work. In 1921, Sukhareva moved to Moscow, where she created a therapeutic school dedicated to children with neuropsychiatric disorders (including consequences of war, revolution, or Spanish flu epidemic traumas) at the Psychoneurological Department for Children.¹² This school was for a long time a point of reference for the diagnosis and treatment of these children, who received training in both social and motor skills.² Sukhareva, who in 1928 became a child psychiatry professor at the University of Moscow, ran the above-mentioned school for many years, despite the hostility of the Soviet regime which had replaced Tsarist Russia in 1922.^2,4,6 From 1933 to 1935, she headed the Psychiatry Department of the Kharkov Psychoneurological Institute (University of Kharkov), while from 1938 to 1969 she headed the Psychosis Pediatric Clinic at the Institute of Psychiatry of the Soviet Union.² It should also be emphasized that in addition to her undoubted professionalism, she combined great human qualities in treating patients, which was another great lesson for all her collaborators and students.⁴ She passed away in Moscow in 1981, in the same month (April) as Kanner and 6 months after the death of Asperger. At least in theory, both Kanner and Asperger would have had plenty of time for a belated recognition of Sukhareva’s work, but this does not appear to have happened.

The Merits of Grunya Efimovna Sukhareva in the Field of Autism Spectrum Disorder

In 1996, Sula Wolff, a child psychiatrist, published the English translation of the original paper by Sukhareva from 1925/1926, emphasizing the great similarity between the clinical picture described by her and the one reported by Hans Asperger in 1944.¹ Asperger’s disorder as such is no longer mentioned in the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5)⁹ and in fact individuals who once received this diagnosis according to DSM-IV criteria,¹³ in most cases are now considered to have a “high-functioning” ASD. In the following years, several articles have been published that have broken the silence regarding Sukhareva’s work about ASD, but unfortunately, even today, much of the literature, at least in the Western scientific world, still seems to be unaware of it. Yet, Sukhareva’s original description of the clinical picture of children with autism is of a precision and modernity that today appears really impressive. Just think of the sensory atypias she reported in the boys she described,¹ atypias that only in the 2013 edition of the DSM (i.e., DSM-5) were adequately valued in the context of the diagnostic criteria for ASD.⁹ Further, Sukhareva observed in cases she reported a great intelligence combined with poor motor functioning.² The failure, albeit subtle, of motor functioning in many of these patients has been adequately highlighted only in relatively recent times, leading to the identification of some signs that one now knows can raise the suspicion of ASD early on.^14,15

But that is not all about autism. In 2020, Charlotte Simmonds, a professional German-to-English translator who reported having Asperger’s syndrome, published the translation in English of the continuation of Sukhareva’s 1925/1926 seminal paper, titled “The particular features of schizoid psychopathies in girls,” which was originally published in German in 1927, again in the Monatsschrift für Psychiatrie und Neurologie. This paper included the description of 5 girls with autistic symptoms, aged 12-14 years. As Simmonds noted, Sukhareva already in this paper emphasized the sex-related differences in autistic features, which today represent a very current and still debated topic. According to Sukhareva, girls with ASD showed a series of differences compared to boys, including a weaker and less prominent overall clinical picture, higher affect dysregulation, and less idiosyncratic interests.¹⁶ Note that none of the 5 girls reported by Sukhareva showed intellectual disability. At least in part, these sex-related differences have been confirmed by the literature of recent years,^17,18 but this topic is still current and the debate on it is still open. This matter is not only of academic value, but could also have some important practical implications on a clinical level. For example, the Autism Diagnostic Observation Schedule, which has been considered the gold standard tool for diagnosing ASD for years,¹⁹ shows no differences between females and males, neither in the administration method nor in the scoring. This appears to be a shortcoming, in light of the sex-related ASD clinical peculiarities that have been identified over time (and precisely by Sukhareva first). In 2022, the most recent version of DSM (called DSM-5-TR) mentioned the peculiarities of females with ASD without intellectual or language deficits, who show a lesser impairment of social skills than males, due in particular to an imitation-based compensation mechanism.^18,20 This is the so called phenomenon of “social camouflaging,” which involves the employment of cognitive and behavioral strategies by ASD individuals to adapt to the social world.^20-23 The constant use of these strategies requires a great effort due to the high consumption of mental energy in daily social interaction, leading to an increased risk of depression, anxiety disorders, and general psychological distress.^{20, 24} Sukhareva does not explicitly mention “social camouflaging” in her descriptions, but it is highly likely that this phenomenon was present in the girls she reported.

Finally, as concerning ASD etiopathogenesis, Sukhareva never agreed with the psychogenic theories developed in the 1940s and remained in vogue for decades, according to which infantile autism would be due to “refrigerator mothers” who raised their children with coldness and emotional detachment. She believed that autism was related to a disorder of brain development hypothesizing a pathogenetic involvement of cerebellum, basal ganglia, and frontal lobes.^2,12 Her statements anticipated a series of theories that developed in the following decades and were supported by data emerging from neuroimaging studies.²⁵ Even in this respect, her thinking proved to be ahead of its time, since psychogenetic theories have over time proven to be unfounded.

Other Merits of Grunya Efimovna Sukhareva

Sukhareva contributed extensively to every branch of child psychiatry:⁴ here the intention is to provide some examples. In the field of what is now called neurodevelopmental disorders, Sukhareva also dealt with conditions that are today known as attention-deficit/hyperactivity disorder (ADHD)²⁶ and intellectual disability; following an etiological criterion, she divided the latter (called at that time oligophrenia) into 3 groups: (a) cases due to parents’ reproductive cell damage; (b) cases due to harmful factors occurring in the prenatal period; and (c) cases due to central nervous system damage occurring in the perinatal period or during the first 3 years of life.²⁷ Already during the 1930s, she forged an evolutionary biological theory about psychiatric disorders, certainly avant-garde for the time, according to which alongside the harmful elements typical of psychiatric disorders and mechanisms of preventive “defence,” also progressive elements could be present, showing the brain evolution and overall development.⁴ Finally, it should be noted that she also dealt with purely neurological topics such as epilepsy and parasomnias.⁴ As can be seen, the topics covered by Sukhareva were not limited to the psychiatric field but also concerned child neurology: this approach to developmental age was very widespread at that epoch and only in more recent times child psychiatry and neurology have become 2 distinct disciplines all over the world, with very few exceptions.²⁸

Possible Reasons for the Silence on Sukhareva’s Work About Autism Spectrum Disorder

This is a very delicate subject for which there are no certain explanations. Let this be started with a fact: Sukhareva was not cited by Kanner nor by Asperger in their respective seminal papers of 1943 and 1944. Kanner certainly showed his knowledge of Sukhareva’s existence in an article on autism published in 1949:²⁹ but even in this article he did not cite Sukhareva’s seminal papers from 1925/1926, but rather her one other article (always in German) from 1932 concerning childhood schizophrenia. It is possible, however, that both Kanner and Asperger were aware of Sukhareva’s papers from 1925/1926 already when they wrote their seminal articles in 1943 and 1944.⁶ But if it was really like that, why did not they mention her in these articles? And in general, why did Sukhareva’s work remain unknown for so many years to much of the international scientific community? One can make some hypotheses regarding this question, according to Manouilenko and Bejerot.²First of all, the fact of being a woman in a world like that of the time in which the male sex was clearly predominant may have been an obstacle to the spread of Sukhareva’s thought. To understand how difficult it was at that time for a woman to establish herself in the world of scientific research, just think that the first woman to receive the Nobel Prize in Physiology or Medicine (established in 1901) was Gerty Cori in 1947 (together with 2 men) and the second was Rosalyn Yalow (also together with 2 men) in 1977.³⁰ Being Jewish could also have been another obstacle for Sukhareva, as anti-Semitism was already widespread at the time, but there are strong doubts about the full validity of this hypothesis: in fact, also Kanner was of Jewish origin, without his work being scotomized by international literature. Another hypothesis formulated to explain the silence on Sukhareva is linked to the political situation of the time: in fact, although she was not a communist and in some ways opposed the Bolshevik regime, Sukhareva was still a citizen of the Soviet Union, a nation which at the time was in a situation of strong political isolation at the international level. Regarding Sukhareva’s decision to publish her 2 seminal articles in German, it should be said that the journal Monatsschrift für Psychiatrie und Neurologie was chosen, which at the time was one of the few journals at an international level in the field of neurology and psychiatry. The fact that the paper was written in German was not in itself an insurmountable obstacle to its dissemination and it certainly did not pose a problem for either Kanner or Asperger, both born and raised in the Austro-Hungarian Empire. In this regard it should be noted that Asperger in his paper of 1944 cited an article by Schröder published in Monatsschrift für Psychiatrie und Neurologie in 1938, but not the 2 seminal papers written by Sukhareva about autism in this German journal in 1926 and 1927.²A final element, not irrelevant, which may have hindered the knowledge of Sukhareva’s work in the field of child psychiatry in general, in the international scientific world, derives from a non-univocal transliteration of her surname from Cyrillic; in fact, in literature you can also find the following versions: Ssucharewa, Suchariewa, and even Suhareva. This constitutes a confounding factor that may have caused misunderstandings, particularly in the past, leading to some of her works being mistakenly attributed to other authors.

Conclusion

The great debt of the international scientific world towards Sukhareva has only been partially repaid in recent years. If Sukhareva’s work had been valued from the beginning, the history of ASD would probably have been different than it was in reality. For example, it is likely that, thanks to Sukhareva, from the beginning a school of thought would have spread that attributed autism to neurobiological etiological factors in opposition to the psychogenic theories, which instead largely prevailed for decades, blaming the parents of affected individuals in a more or less direct way. Furthermore, it is presumable that, thanks to Sukhareva, from the very beginning of autism history an adequate attention would have been paid to the peculiarities of “female autism” as well as to the subtle motor signs that very often characterize the early clinical history of individuals with ASD.

It is the hope of the authors of this paper that the severely conflictual relations between the Western world and the Russian Federation in recent years will not lead to a disregard for the great contribution, still today little known, made by Sukhareva in the history of ASD (and of other child neuropsychiatric disorders). This hope may seem to be anachronistic in a period like the current one in which Eastern Europe is devastated by the bloody conflict between Ukraine and Russia. Yet, perhaps it is precisely by remembering and valuing the work of great figures such as Sukhareva who lived and worked just between Ukraine and Russia dedicating oneself to childhood health, one can perhaps help these 2 nations take a small step towards newfound peace.

Funding Statement

The authors declare that this study received no financial support.

Data Availability Statement:

The data that support the findings of this study are available on request from the corresponding author.