the treatment of autistic children

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This article was downloaded by: [McGill University Library] On: 08 October 2014, At: 09:24 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Australian Journal of Social Work Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rasw19 The Treatment of Autistic Children R. A. Moffatt Published online: 15 Apr 2008. To cite this article: R. A. Moffatt (1970) The Treatment of Autistic Children, Australian Journal of Social Work, 23:4, 22-36, DOI: 10.1080/03124077008549311 To link to this article: http://dx.doi.org/10.1080/03124077008549311 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

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Page 1: The Treatment of Autistic Children

This article was downloaded by: [McGill University Library]On: 08 October 2014, At: 09:24Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Australian Journal of Social WorkPublication details, including instructions for authors and subscriptioninformation:http://www.tandfonline.com/loi/rasw19

The Treatment of Autistic ChildrenR. A. MoffattPublished online: 15 Apr 2008.

To cite this article: R. A. Moffatt (1970) The Treatment of Autistic Children, Australian Journal of SocialWork, 23:4, 22-36, DOI: 10.1080/03124077008549311

To link to this article: http://dx.doi.org/10.1080/03124077008549311

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis, ouragents, and our licensors make no representations or warranties whatsoever as to theaccuracy, completeness, or suitability for any purpose of the Content. Any opinions andviews expressed in this publication are the opinions and views of the authors, and are notthe views of or endorsed by Taylor & Francis. The accuracy of the Content should not berelied upon and should be independently verified with primary sources of information. Taylorand Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs,expenses, damages, and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantialor systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply,or distribution in any form to anyone is expressly forbidden. Terms & Conditions of accessand use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: The Treatment of Autistic Children

R. A. MOFFATT

The Treatment of Autistic ChildrenINTRODUCTION

During 1968, a centre for the treatment ofautistic children was established in Perth,Western Australia, under the administration ofthe Mental Health Services. It was named inhonour of Dr. Mildred Creak, whose authori-tative contribution to the study of autism andher invaluable assistance in establishing thiscentre is thereby recognized.

January, 1969, saw the initiation of what insome respects is a unique application ofoperant conditioning techniques, and this articleis designed to describe, by reference to theliterature, the various conceptual and practicalconsiderations which influenced the formulationof a treatment programme. Such evolvement isstill active and as yet no fully integrated con-ceptual statement or methodological outline is

feasible, apart from recognizing a generalcommitment to operant conditioning theory;but despite such limitations the project issufficiently advanced to discuss some of themajor theoretical considerations as they havebeen thus far formulated and to report thepresent effectiveness of practical treatment.

Conjointly with treatment of the children, agroup of mothers has been meeting under theleadership of a psychiatric social worker. Ex-perience with these mothers raised issuesrelated to discussion in the literature of parentalinvolvement in the aetiology of autism, andhighlighted problems of providing a helpingservice which would resolve parental distressand enhance treatment progress of the children.A description of this experience will be pre-sented in the second part of this article.

PART ITREATMENT OF AUTISTIC CHILDREN

WITH OPERANT CONDITIONINGTECHNIQUES

Infantile Autism

1. SymptomsKanner19 first described the condition of

Infantile Autism, and Creak et al.5 expanded hisoriginal description to nine diagnostic criteria.Although subsequent writers such as Rimland39

have attempted further elaboration, Creak'scriteria remain the most universally accepted.Her first criterion, and by most writers con-sidered the fundamental diagnostic feature,refers to gross and sustained impairment ofemotional relationships with other people; andthe mother of an autistic child describes thisfeature vividly, "How could I be anything elsebut cold after years of trying to warm up thisicy child of mine? We hadn't rejected Peter,he had rejected us. Even rejection is too stronga word. Peter accepted us as he did the furni-ture, as tools to get what he wanted. He simplydidn't recognize us as people."s

Mr. R. A. Moffatt, B.A., Dip.Soc.Stud. (Melb.), issocial worker, Child Guidance Clinic, Mental HealthServices, Perth, Western Australia.

There is also general agreement that onsetof symptoms occurs either insidiously but per-ceptibly within the first year of life or, follow-ing apparently normal development, compara-tively abruptly by the age of three to fouryears. If untreated the difference between thetwo groups by the age of five is insignificant.

Other symptoms frequently though not in-variably described are: lack of appropriateawareness of personal identity, pathologicalpreoccupation with objects regardless of theiraccepted functions, sustained resistance tochange, acute and seemingly illogical anxiety,perceptual disorders, speech defects, motilitydisturbances, emotional outbursts, hyper- orhypo-activity, repetitive play, and disturbancesof eating and sleeping. Coupled with thebland indifference to people, the existence of anumber of these symptoms is usually sufficientto establish diagnosis of the syndrome.

2. Basic DeficitWhile there is substantial agreement in

describing symptoms, identification of thebasic deficit of autism is more controversial.Kanner and Creak emphasized social indiffer-ence and failure of communication, but otherwriters have searched behind these features tounderstand how they arose. Rutter40 arguesthat failure of speech development gives rise to

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R. A. MOFFATT December, 1970

other subsequent defects. Hingten et a/.15 con-sider failure to imitate is primary, and Lovaaset al.-s supporting this view add that failure toimitate limits the development of an extensive"behaviour repertoire" upon which furtherlearning depends. Ferster and de Meyer10-"also note imitation failure and stress thesignificance of environmental reinforcement indeveloping infant behaviour patterns.

They consider that failure of the environmentto provide adequate reinforcement limits thearousal of extensive and varied behaviour pat-terns, with speech and social adjustment beingespecially vulnerable areas. Ferster concludesthat the only basic deficit is in the rate oflearning and that autism is therefore not adisease but a learning defect. This view is notdirectly supported by other writers.

Haemerlin, in Wing,43 reflects an increasinglysupported view when he writes, "a model ofthe environment is gradually built up by anactive interplay of associations and accommo-dation to perception. Thus the initial confusionof the young infant between subject and object,internal and external, mental and physical,permanent and transient, is slowly resolved. Inthe autistic child this model is distorted andincomplete and the child seems to deal withhis world in a purely ad hoc manner".Rimland39 defines this view in terms of faultyperceptual organization and speculates that itmay be due to malfunction of the brain'sreticular system. He further argues that thisconcept effectively disposes of all psychogenictheories of aetiology.

The faulty perceptual organization conceptdoes lead to a more practical recognition ofthe autistic child's problem. If he cannot dis-criminate, organize and appropriately respondto environmental stimuli, this would explainmuch of his restricted and stereotyped be-haviour; and if he cannot organize perceptionsof himself, other people, and the unique caringrole of his parents, then it is not surprising thatfor him interpersonal relationships have littlemeaning. Should this concept prove valid, thenapplication of operant conditioning techniquesin resolving such faulty perceptual organiza-tion would appear to be most appropriate.

3. TreatmentTraditionally most treatment techniques have

aimed at reducing the most obvious symptom,and have sought to establish meaningful per-

sonal contact. Generally therapists haveadvocated a permissive one-to-one relationshipwithin which the child is permitted to regressto his most primitive infantile behaviour.Therapists have associated themselves withsuch behaviour and attempted to graduallydirect the child's interest towards other reality-centred and adult-controlled activity, hopingthat ultimately personal interaction wouldevolve. Lovatt20 by this means sought to developinteraction with other children in a day nursery,Harper13 tried to encourage co-operative playwithin recognized adult-established boundaries.Using a different more forceful approachRendell-Short38 sought speech developmentwith intensive hospitalization and denial offood rewards, while Lovaas et aIPG claimed thatusing a mild electric shock as a negative re-inforcer, more rapidly reduced deviantbehaviour.

However, the impression gained from theliterature, despite the expenditure of consider-able professional skill and ingenuity, is one ofimprovisation and absence of any coherenttheoretical framework. If operant conditioningtechniques do prove effective, then they wouldprovide a strictly conceived precisely appliedtreatment approach, in a hitherto ambiguousfield.4. Evaluation

Disagreement on terminology, conflictingtheories on aetiology, basic deficit, treatmentmethod, etc., make evaluation difficult. Creak,5Rutter,40 and Kanner and Eisenberg21 haveconducted follow-up studies and noted spon-taneous remission in adolescence for somecases, but generally found eventual institu-tionalization for as high as 75 per cent. Theyalso note that even with improvement thereinvariably remains profound eccentricity andpoverty of social relationships.

Treatment results have been hardly moreencouraging. Creak reported that out of onehundred cases only eight improved with treat-ment while nine improved spontaneously,clearly her comment that no treatment can beguaranteed is fully justified.

Those who are experimenting with operantconditioning are hopeful that this gloomy pros-pect may be altered. .Operant Conditioning

Ferster9 describes the. basic principle ofoperant conditioning when he writes, "The

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major cause of an instance of behaviour is theimmediate effect on the environment." Childrenacquire patterns of behaviour as a result oftheir recognition of the immediate consequenceof their actions, when these consequences arerewarding (positively reinforced) their repeti-tion is likely, but if they are not rewarding orare punished (negatively reinforced) repetitionis unlikely.

Ferster stresses the inadequacy of positivereinforcement from the immediate environ-ment of the autistic child, as the main reasonfor his failure to evolve extensive behaviourrepertoires, which in turn leads to a poverty inlearning and adaptive behaviour. Other writers,such as Rimland39 and Haemerlin43 emphasizethe child's inability to recognize the cause-effect relationship between his behaviour andenvironmental consequences, so that he failsto recognize positive reinforcement even whenit is forthcoming. Either way the result for thechild is confusion and inability to identify howhe should function in a normal environment,and causes him to confine himself to therestricted familiar behaviour range in which hefeels secure. Unfortunately, included in hisgeneral confusion is a failure to recognizepeople, especially parents, as positive rein-forcers, with a resultant apparent indifferenceto personal contact.

Perhaps, with such confusion in mind, theoperant conditioning technique may to someextent be seen as training the child to recognizecause-effect relationships, and to therebyidentify environmental consequences of hisbehaviour. Thus by immediately providingpositive reinforcement for desired behaviourone may hope that the child's confusion willbe reduced, and perceiving the rewarding con-sequence of such behaviour he will repeat itand incorporate it into his general behaviourrepertoire.

1. ProceduresAlthough in various experiments individual

refinements have been introduced, generally theapplication of operant conditioning in thetraining of autistic children is relatively stan-dardized. Having determined the deficit area inwhich training is to be given, a series of pre-cisely defined tasks in a graded progression ofcomplexity is compiled. These tasks are thenpresented in a predetermined order to thechild, who whenever he responds as desired is

positively reinforced by something he findsrewarding. Thus he learns to identify pleasantconsequences of his behaviour and is motivatedto repeat it until ultimately the mere offer oranticipation of reward will elicit the desiredresponse. To elicit responses from an autisticchild, even in such an artificial manner, is amajor achievement and if successful woulddemonstrate the child's capacity to respondnormally to some environmental demands.However, despite its apparent simplicity theapplication of operant conditioning in treatingautistic children carries a number of practicaland conceptual problems, of which four willbe discussed in terms of the problems them-selves and the procedures evolved to overcomethem.(a) Control of Deviant Behaviour

Any treatment of autism must from the out-set bring under control the bizarre explosiveself-destructive negativistic deviant behaviour,which though not found in all autistic childrennevertheless appears periodically in most.Wherever it does exist it tends to be triggeredby the kind of pressure for response to environ-mental demands which is implicit in theoperant conditioning approach, and, therefore,it is likely to be encountered very early in theprogramme so that treatment progress dependson its being controlled.

Fortunately the operant conditioning tech-nique itself has been demonstrated as a mosteffective control, either in the form of removingthe reward or in actively punishing such be-haviour. Martin et al.31 used physical restraint,slapping and isolation to control tantrums andnegativism, and found the removal of attentionby turning away from the child reduced bizarreand self-destructive behaviour. Jensen andWomack,16 Wetzel et al.4i also found non-attention effective, while Lovaas et a/.26 claimedthat "punishment" by mild electric shockobtained more rapid results. McConnell,33

Metz,34 and Jensen and Womack also notedthat deviant behaviour decreased as new learn-ing was acquired, and McConnell found thatwhen the new learning was experimentally ex-tinguished the deviant behaviour (aggressionand withdrawal) returned. It would seem,therefore, that operant conditioning is eminentlysuited for controlling deviant behaviour byensuring that it does not receive positive re-inforcement and by providing the child with awider range of alternative behaviour.

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(b) Making Personal ContactAnother basic problem in treating autism is

to break through the "autistic barrier" ofapparent indifference and failure to interactwith persons. McConnell's attempt to establisheye contact is one application of operant con-ditioning to this problem; by reinforcing thechild's looking at (rather than through) theexperimenter, he was able to "make contact"so that the child was attending to his instruc-tions. Others such as Wetzel et al., Martin et al.,and Jensen and Womack designed approachtraining schedules as part of their overall pro-grammes and by offering positive reinforcementwere able to make contact and proceed further.

Hewett,14 reasoning that faulty perceptualorganization hampered the autistic child indiscriminating positive reinforcement forapproach behaviour, observed that in a normalenvironment the presence of many extraneousdistracting stimuli reduced the opportunities toreinforce chance approach responses and theirinfrequency made it impossible for the childto perceive stimulus-response-reinforcementas consistent cause-effect relationships. To re-duce extraneous stimuli to a minimum hecarried out his training in a specially designedbooth which forced the child to focus attentionon the experimenter and the task required. Inthis restricted environment the cause-effectrelationship between approach behaviour andreinforcement was more readily identified and,in addition, personal contact was soon attained.Later these generalized to a more normalenvironment. A consistent and encouragingfeature of these studies is their success withina relatively short space of time.

(c) Selection of Effective ReinforcementOne major problem has always been the

selection of a reinforcement which because heperceives it as rewarding will elicit the child'sresponse. Experience in conditioning studiesfrom the first experiments on Pavlov's saliva-ting dogs, has proved food to be a most con-sistent effective reinforcement. Food has beenidentified as a potent primary reinforcementsince it satisfies a basic biological need, andhas been especially effective as a means ofeliciting responses in the autistic child.

However, as Lovaas27 points out, the effectof primary reinforcement depends on the in-tensity of the biological need, and in the caseof food rewards much depends on the child's

being hungry and having a taste for the rewardoffered. For training purposes responses togiven stimuli can be elicited more frequently bysecondary reinforcement if some other con-sequence becomes rewarding by its associationwith the primary reinforcement, until thatother consequence acquires a reinforcingpotency of its own. Hewett observed, to his sur-prise, that he was increasingly gaining responseswithout the primary food reinforcement, andthat social approval had become an effectivesecondary reinforcer. Ultimately he found thatsmiles, affectionate gestures (e.g. a pat on thehead) and personal contact could invariablyelicit responses without the reward of food,although association with the primary reinforce-ment was necessary to establish and periodi-cally strengthen the potency of the secondaryreinforcement. McConnell, Lovaas et al., andWetzel et al., designed programmes to specifi-cally develop effective secondary social rein-forcement and all have reported considerablesuccess, while one can only speculate on thepossible spontaneous and unwitting socialapproval of other experimenters.

Apart from being a more efficient reinforcer,the effectiveness of social approval and inter-action as a secondary reward seems to havestruck at the heart of the autistic syndrome. Bythis means children were seen to gain pleasureand actively seek out personal contact so thatthe bland indifference of autism was markedlyreduced. Of course, this though extremelysignificant, still left the child with many learn-ing and adaptive deficits for which extensivetraining programmes were necessary.

(d) Generalization Beyond the TrainingSituation

Critics of operant conditioning have ex-pressed concern that although successful intraining specific activities in a laboratory, theend product is likely to be meaninglessrepetition unrelated to normal environmentalconditions. Certainly many studies reportedwere conducted in laboratory conditions with aview to testing the feasibility of using thistechnique, and not with a therapeutic pro-gramme in mind; however, all writers observedthat once an activity had been successfullyconditioned the child spontaneously seemed totake delight in experimenting himself, andusing it in new though not. always appropriatesituations, in a manner reminiscent of a younger

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infant trying out a piece of new learning. Whensuch new activity was tried at home parentsexpressed delight and frequently claimed,especially when the child experimented withpersonal contact, that for the first time in manyyears they could see developmental progress.

Obviously something was happening and thechild himself seemed to be demonstrating thepossibility of acquired behaviour generalizingfrom the laboratory to the normal environment.Workers in this field were not slow to follow sofirm a lead and Hewett, Lovaas, Martin et al.,and Ferster have all incorporated generalizationtraining into their procedures, with impressiveresults, demonstrating that operant condition-ing seems to be compatible with a spontaneousgeneralization process and is effective in speed-ing up and focusing natural development.

2. EvaluationSince most studies have focused on condition-

ing specific tasks the question remains whetherthis method can be used effectively in acomprehensive way as a treatment methoddesigned to help the child acquire a range ofnew learning and adaptive behaviour skillswhich would enable him to function in amanner approaching normal, within his every-day environment. As yet there are no reportsof such an approach and the question remainsunanswered. Reports in the literature con-vincingly demonstrate the effectiveness of con-ditioning specific skills and the generalizationof these skills from the laboratory to the every-day environment, and some writers haveclaimed that once the specific behaviour theyhave conditioned is established, it will becomethe basis for future acquisition of a still widerbehaviour repertoire. But this latter claim hasyet to be established.

At the Mildred Creak Centre an attempt isbeing made, by use of operant conditioningtechniques, to help children acquire a widerange of new behaviour skills, and the applica-tion of conditioning in such a comprehensiveway is felt to be unique. Training concentrateson a number of deficit areas simultaneously,and a steady progression of overall develop-ment is sought. This means a slower rate ofprogress in acquiring specific new behaviour,but it is hoped that ultimately the wider rangeof new behaviour will be more effective inhelping the child function adequately in hisusual home, play and school environments.

The Mildred Creak Centre1. Description

A converted suburban house provides fivetraining rooms, play area, dining and officefacilities for about ten autistic children whoattend for individual and group sessions fouror five days a week. It is staffed by a super-vising psychiatrist, a clinical psychologist whoadministers the programme, an occupationaltherapist, two training assistants, a visitingsocial worker, a clerical assistant and, at varioustimes, male student psychiatric nurses andstudent occupational therapists. Consultation oneducational matters and speech therapy is alsoavailable. Selection of children is based on astrict application of Creak's criteria especially"gross and sustained impairment of emotionalrelationships with people". There is a strongemphasis on informality and although con-ditioning programmes are strictly applied, out-side training sessions the emotional atmosphereis relaxed, encouraging and warm; inter-personal contact with the child is continual.Contact with parents is maintained through amothers' group, led by the social worker, anda parents' association. Perhaps the most strikingfeature of the centre is the dedication andmorale of the staff, which must rate as a highlysignificant factor in whatever progress has beenmade.

2. Identification of Base-line DeficitsA child on first entering the Centre is for a

number of weeks placed under close observa-tion so that his deficit areas and the base-lineof such deficits may be determined. In thisthere is considerable variation, e.g., a speechdeficit for one child might mean inappropriateuse of words, for another failure to use wordsat all, and for another the absence of anymeaningful vocalization in the form of pre-speech babbling. Training for one child will beat a primitive level in helping him form thesounds that will later become words, foranother learning a series of specific words,especially names of people and objects, and foranother the use of words in meaningful com-munication.

It has been frequently observed though neverreliably established, that as a child progressesboth in specific learning areas and in overalldevelopment, a pattern emerges which seems toclosely resemble the normal developmentalsequence, which almost appears to have been

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halted by the autism and then restarted bytreatment. On the other hand there are alsonumerous examples of new behaviour skillssuddenly emerging at what seems to be a fairlyadvanced level, almost as if such skills weredeveloping, though obscured, all the time.

3. Training ProgrammeThe acquisition of new behaviour through

operant conditioning requires that deficit areasonce identified should be defined into a seriesof precise tasks and arranged on a schedule ofincreasing complexity, along which orderedprogress can be made. The drawing up of suchschedules and ensuring that they correlate intoa coherent comprehensive overall programmefor each child, is perhaps the most difficultaspect of the entire training programme. Suchtasks must be appropriate to the deficit areas,commence at a level within the child's capacity,progress enough to stimulate but not so muchas to discourage, and be so precisely definedthat conditioning can be absolutely consistent.

Drawing up training programmes for eachchild is seen to require the skill of a fullyqualified clinical psychologist who has experi-ence in using operant conditioning techniques;any attempt by an unqualified person to do thisis seen as completely undesirable. Especiallyit is felt that parents should not be asked toapply these methods at home since adequateenvironmental control could not be maintained;however, parents are guided towards en-couraging behaviour which is developed at theCentre, and in providing a home environmentwhich does not clash with treatment goals.

In practice, procedures are modelled on thosewhich have been demonstrated as effective inprior studies and early training is aimed at mak-ing personal contact and gaining co-operation.Using a training booth based on Hewett'sdesign, food rewards are used to reinforce eyecontact, physical approach, vocalization, andobedience to simple commands; while simul-taneously deviant behaviour is controlled inthe manner advocated by McConnell, Metz,and Jensen and Womack, with non-attentionbeing effective for most situations and con-trolled brief isolation being occasionallynecessary. As in these studies, deviant be-haviour was reduced to insignificance in amatter of weeks.

Incorporated in the programme along thelines established by McConnell, Lovaas et al.,

and Wetzel et al., social approval has from theoutset been associated with the primary rein-forcement of food, until its potency as a second-ary reinforcer was established. It has beenfound that social approval developed into suchan effective reinforcer that primary reinforce-ment could be reduced, and pleasure in socialinter-relationships spontaneously generalized toother children in the play area and made formalgroup sessions possible. Most pleasing of all, itgeneralized to the home and mothers beganreporting that they were making emotional con-tact with their child for the first time in manyyears.

Outside formal training sessions free playunder supervision of a staff member occupiesmost free time. Though these periods are notstructured the staff members encourage appro-priate use of play objects, play which aidsmotor co-ordination and helps increase aware-ness of body image, and group co-operation.Deviant behaviour in play periods is treated inexactly the same manner as in formal trainingsessions. A further extra activity which is be-coming more frequent is excursions to localparks and shops, upon which two or threechildren are taken at any one time.

This was the stage of progress reported byCalnan et al.3 after four months of operantconditioning, and it seemed that a significantbreakthrough in the treatment of autism hadbeen made. Indeed the major symptoms seemedto have been brought under control.

However, in the subsequent nine months,although the initial advances have been main-tained and children who were lagging behindhad progressed to a point where it could beclaimed that even the most severely autisticchildren were consistently controlling theirdeviant behaviour, showing pleasure in socialrelationships, and acquiring new skills,periodic lapses still occurred, especially if thechild became physically ill or his environmentbecame too demanding. Progress was obviouslytenuous and seemed to depend as much on whathappened to the child, as on the child himself.It is perhaps significant that at the Centrewhere the child is handled consistently progressis most evident in overall development, but thesame child who appears as sociable, co-operative and shows a capacity to learn at theCentre can be described by the parents asisolated, negativistic and unresponsive. Clearlysome potent variables outside treatment cannot

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be brought under control, but fortunately suchcontradictions are becoming rarer.

Also in the subsequent nine months, as the"veil of autism" has been lifted and the childhas become more accessible, it has beenapparent that the further task of developingdeficit areas was still far from completed. Infact it had only begun and further trainingschedules progressing through perceptual dis-crimination, imitation, vocalization, and pre-school formal learning, have been evolved, sothat training at this level now occupies mosttime and only for newly arrived individualchildren is it necessary to repeat the earlytraining procedures. Generally speaking, train-ing in deficit areas is slow especially comparedto the rapid progress of the first four months,but it has been steadily advancing for allchildren.

Again following the lead of Hewett, Lovaaset al., Martin et al. and Ferster, specific train-ing for generalization has been incorporatedinto the training programme and is still usedin the training of deficit areas. This takes twoforms, of environment and of persons. Asindicated, new training usually commences inthe training booth to avoid extraneous stimuli,once this is established the training is repeatedin a series of graded environments; a screened-off portion of a room, a room with littlefurnishing, etc., and a room furnished as aschool classroom. In this way learning estab-lished in a clearly defined environment is bystages generalized to a more complex environ-ment and this procedure has proved veryeffective.

Once one staff member has been successfulin establishing a piece of behaviour, two othermembers in turn undertake the same traininguntil the child reliably responds to all three.This not only made the child accessible to allstaff, but enhanced the establishment of socialapproval as a secondary reinforcer.

Such training for generalization is seen as ahighly significant part of treatment and a vitalfactor in developing socialization. It is perhapsa unique aspect of work at the Centre thatstructured generalization training has been in-corporated into comprehensive treatment pro-gramme, and extends beyond specific trainingsessions to informal contact at play, mealtimes,etc., for the whole of the child's stay at theCentre.

4. ResultsAll nine children who commenced this pro-

gramme in January, 1969, have now shown con-trol of deviant behaviour, increasing capacityfor and pleasure in social relationships both atthe Centre and at home, and acquisition ofnew behavioural skills, but most are stillstruggling to consolidate their gains and toovercome the various deficits that resulted fromimpeded developmental progress.

However, one child has progressed to school,another to part-time kindergarten attendance,and two others are approaching part-time schoolor kindergarten.

Apart from general improvement two specificareas have shown dramatic and unexpectedchange. Parents had invariably listed amongtheir most serious complaints, sleep disturb-ances and asociable or even bizarre eatinghabits. In recent months there have been fewcomplaints, and parents are no longer con-cerned about behaviour in these areas whichnow to them appears normal. What is behindsuch improvement is something of a mystery,but since medication has in most cases beenreduced it seems likely that it is a by-productof the overall treatment programme.

PART IIHELPING PARENTS OF AUTISTIC

CHILDREN

Aetiology and Parental InvolvementFrom Kanner's first description of the AutisticSyndrome in 1943,7 and reiterated by Kannerand Eisenberg in 1955,8 there has been a beliefthat parents of autistic children could beidentified as a specific and unique group. Theyhave been described as coming predominantlyfrom the upper social strata, being highly in-telligent and well educated and having per-sonalities described as (cold, detached, obsessiveand unresponsive). Words such as "refrigerated"and "mechanical" have been applied to them,and writers such as Bettleheim, reported inRutter,35 have seen in such personalitycharacteristics an explanation for the lack ofemotional response so obvious in autisticchildren.

The mother of an autistic child, Eberhardy,8believes that she speaks on behalf of parents inchallenging the idea that autism is a responseto specific personality traits of the parents. She

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claims that parents of autistic children have noobvious distinguishing characteristics, andtheories suggesting the contrary are highlyspeculative. Surveys which have been conductedwould appear to support her claim. Peck et a/.36

and Pitfield and Oppenheim,37 studying psy-chotic children in general, found no evidence ofparental mishandling and no significant trendson a maternal inventory scale measuring strict-ness and affection. Gillies, reported in Cazes,1studying parents of autistic children, found nosignificant trends except a slight indication ofneuroticism in fathers, while Creak and Ini6

found only a slight indication of detachment inmothers whose only child was autistic. Whilenot supporting Kanner's refrigerated mechanicalparent description, Rimland,39 Wing et a/.46

and Rutter40 did notice that parents tended tobe from the upper social classes, were highlyintelligent and well educated, and had veryconscientious even obsessive personalities.

Therefore, it would seem that objectivestudies have not clearly verified clinical im-pressions of parental personality and Eber-hardy's resentment at being typed may havejustification.

However, from a different point of view,recognition of parental contribution to thechild's symptoms is seen to be pertinent irre-spective of any theory regarding specificparental personality.

Watson43 had observed that the early homelife of the child was a "laboratory" for theestablishment of conditioned responses, andFerster9 identified parents as the main agentsproviding reinforcement in the infant's earlylife. Ferster's conclusion arose out of his theorythat autistic children failed to evolve a normalrange of behaviour because the environmentfailed to provide adequate positive reinforce-ment for normal behaviour, and instead tendedto reinforce undesirable behaviour. Accordingto this theory the responsibility for inadequateor misdirected reinforcement must be laid onthe parents, since they are the most significantelements in an infant's environment. Certainlythese ideas are helpful in guiding parents sincethey direct attention to the significance ofparental responses to child behaviour as ameans of control over or encouragement ofsuch behaviour, and conceptually they are use-ful in understanding how some symptomaticbehaviour might be established. However, anumber of questions are left unanswered, e.g.,

how powerful must reinforcement be before itis effective, is it possible for its absence to beso complete that the extreme symptoms ofautism result, and how much does the child'spossible incapacity to perceive existing andappropriate reinforcement explain his failure torespond?

Parental Distress

Eberhardy, in describing parental distress,considers that it is most intense from the firstawareness that something is amiss until adefinite diagnosis is made. Parents generallyresist acknowledging that their child is ab-normal, yet increasingly they are forced torecognize that development is not progressingas it should, and uncertainty, doubt and fearare likely to reach overwhelming intensity.Seeking professional advice and help typicallyprovides little reassurance or satisfaction, andin the invariable round of consultations andassessments, parents are usually left with theimpression that they are either incompetentor are exaggerating their problems. Eventuallythey come to doubt their own adequacy, andat times sanity, until they are desperate forsomeone to recognize their problem and offerhelp. In their uncertainty, fearful and oftenhostile emotions become so intense that feelingsabout the child, family coherence and maritaladjustment are placed under unbearable strain,perhaps to the point where irreparable damageis done.

It is not surprising that definite diagnosis isoften something of a relief, especially whenthe feared pronouncement of mental retardationis not forthcoming. However, as Peck pointsout, such relief is short lived and a whole newseries of questions, doubts and fears arise.What is this autism? What does it mean forthe child? Can it be cured? What caused it?How on earth does one explain it to family andfriends?

Perhaps the most immediate question is,what caused it? Many parents become pre-occupied in reading, discussing and thinkingabout how autism may have arisen, and theirendless questions are apt to increase their fearsand estrange them from professional and publicsympathy. Suggestions of parental failure as asignificant factor in aetiology are keenly felt,and vague doubts, fears and worries crystallizeinto feelings of guilt, shame, and anger, which

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drive a wedge between the parents, isolatingthem from other people and each other.

But the most soul-destroying stress of all isidentified by Eberhardy, Lovaas,28 Walsh,42 andLeighton,23 as the almost total lack of rein-forcement by the child of maternal and paternalaffection and care. Where is the joy of parent-hood, when the child seems indifferent to hisparents as people, fails in any way to acknow-ledge his union with them, and apparentlyvalues them no more than inanimate objects inthe environment which are occasionally usefulbut mostly irrelevant? In these circumstances,how can there be evaluation and adjustmentof the parent role (especially if there are noother children in the family), and how is itpossible to avoid seeing parenthood in terms ofa joyless mechanical duty? Above all how doyou live with the tearing anguish you feel foryour emotionally sterile child, for yourself inyour yearning to receive the child's trust andlove, and the feeling of utter worthlessnessbecause you have failed the child you so badlywanted to love? The unresponsiveness of thechild strikes at the heart of parental self-imageand self-evaluation, and all but destroys self-confidence and self-respect.

So the parents bring the child to treatment,dominated by feelings of guilt, shame, anger,doubt, confusion, anguish, worthlessness, anoverall apathy and profound despair. Perhapsit is understandable that they face the prospectof years of painstaking persistent treatment, theweary hours of clinic or school attendance,imperceptible progress, with something less thanenthusiasm. Their demands for explanations,sympathy and results, though often inappro-priate, are perhaps after all not unreasonable.

It is strange how frequently parents reportthat public sympathy is almost totally lackingfor autistic children and their families, thoughperhaps through growing awareness this may bein the process of changing. Other mentally andphysically handicapped children are seen asbeing readily accepted and supported, butparents feel little latitude is permitted theautistic child. How much such feeling exag-gerates or provokes unsympathetic publicreaction is hard to say, but certainly the parentsfeel that they will not meet understandingeither from the general public or their familyor friends. So they do not leave home morethan is absolutely necessary, and eventuallyisolate themselves from interests, people and

outside activities until they are in danger ofdrawing more and more into an isolated shellin which the unresponsive child, and ultimately,the equally unresponsive parents, exist mean-inglessly side by side. Typically, mothers facethis danger more than fathers and marital dis-cord is almost inevitable as the fatherdesperately and with increasing anger born offutility, tries to break what he sees as a dread-ful stalemate which is likely to make life in-tolerable for the whole family. How siblingsfare in all this is unknown. Perhaps they tooare trapped, certainly they suffer from parentalpre-occupation with the autistic child, but per-haps ultimately through school and peer groupsupport they may find a life of their own andbreak loose from the family deadlock.

Once the parents' distress is appreciated, andthey are viewed from a different perspective, itis tempting to agree that they are unique people.For in the face of such distress it is incredibleto observe how most parents never finallysuccumb to despair, and somehow retainreasonable emotional stability. Despite the oddsagainst them they continue to provide lovingcare for the child, and the slightest responsefrom him is likely to release a flood of affectionand joy even though it is recognized that the"veil" will once more drop and the sufferingfor the parent will be intensified even further.There can be no doubt that these parents needand deserve whatever help can be given, andexperience has shown that when it is givensincerely without judgment, their faithful andpatient co-operation without any treatment pro-gramme can almost invariably be guaranteed.In this context, one can sympathize with Mrs.Eberhardy's plea, "Parents want to be treatedas partners in the job of helping their troubledchildren. It takes courage for us to come toyou . . . and we are worried sick. What willbecome of this child if we can't get help now?We need your support . . . (but) whoever elseworks with our children, we are their principalcontacts with the world".

Therapy For Parents*Recognizing the need to provide help for

hard-pressed parents, most treatment pro-grammes include some kind of therapy for

* The experiences and concepts of the followingwriters are incorporated in this discussion: Cazes,1Eberhardy.s Leighton,23 Lovatt,29 McCollum ,32 Pecket a/.,3" Rendell-Short38 Walsh" and Wing (ed.).«

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them, and usually this is the responsibility ofthe psychiatric social worker. The word"therapy" is here applied loosely as a con-venient composite term, and may range fromsuperficial advice-giving to quite intensive con-centration on attitude modification. Typically,in working with parents during fluctuating pro-gress of their childen, the "therapist" is cast ina number of varying roles and it is impossibleto define his overall approach in precise terms.

When parents commence therapy, there isalready a consolidation of feeling and attitudeswhich have been forming in the pre-diagnosticperiod, and these may constitute a severe initialimpediment to involving them in a therapeuticprogramme. Such involvement pre-supposes thatthey will be called upon at some point to facefeelings of which they are terrified andashamed, and while this is true for any parentscommencing therapy, those facing autism seemto have especially intense feelings and initiallyoften appear as resistant. Therefore, the firsttask is to win trust and confidence, a processwhich may well require considerable effort andpatience, with the therapist in the main adopt-ing a passive role and communicating under-standing and appreciation of depth of feelinginvolved. Although direct answers to questionsmust be given, especially in explaining thetreatment programme, and although manyopportunities to challenge existing ideas andattitudes will present themselves, the therapistmust be aware that feelings are so intense thatsignificant modifications of behaviour are un-Jikely until they are resolved.

Dominating early therapy sessions is a con-tinual recital of detailed descriptions of sympto-matic behaviour, often couched in the form ofhumorous anecdotes but clearly a communica-tion of anxiety, and a theme which is likely torecur whenever pressure is felt or, on occasions,as a means of "filling-in" sessions when no par-ticular issues are being examined. In the earlysessions this recital often incorporates many un-realistic hopes for the child's future andunreasonable demands for rapid treatment pro-gress, and again feeling is so intense thatdevelopment of sound insight is unlikely untilmuch later.

Gradually, however, interspersing theanecdotal material, serious examination ofautism, treatment prospects, and parental in-volvement begins to emerge, allowing thetherapist to emerge from a passive listening to

a more active explaining or educating role.This change of role would appear essential atsome point and requires complete franknessand willingness to engage in theoretical dis-cussion, so that destructive half-knowledge andambiguity may be reduced.

Sooner or later, probably in discussingparental involvement, underlying emotions willbegin to emerge and feelings long-hidden behinda controlled facade will be revealed. There isno particular sequence that can be anticipated,but anger at any suggestion of parental blame,confusion and self-doubt, and fear for thefuture are among earlier manifestations. Ifthese feelings are perceived by the parents asbeing accepted and understood, and this in-volves the therapist in utilizing "reflectingback" techniques, then the deeper feelings ofguilt, shame and unworthiness may be ex-pressed. At this point therapy is likely to behighly emotional and often attendance falls offas tolerance limits are approached. Experiencehas shown that it is best to focus discussion oneveryday incidents which may always beapproached on either the superficial descrip-tive level with evaluation of handling methods,or at the deeper level aimed at developing in-sight into attitudes. Given such alternativesparents can focus their discussion on whichever level meets their prevailing need, providingthe therapist remains sensitive to the changesrequired and is not inflexibly committed to asingle therapeutic approach.

Once emotions have been released andparents are freed to re-evaluate their roles, andfeelings, it is possible to adopt a more animatedtherapeutic role, and a considerable amount ofconfident give and take makes for more lively,stimulating sessions. Sometimes a complete re-appraisal of self and of other family memberstakes place, though more often reappraisal andmodifications are relatively confined to theproblems arising out of the autism, while manyparents, unable to tolerate the emotionalrevelation period, never advance beyond thesuperficial discussion of handling methods.However, if the therapist is sensitive to parentalneed and tolerance, constructive work at onelevel or another is usually feasible.

Having passed through a period of emotionalupheaval and reappraisal, parental attitudes tothe child tend to be more relaxed, handlingmethods more confident and effective, andsocial isolation less severe. Obviously since the

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autism is still present, though hopefully treat-ment is progressing, it would be unreasonableto expect total and sustained parental con-fidence. Therapy tends to fluctuate betweenconstructive application of developing insight,"plateau" periods during which weariness ofdiscussion is obvious, and periodic despon-dency as the child's treatment and parentaltolerance fluctuate. Many parents break offregular contact and attend only as they feel theneed, and organizational flexibility is requiredin recognition of changing reality pressures andtherapeutic aims.

In providing therapy for parents many pro-grammes incorporate group sessions, mainly itwould seem, on grounds of economy. Peck hasnoted the value of group identification forproviding support during the emotional revela-tion sessions, and describes it as a force whichliberates feelings of guilt, shame and self-doubt.However, since parents may be approachingtheir problems on different and perhapsmutually exclusive levels, it is difficult to avoidsome members feeling impatience at super-ficiality, or others feeling the threat of emotionaldepth, and such conflict may disintegrate thegroup. Since the group will continue for a longtime, it is also a problem to integrate a newmember who is likely to require acceptance ata level the group has long since passed. Tosome extent being together for a long timeforces resolution of such problems, whileanecdotal discussion is always a safe retreat iftension becomes intolerable. Overall, grouptherapy is usually recognized as a most effectiveand practical means of helping parents.

Of interest is the training of some parents inapplication of operant conditioning techniques.Generally it is felt that parental emotions makerequired objectivity impossible, and that theexistence of extraneous uncontrolled variablesin the home are more likely to confuse thechild and impede his learning. However,Wetzel et al.4i were able to help parentsidentify their unwitting reinforcement of nega-tive behaviour; Jensen et al.16 coached parentsin applying conditioning techniques for thespecific stimulation of speech; and Hewett14

with the same goal as Jensen included siblingsin the coaching. These attempts have been re-ported as successful, but possibly depend onbeing applied to a quite specific goal. In sup-port of the treatment programme parents areasked to provide a responsive environment for

acceptable behaviour, and non-responsive fordeviant behaviour, and the practical applicationof such a request becomes a major focus ofdiscussion in therapy sessions.

Work with Parents at theMildred Creak Centre

Initial attempts over a two-year period toestablish a discussion group for parents neversuccessfully passed the formative period. At thetime various practical problems seemed tosabotage the group before it began, e.g., baby-sitting problems made it impossible for bothparents to attend together and alternating soonthrew group identification into confusion; inaddition, some parents had previously been seenregularly on an individual basis and did nottransfer readily to a group setting. Not until acentre was established and a coherent compre-hensive treatment approach was inaugurated,did parents feel that they could gain anythingfrom group attendance. Prior experience hadconvinced them that nothing they did wouldalter the gloomy prognosis for their childrenand they could see no purpose in exposingthemselves to "soul searching" only to be facedwith the unaltered reality of the child's con-dition. Indeed it seemed futile to expect atti-tude examination unless it was accompanied bysome obvious progress in the treatment of thechildren. Until that progress was forthcoming,parents would not surrender their defensivemeans of coping with their on-going stress.

Therefore, group identification and thera-peutic participation required a treatment focusfor the children, and the introduction ofoperant conditioning techniques provided this.Although sceptical at first, eventually parentssaw this approach as achieving results andgroup coherence was possible. However, it wasstill not practical to involve both parents, so amothers' group was inaugurated early in 1969,and after some difficulty in arranging a suitabletime eventually five mothers attended fairlyregularly every week. The group meets at theCentre, lasts for about an hour and a half, andis led by the social worker. Ultimately it ishoped that a fathers' group may be establishedin the evenings, but so far this has not beenpossible to arrange.

Throughout group sessions the issues alreadydiscussed in this article arose, but it is perhapsof interest to record the sequence in which theyemerged and highlight issues not previouslymentioned.

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Early meetings following on previous abor-tive attempts to establish a group were verystilted, defensive and frustrating, and weremarked by a sceptical approach to the operantconditioning techniques and to the group itself.The group leader was becoming quite desperateto find some central focus, when to his reliefone mother defined it to the satisfaction ofeveryone. She said, "We cannot share your op-timism because we have been too hurt beforeand dare not hope, but please don't you stophoping and we will try to understand". This,after about four meetings, allowed the group tosettle down, and the earlier noted pattern ofsymptom description and anecdotal recitaltook over. The leader was only too thankful tobe "under way" and adopted a passive listeningrole which became firmly established for afurther six to eight weeks. It may have beenpossible to break into this pattern earlier, butin the circumstances this seemed unwise. How-ever, as sessions appeared to degenerate intomeaningless gossip it was obvious that inter-vention of some kind was needed.

Attempts to adopt an educative role and dis-cuss operant conditioning theory and practicefell completely flat, although their successfulre-introduction at a later date seemed to in-dicate that they were pertinent. Concentrationon everyday events as recommended in somereports, seemed to encourage the continuanceof anecdotes, although again successful use ofthis method later pointed to another misjudg-ment of timing. Eventually the break came asthe leader concentrated on communicatingappreciation of parental distress. At first thisfocused on practical matters such as the diffi-culty of taking the family on outings or holi-days, or problems in driving a car and watchingan autistic child at the same time; but graduallymore feeling emerged, largely of an anxiousand despairing kind. Discussion of publicopinion eventually proved to be the emotionaltrigger which had been elusive for so long, and,after three months, emotional expression camein a rush. It was mainly in the form of hostilityagainst public reaction to autism. This wasqualitatively different from the resentments andresistances which had been sporadicallyexpressed earlier.

In expressing hostility the mothers were forthe first time united into a coherent group re-quiring the leader to be the passive recipientof their feelings, and it was vital that they

should feel completely confident that theirfeelings would be accepted without judgment,excuses or any attempt at modification. After afew weeks, hostility petered out and the groupwas left feeling a profound despair as itgradually became apparent that underlying thehostility were feelings of guilt, shame and un-worthiness which had been long resisted butwhich were now exposed.

Sensing the group's desire to retreat intolong-established defensiveness, the leader be-came more active, using reflecting-back tech-niques, encouraging verbal expression of feel-ings, and supporting members as they "con-fessed" and shared them with each other.Although some members found this hard totolerate, over three or four months they cameto trust and support each other and seemed toneed the group identification as they struggledwith a reappraisal of their own attitudes andre-evaluated their methods of handling theirchildren. Progress of the children in treatmentwas the most positive factor in holding them tothis task.

During this period, much discussion arisingout of description of everyday events focusedon improving methods of coping with thechildren, and Ferster's theories of reinforcementwere applied with considerable success. Parentalhandling and response to child behaviour wereassessed in terms of whether they reinforcedthe normal or the deviant behaviour, andmothers began to recognize how deviant be-haviour compelled attention and was therebyreinforced, while normal behaviour wasaccepted with passive relief and went un-rewarded. A deliberate programme of attendingto and reinforcing normal behaviour while asfar as possible ignoring deviant behaviour, wasintroduced with encouraging results.

Once mothers identified and modified theirpatterns of reinforcement, they began to realizethat in judging their children's behaviour theyhad failed to discriminate autistic from non-autistic. For instance, if reaction to frustrationis likely to be a tantrum for many normalchildren, why then assume tantrum behaviouris autistic? Perhaps it could be viewed as apiece of normal behaviour which could be con-trolled without too much reference to theautistic bogey, and since earlier experience inthe Centre supported such reasoning themothers embarked on experimenting in practiceat home, and in the group sharing their resultswith each other.

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Within a few weeks deviant behaviourwhich had dominated the family for years wasseen as no longer a major concern, and mothersreported that recognition of similar behaviour innormal children reduced their fears so thatthey could handle it with confidence, firmness,and clarity, to which the autistic child respondedas well as the normal child. These discoveriesoccupied group attention for some months asvarious behaviour examples were evaluated onthe basis of whether they should be viewed asautistic or not. It is interesting to note themothers' final conclusion that only withdrawaland non-communication need be seen as be-haviour over which they had no immediateinfluence, but for all other behaviour they feltparental response determined its continuity; aconclusion substantially in agreement withFerster. Undoubtedly this significant discoveryby the mothers was dependent on treatmentprogress for the children, for by this time atthe Centre the children had firmly acquiredapproach behaviour and were generalizingtheir obvious pleasure with human contact.Consequently at home parents were aware ofgrowing contact with their child and his in-creasing response to and seeking for theiraffection. As we have already seen such anexperience is vital for parental self-respect andself-confidence, and these in turn permittedmodification of attitudes and handling methods.

As emotional expression emerged andchanges in handling proved effective, feelingsof guilt, shame and unworthiness were signifi-cantly reduced, and it was possible to evaluatesuch topics as over-protection, loss of emotionalcontrol such as losing one's temper, andparents' rights to have some life and interestsof their own, without raising anxiety to an in-tolerable level. The leader could afford to bemore challenging and the educative approachof instruction on operant conditioning methodsand goals was accepted and appreciated.Despondency still returned, especially if thechild's treatment progress slowed down or ifother pressures like illness reduced themother's coping capacity, but the group spirithad become strong enough to tolerate such set-backs and offer support for the mother con-cerned.

After about fifteen months the group con-tinues to evaluate attitudes and handlingmethods constructively, and provides consistentsupport for members undergoing critical stress.

It is occupied with the problem of introducinga new member, and it is seeking ways of moredirectly involving parents in the treatment pro-gramme. Mothers taking turns to mind thechildren during a weekly staff meeting haveproved an unexpected aid to establishing groupcoherence as mothers compare notes about theirexperiences with each other's children.

Thus by trial and error this group hasachieved the original goals of enhancing co-operation with the treatment programme andhelping mothers identify, evaluate and modifytheir attitudes and methods of handling theirchildren. Experience of other groups reportedin the literature has been confirmed, and thevalue of providing "therapy" for parents, atleast for mothers, has been demonstrated.

ConclusionExperience at the Mildred Creak Centre con-

firms that parents of autistic children are notnecessarily abnormal in their attitudes orespecially inadequate in their handling methods,but they do suffer distress which is at timesdesperate and has in many ways led to diffi-culties in bringing up their children. When theirdistress is recognized and relieved, these parentsshow dramatic improvement in handling theirchildren, and as self-confidence increases theyare capable of both critical self-appraisal andconstructive co-operation with a treatment pro-gramme. To some extent such improvementdepends on the children's response to treat-ment, but experience with this group has shownthat it can also occur independently and posi-tively reinforce the treatment goals.

As far as autistic children themselves areconcerned, the application of operant condition-ing in a comprehensive treatment programmehas already demonstrated its effectiveness inmaking contact with the child, controlling hisbehaviour, and teaching him new skills.Whether it will be successful in overcomingbehavioural deficits and establishing somethingapproaching normal behaviour for a higherproportion than other methods, remains to beseen. However, results so far have been en-couraging. Perhaps prolonged application ofthis technique will not only demonstrate itsvalue, but also offer a more hopeful outlook forthe treatment of autism.

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ACKNOWLEDGMENTSI wish to express my appreciation to Dr. A. S.

Ellis, Director of the Western Australian MentalHealth Services, for permission to publish this article;and to Dr. W. E. Robinson, Superintendent of thePerth Child Guidance Clinic, and Miss Y. M.Atkinson, Clinical Psychologist supervising treatmentat the Mildred Creak Centre for Autistic Children,for their constructive criticism and encouragement.

R.A.M.

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35. Metz, J. R.: "Stimulation level preferences ofautistic children", Jnl.Abn.Psychol., Vol. 72, No.6, 1967, pp. 529-35.

36. Peck, H. B., Rabinovitch, R. D., and Cramer,J. R.: "A treatment programme for the parentsof schizophrenic children", AmerJnl.Ortho.Psychiat., Vol. 19, 1949, pp. 592-98.

37. Pitfield, M., and Oppenheim, A. N.: "Child-rearing attitudes of mothers of psychotic child-ren", Jnl.Child Psychol. and Psychiat. and AlliedDisciplines, Vol. 5, 1964, pp. 51-57.

38. Rendell-Short, J.: "Infantile autism in Australia",Med.Jnl.Aust., Aug. 2, 1969, pp. 245-49.

39. Rimland, B.: Infantile Autism, Methuen, London,1965.

40. Rutter, M.: "Concepts of autism: a review ofresearch", Jnl.Child.Psychol. and Psychiat., Vol.9, 1968, pp. 1-25.

41. Rutter, M., Greenfield, D., and Lockyear, L.:"A 5-15-year follow-up study of infantilepsychosis", BritJnl.Psychiat., Vol. 113, 1967, pp.1183-99.

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WILGA FLEMING MEMORIAL PRIZE

The award for this prize in 1969 has been made to F. Hayes for his paper "TheUse of Authority", which appeared in two parts, in June and September.

The judges also commended highly, as an excellent piece of research reporting,the paper by Edna Chamberlain, "Testing with a Treatment Typology", whichappeared in December.

Editor.

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