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TEACHING NEW SOCIAL BEHAVIOR TO SCHIZOPHRENIC CHILDREN
TEACHING NEW SOCIAL BEHAVIOR TO SCHIZOPHRENIC CHILDREN
Marian K. DeMyer} M.D. and C. B . Feister, Ph .D.
Since Kanner described the syndrome of early infantile autism in 1944 and Margaret Mahler differentiated the symbiotic child in 1952, continuous effor ts to tr eat the se types of children have met with only sporadi c successes (Eisen berg, 1957). Much of the literature de aling with treatment of these severely ill children discusses types of approaches used in the one-to-one therapy situation by professionally trained therapists (Ekstein, 1954; Waal, 1955). This paper tells of a study in a residential treatment setting using untrained psychotherapists, consisting of child-care workers, nurses, and teachers, as the principal th erapists of a group of autistic and symbiotic children. The treatment is a combined individual-milieu process directed by a psychiatr ist. Dr. DeMyer is Director of th e Research Cente r for Childhoo d Schizophrenia and Assistant Prof essor of Psychiatry, I ndiana Univ ersity M edical Center, I ndianapolis, I ndiana; and Dr. Ferster is th e Principal Investigator in Experim enta l Psychology, I nstitute of Psychiatric R esearch, and A ssociate Professor, Department of Psychiatry (Psychology ), Indiana University M edical Center, I ndianapolis, Indiana. This study was financ ed in part by a grant f rom the Nat iona l Association of Me ntal Health. Thanks to Donald F. Mo ore, M edical Director, LaRue D . Carter M em orial Ho spital and to James E. Simmons, Coordinator of Chil d Psychiatry, Indiana University School of Medicine, for th eir advice and assistance. We are grat eful to the co-workers on the p roject for their untiring work : Sally McMahan , Bethel Martin, Barbara Smith, Horty Springfield, L orenzo L ewis, Mary Logan, Mo rton Smith, Murtice Parr, Jack Fadely, Richard Feezle, Elizab eth Seitz, Adell Carlton, and William McBeth . Presented at the A nnual Meet ing of the A merican Psych ological Association, Sept emb er, 1960.
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Marian K. DeMyer and C. B. Ferster DESCRIPTION OF STUDY
Children Studied The patients studied consisted of eight children, sexes equally divided, ranging in age from two to ten years when the project began November, 1959. The diagnosis in three probably conforms to Kanner's description of early infantile autism, and in two to Mahler's symbiotic child. The remaining three children have features characteristic of both descriptions. A t the start of the study each of the children showed the common ch aracter isti cs of an extremely narrow r ange of behavioral repertoires, disorders in sp eech ranging from muteness to atypical speech with reversal of pronouns and echolalia, lack of or capricious control over affectual expression, rage reactions with certain changes in routine, serious problems in self-identification (Rabinovitch, 1954) and interpersonal r elationships.
Background of Study Previous th erapy with severe ly sch izophrenic ch ild re n on the Carter Hospital Children's Service had been done mainly by psych ologists and psych iatrists, with th e ch ild-care workers participating on a marginal basis. Several factors played a r ole in th e minimal su ccess of the program, one being that professionall y trained th erapists spent at best on ly three or four hours per week with th e child; most of th e time the child was with untrained wor kers. These workers cou ld not take u p where the therapist lef t off be caus e it was often im possible for them to com prehend the complex, d yn amically or iented framework of the th erapy. Since all psychotherapy is essentially a learning experience, with the therapist be com ing for th e ch ild one of th e ch ief r ein forcers and punishers of beh avior, th e question was rai sed as to whether a less com p lex theory of learning migh t be u sed by ch ild-care workers in a treatment situation to modify the beh avior of th e ch ild and to conv er t human beings into acceptable obj ects for the au tistic ch ild. On the basis of its simplicity and thus its potential worka b ility by the untrain ed therapists, th e th eory of operant cond ition ing w it h the concept of r einfor cement (Skin ner, 1953; Ferster, 1958) was chosen as a therapeu tic tool. R einforcemen t refers to a tec h n iq ue for increasing the fre q uency of an activity by followi ng the act wit h specific consequences in th e en vironm ent. Previous wor k with th e same type of
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children in an automatically controlled experiment by Ferster and DeMyer (1962) has shown the feasibility of using these concepts. In this stu dy social m ethods have been the reinforcers , a form of free operant cond itioning (Skinner, 1953). Met hod of Stu dy
The first step in th e program was to observe care fully each child' s pattern of behavior. Behavior was th en cat egori zed as follo ws: (1) response of child to approach of adult (affective re sponse, eyeto-eye contact, receptivity-avoidance behavior) (2) response to approach of oth er children (3) use of toys and inanimate objects (4) use of own bo dy (5) verbal behavior (6) changes in environment disturbing to child (7) responses to daily routine (a) sleeping, eating, elimination (b) scheduled act ivi ties. On the basis of th e detailed observations a second step was taken. Tentative social overtures were ma de car efu lly by th e ch ild-care workers so that the behavioral pattern of the child would not be interrupted. The pattern of behavior of most young schizophrenic children is the manipulation of a few obj ects in an endless, repetit ive fash ion, the exploitation of their own bodies or body products for immediate pleasure, and r age reactions or anxiety attacks when another individual upsets this routine, either by forci ng h im to do something else or by failing to set the stage so that the rou tine may be completed as usual. The first step in our process was designed to help the adult insinuate himself into the behavior pattern of the child with ou t upsetting him. This technique is a familiar one used by man y therapists with autisti c children ; it has been termed "resolving the au tistic barrier" (Betz, 1947). As soon as the child was accepting th ese social overtures, then the adult who was generally most successful was selected to do individual wor k with the child. Three children had more than one therap ist. The individual worker and the project d irector decided together wh ich aspects of th e child' s behavior would be selected for
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shaping. For one half hour, three or four times a week the children were seen individually by a child-care worker, a nurse, or a teacher. During these half hours the adult used as reinforcers the social contacts found pleasurable to the child in the initial phase of the study. These reinforcers varied with each child, bu t in general consisted of verbal praise and reassurance, the type of physical contact acceptable to the child, and reading, singing, playing music, and dancing. The type of activity selected for reinforcement in the beginning was generally something that would have the most likelihood of success in that the new activity would be a broadening of some activity already in the child's repertoire. As the child acquired a new activity, the worker would also learn new reinforcers so that the interaction between the two of them took on more depth and variety. Because describing the process with each child is too complex for a short paper, the methods and results for the eight children are listed in outline form; the work with one four-year-old child, P ete, is described in detail to exemplify the process. In mo st ways it is typical of that used with all eight children.
Behavioral Observations on Pete 1. R esponse to adults: If adults interrupted a routine or failed to give Pete something he wanted, he would butt them with his head and often bite them. Sometimes he would pucker up his lips as if he were going to kiss an adult, only to bite him instead. He did not reo spond to his name being called. He paid no attention to emotional reactions of adults. He showed no eye-to-eye con tact. He u sed adults to make possible the continuation of narrow behavioral patterns. 2. R espo nse to children: This was essentiall y the sam e as hi s reo sponse to adults. 3. Use of toys and inanimate objects: There was a heavy concentration on inanimate objects and toys in his to tal day's activity. Ho wever, he never used them appropriately; he played with toys by flipping, sucking, or spinning them. He spent much time moving doors, turning the knobs, or sucking them. 4. Use of own body: He looked at his hands and feet. Sometimes he sat on his knees with feet tucked under his buttocks, then h e would slowly scoot one foot out, and as it came into view he would laugh uproariously. He examined his fingers while he put them in queer
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postures. He was vigorous in activity of running up and down the hall. 5. Verbal behavior: He cried, screamed, and yelled at changes in routine or when wishes were denied. When playing by himself he frequently let out a high-pitched "ah-ah-ah-ee-ee-ee" sound. He had been known in his home to sing snatches of songs with his mother. 6. Changes in environment disturbing to the child: Rage reactions resulted from changes in positions of doors and attempts to make him give up his characteristic use of ob jects. 7. Response to daily routines (a) Sleeping, eating, elimination: He was a poor sleeper, would not go to sleep until late at night, and took no naps during the day . He ate nothing by himself. His diet consisted of milk, and strained baby food . He was not toilet trained. (b) Scheduled activities: He did not participate in music or art. Outdoor activities were turned into a repetition of his usual behavioral pattern. He did not play in dirt or finger paints. In the first stage of the experiment when workers were trying to find if they could insinuate themselves into his behavior pattern, the first contact he allowed with equanimity was that of the adult standing close to him and talking to him when he was playing with doors, and of holding his hand when he was seemingly fearful. Gradually he allowed brief moments of eye-to-eye contact and finally went to personnel when they called his name. He then also allowed people to pick him up and, for the first time, he raised h is arms to be picked up. At this stage of Pete's response to adults, the second part of the study, the teaching of new social behavior could begin. The counselor selected for individual work had noted that Pete looked at him closely when the counselor rode a large tricycle. For several days the counselor smiled and talked to Pete as the counselor rode the tricycle. Then for several days he placed the boy briefly on the seat. Each time Pete sat there the counselor rewarded him by carrying him on his shoulders, telling him he was a fine boy . After two weeks Pete was riding the tricycle. It was his first appropriate use of a toy. Shortly after he learned to use the tricycle he had several vacation days, spending his time at home. He lost the appropriate use of the tricycle, a facility he regained in two weeks. Also participating in Pete's program were a man teacher, a woman
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teacher, and an occupational therapist. While the counselor concentrated on teaching him to play appropriately with toys, the teachers and occupational therapist developed his vocalization, speech, listening to music, an d working with simple art media. In these special times again the reinforcements used were such things as verbal encouragement, carrying him, the woman teacher's kissing him and holding him. These social reinforcers at first would be delivered as soon as Pete would perform a part of the activity the therapist was trying to develop; finally only the exact performance was rewarded. RESULT OF STUDY
The results of the study are difficult to ascertain because other approaches were used with the children, and much attention was directed toward planning a program for each child's day . Most of the time an effort was made to use the principle of operant reinforcement in activities such as art and music, but often this goal was not attained. However, changes in the behavior of the individual children can be categorized roughly in two ways: those results directly attributable to the social shaping program, and general behavior changes not so attributable. All the cases have been studied within these categories and tabulated. Results with Pete
In the case of Pete, the results which were considered attributable to the effect of the social shaping program were: 1. Response to adults: He responded to the approach of adults in most situations by kissing them, looking at them, and wanted to be picked up; there was great increase in response to verbal directions. 2. Response to children: There was no effort to change his behavior in regard to other children in the shaping program. 3 & 4. Use of toys and inanimate objects; use of own body: He could ride a tricycle, a rocking horse, push a train on a track, and playa record player. There was a general decrease in flipping of objects, amount of time spent with doors, and mouthing of objects. However, without a good deal of specific stimulation, he reverted to his former patterns of behavior with objects and his body. 5. Verbal behavior: There was an increase in vocal sounds, he said a few words, and hummed tunes learned in music.
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6. Changes in environment disturbing to the child : T he child allowed ma ny more changes in h is environment wi thout anxiety reactions. 7. Response to dai ly routines: T he re was no specific effor t to use a shaping program in sleeping, eating, and elimination. As far as scheduled act ivities were concerned, he showed a great deal of interest in music and some interest in drawing. General behavioral changes not specifically attributed to the shaping program that Pete manifested were a willingness to approach other children, staying in a room with his family, and a desire for his mother and father to hold him a great deal. He began to play appropriately with his sister, responding to her directions in play activities. T her e was appropriate response to the emotional state of his mother and that of other children. For example, du r ing a period when his mother was under much pressure and cried in front of him several times, he would go over to her, pull her hand away from her eyes and look with a sad expression into her face, then respond with a smile when she would cease crying. On one occasion when the counselor had the children in a group and most of them were saying " H ello," Pete did not respond. The counselor said to him, "Pete, aren't you ashamed of yourself? All the other children can say 'Hello,' and here you are not saying it." In a few seconds Pete said "Hello." In h is response to daily routines he began to sleep the night through, goi ng to bed at an early hour and not waking up. He now feeds himself a variety of solid foods and is practically toilet trained. Outdoors he plays appropriately with outside toys and plays in the dirt, an activity he ne ver before engaged in. Results with Other Children The results of this study of eight children ar e described in the following outline below. We could not include more th an the general response of the chi ldren to the re inforcements, nor could we include all of the reinforcements tried. The children's responses to the social reinforcements were highly variable from day to da y. Those listed in the outline are the most consistently successful. We learned from this study that some of the children's devotion to their rituals on many occasions was not so strong as their motivation to thwart th e adults. For example, one child (K. S.) played for weeks with cardboard boxes ,
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tearing to shreds any box she could get hold of and crying whenever she saw a box. This kind of behavior during a certain period far eclipsed any other. We purposely did not reinforce her playing with boxes since it was obviously used to withdraw from people and other environmental stimuli. We then decided to use cardboard boxes as a reinforcer because all other reinforcers were failing. On the first occasion that we presented the box as a reinforcer, the child refused it and thereafter showed no interest in boxes. DATA ON OTHER CHILDREN
K. P.) 2% yrs., AutisticBEHAVIOR AT START OF STUDY
1. No eye-to-eye contact. Inspected pocketbooks of women and pockets of men. Otherwise ignored adults. 2. Ignored other children. 3. Toys: played with sand and water pouring it over herself for hours at a time. Little interest in playing with toys, but much mouthing of objects. 4. Stood in one spot rocking sidewise from one foot to another for long periods. Much masturbation. Moaned and twitched on the floor if wants were not met. She did like to rock and sit near adults. Ate paper. Had a frown on her face most of the time. 5. No words. No babbling. Scr eaming and moaning if th warted. 6. Upset in any change of her behavioral pattern. 7. Slept late in th e morning. Eating fairl y good, except th at she would not sit at the table but ran around the tables snatching food from other people's plates. Not toilet trained. No interest in scheduled activities. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. 2.
Holding, rocking, patting. Singing, talking to her, smiling, looking at her directl y.
BEHAVIOR SELECTED FOR SHAPING
I. 2. 3.
Develop eye-to-eye contact. Playing with toys. Toilet training.
1 All children . with one excep tion, were in the program for ten months. T he exception was H. C.• who was in the pr ogram for only five months.
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REINF ORCEMENTS-SOCIA L
1. Half an hour four times every week with O . T . 2. Half an hour three times every week with teacher. 3. Counselor assigned to take care of most physical nee ds and toilet training. 4. All three people held her, praised her, kissed her when she played with toys, looked at picture books, urina ted in toilet, looked at or interacted with other children. RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SH APING PROGRAM
1. 2. 3. 4. child
Played with several toys appropriately. Toilet training nearly accomplished. Looked at books. Patting, looking at, chasing other children; resentful if another took away possessions or attention of favorite adults.
GENERAL BEHAVIORAL CHANGES2
1. More friendly, more outgoing. 2. Smil es often at appropriate times. 3. J abbers, says a few words. 4. Directly conveys her wishes by friendly appropriate actions rathe r than by screaming and yelling.
T . B.}10 yrs., Symbiotic-A utistic BEHAVIOR AT START OF ST UDY
1. Allowed no ph ysical contact. Eye-to-eye contact. Screaming, hitting self and adu lts if thwarted . Often had this sort of reaction without known provocation. Principal response to adults was avoidance. 2. Urina ted in other childr en' s beds. Pulled their toys away from them, destroying them. 3. Toys, in animate objects: smashed anything he could with his hands or under a table leg. Pl ayed with clay, using his urine to soften it. No appropriate use of toys. 4. Use of body: played often in own urine. Some masturbation. Grim, dour facial expression. 5. Verbal behavior: some grunting, screaming. In thr ee years he said three separate phrases. Made no pleasurable sounds. 6. Any change in his behavioral pattern was upsetting to him. • All "General Behavior Chan ges" in all children listed here refer to the period covered by this study, i.e., November 21, 1959 to August 1, 1960.
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7. Slept, ate well. T ook no responsibility for to ileting, exce pt to urinate any place that struck fancy. No in terest in adult-sponsored activities. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT W ITH CHILD
1. 2. 3.
Going swimming. Going for walks outside hospital. Holding him when he was h itti ng himself or banging his head.
BEHAVIOR SELECTED FOR SHAPING
1. 2. 3.
Develop interest in music activity. Color with crayons instead of smashing them. Develop more varied vocalizations.
REINFORCEMENTS--SOCIAL
I . During music period counselor rode child on shoulders in circle when child looked at or came close to children involved in music games. 2. During art period counselor played tumble games after T. B. marked on pap er instead of smashing crayon. 3. Verbal praise, imitating T.'s sounds when he made pleasurable ones. RES ULTS ATTRIBUTA BLE DIRECTLY TO SOCI AL SH APING PROGRAM
1. 2. 3.
Marching in music circle with smile on face. Coloring with crayons consistently. Humming tunes sung during music period throughout da y.
GE NERAL BEHAVIORAL CHANGES
1. 2. them, 3.
Generally appears smiling and relaxed. Seeks both adults and children more often for affection, kisses dances around room with them. Fewer tantrums and self-destructive acts .
B. S.) 8 yrs., Symbiotic-A u tistic BEHAVIOR AT START OF STUDY
1. Grabbed adults' glasses, dug fingernails into their ears , gritted her teeth and smiled when an adult displeased her, smelled adults' hair, pinched adults. Sought out men more than women. Most of her response to adults was aggressively tinged. She had eye-to-eye contact. 2. R an from older boys crying. Pushed and pulled hair of other ch ildre n . Grabbed toys. Knocked children. Knocked children off riding toys.
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3. Put clothes in toi let. Drank from toilet. Clutched toys to her; did not play with them, but tore them up. 4. When thwarted she would roll, hit her head on the floor, hit and scratch self, and pull out her hair. 5. No speech, just grunting and grimacing. 6. Any forced change in behavioral pattern was upsetting. 7. Sleeping, eating good. Some smearing of feces. Not consistently responsible for toilet. No interest in scheduled activities. METHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Giving physical and verbal attention before she could pinch or dig in adults' ears or hurt herself. 2. Hold her hands and smi le and talk wit h h er. BEHA VIOR SELECTED FOR SHAPING
1. Develop interest in rock-a-boat. 2. Play face-and-hand games. . 3. Develop new methods for expressing h er anger other than selfmutilation, gritting teeth, and smiling. REINFORCEMENTS-SOCIAL
1. One hour each day with nurse who took her to snack bar; after one half hour of playing face-hand games, encouraging her to frown when angry. 2. Ball-and-paper throwing on ward wi th adult. RESULTS ATIRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Self-destructive activity ceased. 2. For a while great interest in face-hand games and said few words. This activity ceased when Mrs. M- absent for long period; it was never regained. 3. No longer smiles when other actions show she is angry. GENERAL BEHAVIORAL CHANGES
1. Little general change in behavior except improved physical status and disappearance of self-destructive behavior. 2. Few adults could work comfortably with her.
R. M. ) 8 yrs., Symbiotic BEHAVIOR AT START OF STUDY
1. Never wanted to be left alone. Pinched arms, twisted fingers of adults .
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2. Pushed peers down, twisted their fingers, pinched them. When with bigger boys trembles and puts hands over ears. 3. Small toys, sticks, pencils, he knocked together furiously, mumbling to himself. This was a favorite activity with little acceptable social interaction with peers. Could color well, but difficult to get him interested in any activity but the hitting of small toys and objects together. 4. Often stamped feet, trembled, put his hands over ears when upset. Overly neat and clean. Not much large-muscle activity. 5. He has a large vocabulary. Speaks in sentences, but with most people he speaks so rapidly in a high breathless way that they cannot understand him. 6. Is particularly upset if he has to take responsibility for a largemuscle activity on his own or with a change in any scheduled routine. 7. Often sleeps poorly. Eats poorly. Urinates in pants with responsibility for fecal elimination. Goes along with all scheduled activities. METHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Verbal reassurance when trembling or running to adult for protection. 2. Coloring or pasting with him. 3. Close attention during music period. BEHAVIOR SELECTED FOR SHAPING
1. 2. 3.
Interest in rough-and-tumble games. Converting pinching to throwing, boxing, running. Decrease neatness and cleanliness.
REINFORCEMENTS-SOCIAL
1. One half hour each day with recreation person who praised him for each effort to playa jumping or roughhouse game and verbally discouraged pinching. 2. Praise, attention by adult whenever he gets in sandbox or becomes dirty; was dressed in old clothes. RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Pinching, pushing nearly replaced by acceptable roughhouse games. 2. Decrease in neatness, greater comfort when dirty. GENERAL BEHAVIORAL CHANGES
1. Began to relive, with mother, days before and after "break" (period of great anxiety and hallucinations at age of five), going over
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things said and done then, getting reassurance from her that he is not a bad boy, getting her permission to be dirty. 2. Taking dancing lessons with his sister. 3. Roughhousing often with his father. 4. Much conversation at home.
K. K' 7 yrs., Symbiotic J
BEHAVIOR AT START OF STUDY
1. Fearful of physi cal closeness, demanding of adults. Refused to accept any set limits. Often ignored adults by engaging in repetitive, purposeless, stereotyped play. Laughing and crying inappropriately. Misidentification of people, particularly men. 2. Did not play with other children. Fearful of the children. Aggressive toward smaller children. Misidentification of children. 3. Pla yed constantly with shoes. Wandered from one toy to another, playing with none. 4. Ritualistic finger flipping. Constantly washing her hands, masturbating, self-destructive (butts head, hits chin with fists). 5. Usuall y spoke in sentences with a reversal of pronouns or using third person. 6 & 7. Eating: large appetite. Sleeping: demanded lights be on until she went to sleep. Elimination: went after activities. No response over changes. METHOD OF ATTA IN ING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Allowing K. K. to be a little baby with her own bottle. 2. Joining in her play with inanimate ob jects (shoes, pures). BEHAVIO R SELECTED F OR SH APING
1. En couraging doll-house play, painting, water play. 2. Encourage her in doing things for others, such as getting cigarettes and matches out of purse, running small errands. 3. Developing proper use of pronouns. REINFORCEMENTS-SOCIAL
1. Praising child for appropriate response, such as playing with doll house, referring to self as "I." (She was particularly responsive to praise from one teacher.) 2. Reassurance and encouragement. RESULTS ATTRIBU T A BLE DIRECTLY TO SOCIAL SHAPING PROGRA M
1. K. K. plays with doll house for fifteen-minute periods. Paints. 2. She is able to carryon a conversation using "I" and without reversing pronouns.
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1. No longer needs light on until asleep. 2. Talks about going to activities, able to discuss a change in schedule, plays with shoes and body less, plays occasionally with other children, not aggressive to little children. 3. Differentiates people properly. 4. Eats less. 5. Compulsive hand washing ceased.
H . C,) 6 yrs., Autistic BEHAVIOR AT START OF STUDY
1. He believed each new woman coming on the ward was his mother. He believed this for a period of about two weeks, then believed some other new person was his mother. He constantly felt the elbows of women; called them breasts. Often hit out at women when upset. 2. Some appropriate interaction with peers. However, he often pretended he was Superman and that he was flying. . 3. Used large-muscle toys appropriately. 4. Constantly in motion, screaming, yelling, hitting head when displeased. 5. Some speech for expressing immediate needs and some of his thoughts, often quite bizarre. 6. Any change in routine upset him, particularly if he was pl aying alone that he was Superman. 7. Some sleep disturbances. Ate fairly well. Responsible for own elimination. Music period especially upsetting to him. Cried, hit, screamed; hit his head during this period. He would respond by drawing to art activities. Played outdoors. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. 2.
Holding him. Reading simple stories to him.
BEHAVIOR SELECTED FOR SHAPING
1. To help him attain pleasure in an adult woman even after he had decided she was not his mother. 2. Focus on drawing activities. REINFORCEMENTS-SOCIAL
1. Reading to him, sitting beside him in his quiet moments. 2. One half hour four times a week with nurse to draw with him and try to observe other reinforcing social stimuli.
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RESULTS ATIRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Less hyperactivity. GENERAL BEHAVroRAL CHANGES
I. During the period his father brought him irregularly to the day-car e program he changed little. J ust as he was beginning to be less hyperactive, he contracted measles, developed measles encephalitis and died. C. S.) 5 yrs., Autistic BEHAVIOR AT START OF STUDY
I. Played with adults' hair, face, and elbows. Avoided adults, walking away when they approached her. Shunned adults' affection. 2. Avoided all peers. Showed no interest in their activities and never looked at them. 3. Looked at TV frequently and at self in the mirror. Looked often at magazines. Play with other toys extremely limited. 4. Hit herself. Slapped arms and h an ds on wall and her legs on the floor. Kicked and scratched her face. Often put hands behind ears. Lies on the floor often. 5. Jabbered TV commercials at a rapid rate so that words nearly unintelligible. Whined and fretted often. No language for communication. 6. Upset with an y change of her routine. 7. Poor sleeper. Finicky eater. Responsible for own elimination. No interest in adult-sponsored activities. M ETHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
I. Sitting beside child, pointing out objects in magazines, reading slogans and pointing to words (she would take adult's hand and indicate she wanted this) . 2. Repeating understandable words, an action which brought a smile to her face. BEHAVIOR SELECTED FOR SHAPING
1. Using her speech and interest in magazines to develop closer physical contacts and more verbalization with adults. REINFORCEMENTS-SOCIAL
1. Half an hour, four times every week with counselor in room. Counselor praised her for playing appropriately wit h doll house, read to her when child allowed counselor to sit beside h er or pick her up.
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RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1.
2.
Child learned to recognize words, in a sense to "read." Allowed adults to pick her up, approached them for affection.
GENERAL BEHAVIORAL CHANGES
1. Sleeps better. 2. Approaching neighborhood children and talking to them; e.g., child offered her a rose and C. S. said, "My, that's pretty." Noticing her peers on dorm. 3. Fewer tantrums, less destructive to self and to others. 4. Joins music and art activities on ward.
P. K.) 4 yrs., A utistics BEHAVIOR AT START OF STUDY
1. If adult failed to set stage for his routine behavior, he butted or bit the adult. Wide ambivalence. No response to name or emotional reaction of others. No eye-to-eye contact. 2. Behavior with children essentially same as with adults. 3. Spent most of day flipping, sucking, or spinnnig toys, positioning doors, turning and sucking door knobs. 4. Looked often at hands and feet while putting them in strange postures. 5. Cried, screamed, yelled with changes in routine or denial of wishes. Frequently emitted high-pitched sounds. No words, except at home occasionally sang snatches of songs with mother. 6. Poor sleeper, would not feed self; diet consisted of milk and strained baby food; not toilet trained. No interest in scheduled activities. Refused to play in dirt and finger paints. METH OD OF ATTAI NI NG PLEASURE-PRODUCING ADULT CO NTACT WITH CHILD
1. Adult stood close and talked to him while playing wi th doors. 2. Later holding him and riding him on shoulders. BE H AVIO R SELECTED F OR SHAPING
1. Appropriate use of toys. 2. Listening to music. 3. Pl ay with art media and dirt. 4. De veloping words. REINFORCEMENTS-SOCIAL
1. Verbal encouragements, carrying him, kissing. • P. K. is Pete , more extensively described abov e.
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RESULTS ATllUBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Responded to adults' approach by kissing them, looking at them, holding out arms to be picked up; appropriate response to verbal directions. 2. Used several toys appropriately and decreased amount of ritualistic use of body, toys, and doors. 3. Babbling, saying a few words, humming tunes. 4. Allowed several environmental changes without anxiety reactions. 5. Interested in music. GENERAL BEHAVIORAL CHANGES
1. Approaches other children and staying in a room with family. Sometimes plays with sister. Responds to other's emotional expression. 2. Sleeps night through, feeding self a variety of foods, nearly toilet trained, plays in dirt. DISCUSSION OF RESULTS
The evaluation of the effectiveness of any psychotherapeutic intervention is a difficult problem (Eisenberg, 1957). These troubles are compounded in a residential treatment unit because so many things are done with the child and so many people come in contactiwith him. Thus the study in no sense could be rigidly controlled. Because the group of children was small and because there were no attempts at quantification of data, only general impressions can be given. With all of the children, it was possible It Ochange their behavior by the use of social reinforcements in a predicted direction. There appear to be two important elements in limiting the range and variety of behavior that can emerge from this technique as it was utilized in this study. The older children were more difficult to deal with in all steps of the process. We relied heavily in the first stages on physical contact, such as kissing and picking up the children, playing rough -and-tumble games, and cuddling them. In the case of the older children, it was more difficult for the workers to use such methods, partly because of size considerations, and partly because this activity was not so rewarding to the adults as it was with the younger children; thus they did not put as much energy into this process . In the cases of the two younger children, ages two and four, the results seemed to be most far-reaching. Perhaps the changes in the oldest boy, a ten-year-
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old who before this program was introduced had responded little, were the most amazing to the staff. T he boy changed from a child who always appeared dour and angry to a smiling one, often humming a tune, and seeking both adults and children for affection . In terms of age appropriateness, however, his activities ar e still at a much younger level, whereas with the three younger chi ldren, the changes have resulted in the total pattern of behavior reaching a more n early ageappropriate level. This result is to be expected, of course. Another observation in two of the children (B. S. and H . C.) with whom the program had little success was that there were many interruptions during the procedures. It is not possible to evaluate whether the technique used by an individual can be transferred successfully to another person without the child losing the new behavior he has gained, because in general there has been excellent daily attendance of the workers, and th ere have been no re signations among the people working on the project. From this initial study it is possible to say that the technique of social reinforcements to teach new social behavior to autistic and sym. biotic children is one that can be learned successfully by professionally untrained psychotherapists, that some changes in behavior directly attributable to the reinforcement program can be predicted, and that cha nges are more likely to be closer to age appropriateness in the very young children th an in those older than six . We cannot state that these results ar e more likely to be permanentl y successful th an approaches based on other theories. Nor can we state tha t all improvement in this group of children resulted [Tom thi s teaching process since other techniques, such as interpretation based on other theories, were used, and most of the childr en had many contacts with changing parents in treatment.
REFERENCES
BETZ, B. J. (1947), A study of tactics for resolving th e autistic barrier in th e psychotherapj of th e sch izophre nic personali ty. Amer, ] . Psychia t ., 104:267-273. E ISENBERG, L. (1957). T he course of childhood sch izophrenia. A .M .A . Arch . Neurol. p $)' chia t., 78:69-83. EKST EI N, R . (1954), The space child's tim e machine: on " reconstru ction" in th e psychoth erapeutic treatment of a schizoph renoid child. A m er. ] . Orthopsychiat ., 24:492-506 FERSTE R, C. B. (1958), Reinforcement and pu nishment in th e control of human behavior by social agencies. Psychiat , R es. R ep ., 10, 12:101-118.
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_ _ & DEMYER, M. K. (1962), A method for the experimental analysis of the behavior of
autistic children. Amer. ] . Orthopsychiat ., 32:89-98. KANNER, L. (19·14), Early infantile autism. ]. Pediat., 25:211-217. _ _ (1943), Autistic disturbances of affected contact. Nero. Child, 2:217-250. IIIAHLER, M. (1952), O n child psychosis and schizop hrenia: autistic and symbiotic infantile psychoses. The Psychoanalytic Study of the Child, 7:286-305. New York : International Universities Press. - - & GOSLINER, B. J. (1955), On symbiotic child psychosis: genetic, dynamic and restitutive aspects . The Psychoanalytic Study of the Child, 10:195-211. New York: International Universities Press . RABiNOVITCH, R . D. (1954), Discussion of child schizophrenia. Res. Nero. & M ent, Dis. Proc., 34:468-469. SKINNER, B. F. (1953). Science and Human Behavior. New York : Macmillan. WAAL, N. (1955), A special technique of psychotherapy with an autistic child. In: Emo tional Probl ems of Early Childhood, ed . G. Caplan. New York: Basic Books, 431-449.
Marian K. DeMyer} M.D. and C. B . Feister, Ph .D.
Since Kanner described the syndrome of early infantile autism in 1944 and Margaret Mahler differentiated the symbiotic child in 1952, continuous effor ts to tr eat the se types of children have met with only sporadi c successes (Eisen berg, 1957). Much of the literature de aling with treatment of these severely ill children discusses types of approaches used in the one-to-one therapy situation by professionally trained therapists (Ekstein, 1954; Waal, 1955). This paper tells of a study in a residential treatment setting using untrained psychotherapists, consisting of child-care workers, nurses, and teachers, as the principal th erapists of a group of autistic and symbiotic children. The treatment is a combined individual-milieu process directed by a psychiatr ist. Dr. DeMyer is Director of th e Research Cente r for Childhoo d Schizophrenia and Assistant Prof essor of Psychiatry, I ndiana Univ ersity M edical Center, I ndianapolis, I ndiana; and Dr. Ferster is th e Principal Investigator in Experim enta l Psychology, I nstitute of Psychiatric R esearch, and A ssociate Professor, Department of Psychiatry (Psychology ), Indiana University M edical Center, I ndianapolis, Indiana. This study was financ ed in part by a grant f rom the Nat iona l Association of Me ntal Health. Thanks to Donald F. Mo ore, M edical Director, LaRue D . Carter M em orial Ho spital and to James E. Simmons, Coordinator of Chil d Psychiatry, Indiana University School of Medicine, for th eir advice and assistance. We are grat eful to the co-workers on the p roject for their untiring work : Sally McMahan , Bethel Martin, Barbara Smith, Horty Springfield, L orenzo L ewis, Mary Logan, Mo rton Smith, Murtice Parr, Jack Fadely, Richard Feezle, Elizab eth Seitz, Adell Carlton, and William McBeth . Presented at the A nnual Meet ing of the A merican Psych ological Association, Sept emb er, 1960.
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Marian K. DeMyer and C. B. Ferster DESCRIPTION OF STUDY
Children Studied The patients studied consisted of eight children, sexes equally divided, ranging in age from two to ten years when the project began November, 1959. The diagnosis in three probably conforms to Kanner's description of early infantile autism, and in two to Mahler's symbiotic child. The remaining three children have features characteristic of both descriptions. A t the start of the study each of the children showed the common ch aracter isti cs of an extremely narrow r ange of behavioral repertoires, disorders in sp eech ranging from muteness to atypical speech with reversal of pronouns and echolalia, lack of or capricious control over affectual expression, rage reactions with certain changes in routine, serious problems in self-identification (Rabinovitch, 1954) and interpersonal r elationships.
Background of Study Previous th erapy with severe ly sch izophrenic ch ild re n on the Carter Hospital Children's Service had been done mainly by psych ologists and psych iatrists, with th e ch ild-care workers participating on a marginal basis. Several factors played a r ole in th e minimal su ccess of the program, one being that professionall y trained th erapists spent at best on ly three or four hours per week with th e child; most of th e time the child was with untrained wor kers. These workers cou ld not take u p where the therapist lef t off be caus e it was often im possible for them to com prehend the complex, d yn amically or iented framework of the th erapy. Since all psychotherapy is essentially a learning experience, with the therapist be com ing for th e ch ild one of th e ch ief r ein forcers and punishers of beh avior, th e question was rai sed as to whether a less com p lex theory of learning migh t be u sed by ch ild-care workers in a treatment situation to modify the beh avior of th e ch ild and to conv er t human beings into acceptable obj ects for the au tistic ch ild. On the basis of its simplicity and thus its potential worka b ility by the untrain ed therapists, th e th eory of operant cond ition ing w it h the concept of r einfor cement (Skin ner, 1953; Ferster, 1958) was chosen as a therapeu tic tool. R einforcemen t refers to a tec h n iq ue for increasing the fre q uency of an activity by followi ng the act wit h specific consequences in th e en vironm ent. Previous wor k with th e same type of
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children in an automatically controlled experiment by Ferster and DeMyer (1962) has shown the feasibility of using these concepts. In this stu dy social m ethods have been the reinforcers , a form of free operant cond itioning (Skinner, 1953). Met hod of Stu dy
The first step in th e program was to observe care fully each child' s pattern of behavior. Behavior was th en cat egori zed as follo ws: (1) response of child to approach of adult (affective re sponse, eyeto-eye contact, receptivity-avoidance behavior) (2) response to approach of oth er children (3) use of toys and inanimate objects (4) use of own bo dy (5) verbal behavior (6) changes in environment disturbing to child (7) responses to daily routine (a) sleeping, eating, elimination (b) scheduled act ivi ties. On the basis of th e detailed observations a second step was taken. Tentative social overtures were ma de car efu lly by th e ch ild-care workers so that the behavioral pattern of the child would not be interrupted. The pattern of behavior of most young schizophrenic children is the manipulation of a few obj ects in an endless, repetit ive fash ion, the exploitation of their own bodies or body products for immediate pleasure, and r age reactions or anxiety attacks when another individual upsets this routine, either by forci ng h im to do something else or by failing to set the stage so that the rou tine may be completed as usual. The first step in our process was designed to help the adult insinuate himself into the behavior pattern of the child with ou t upsetting him. This technique is a familiar one used by man y therapists with autisti c children ; it has been termed "resolving the au tistic barrier" (Betz, 1947). As soon as the child was accepting th ese social overtures, then the adult who was generally most successful was selected to do individual wor k with the child. Three children had more than one therap ist. The individual worker and the project d irector decided together wh ich aspects of th e child' s behavior would be selected for
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shaping. For one half hour, three or four times a week the children were seen individually by a child-care worker, a nurse, or a teacher. During these half hours the adult used as reinforcers the social contacts found pleasurable to the child in the initial phase of the study. These reinforcers varied with each child, bu t in general consisted of verbal praise and reassurance, the type of physical contact acceptable to the child, and reading, singing, playing music, and dancing. The type of activity selected for reinforcement in the beginning was generally something that would have the most likelihood of success in that the new activity would be a broadening of some activity already in the child's repertoire. As the child acquired a new activity, the worker would also learn new reinforcers so that the interaction between the two of them took on more depth and variety. Because describing the process with each child is too complex for a short paper, the methods and results for the eight children are listed in outline form; the work with one four-year-old child, P ete, is described in detail to exemplify the process. In mo st ways it is typical of that used with all eight children.
Behavioral Observations on Pete 1. R esponse to adults: If adults interrupted a routine or failed to give Pete something he wanted, he would butt them with his head and often bite them. Sometimes he would pucker up his lips as if he were going to kiss an adult, only to bite him instead. He did not reo spond to his name being called. He paid no attention to emotional reactions of adults. He showed no eye-to-eye con tact. He u sed adults to make possible the continuation of narrow behavioral patterns. 2. R espo nse to children: This was essentiall y the sam e as hi s reo sponse to adults. 3. Use of toys and inanimate objects: There was a heavy concentration on inanimate objects and toys in his to tal day's activity. Ho wever, he never used them appropriately; he played with toys by flipping, sucking, or spinning them. He spent much time moving doors, turning the knobs, or sucking them. 4. Use of own body: He looked at his hands and feet. Sometimes he sat on his knees with feet tucked under his buttocks, then h e would slowly scoot one foot out, and as it came into view he would laugh uproariously. He examined his fingers while he put them in queer
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postures. He was vigorous in activity of running up and down the hall. 5. Verbal behavior: He cried, screamed, and yelled at changes in routine or when wishes were denied. When playing by himself he frequently let out a high-pitched "ah-ah-ah-ee-ee-ee" sound. He had been known in his home to sing snatches of songs with his mother. 6. Changes in environment disturbing to the child: Rage reactions resulted from changes in positions of doors and attempts to make him give up his characteristic use of ob jects. 7. Response to daily routines (a) Sleeping, eating, elimination: He was a poor sleeper, would not go to sleep until late at night, and took no naps during the day . He ate nothing by himself. His diet consisted of milk, and strained baby food . He was not toilet trained. (b) Scheduled activities: He did not participate in music or art. Outdoor activities were turned into a repetition of his usual behavioral pattern. He did not play in dirt or finger paints. In the first stage of the experiment when workers were trying to find if they could insinuate themselves into his behavior pattern, the first contact he allowed with equanimity was that of the adult standing close to him and talking to him when he was playing with doors, and of holding his hand when he was seemingly fearful. Gradually he allowed brief moments of eye-to-eye contact and finally went to personnel when they called his name. He then also allowed people to pick him up and, for the first time, he raised h is arms to be picked up. At this stage of Pete's response to adults, the second part of the study, the teaching of new social behavior could begin. The counselor selected for individual work had noted that Pete looked at him closely when the counselor rode a large tricycle. For several days the counselor smiled and talked to Pete as the counselor rode the tricycle. Then for several days he placed the boy briefly on the seat. Each time Pete sat there the counselor rewarded him by carrying him on his shoulders, telling him he was a fine boy . After two weeks Pete was riding the tricycle. It was his first appropriate use of a toy. Shortly after he learned to use the tricycle he had several vacation days, spending his time at home. He lost the appropriate use of the tricycle, a facility he regained in two weeks. Also participating in Pete's program were a man teacher, a woman
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teacher, and an occupational therapist. While the counselor concentrated on teaching him to play appropriately with toys, the teachers and occupational therapist developed his vocalization, speech, listening to music, an d working with simple art media. In these special times again the reinforcements used were such things as verbal encouragement, carrying him, the woman teacher's kissing him and holding him. These social reinforcers at first would be delivered as soon as Pete would perform a part of the activity the therapist was trying to develop; finally only the exact performance was rewarded. RESULT OF STUDY
The results of the study are difficult to ascertain because other approaches were used with the children, and much attention was directed toward planning a program for each child's day . Most of the time an effort was made to use the principle of operant reinforcement in activities such as art and music, but often this goal was not attained. However, changes in the behavior of the individual children can be categorized roughly in two ways: those results directly attributable to the social shaping program, and general behavior changes not so attributable. All the cases have been studied within these categories and tabulated. Results with Pete
In the case of Pete, the results which were considered attributable to the effect of the social shaping program were: 1. Response to adults: He responded to the approach of adults in most situations by kissing them, looking at them, and wanted to be picked up; there was great increase in response to verbal directions. 2. Response to children: There was no effort to change his behavior in regard to other children in the shaping program. 3 & 4. Use of toys and inanimate objects; use of own body: He could ride a tricycle, a rocking horse, push a train on a track, and playa record player. There was a general decrease in flipping of objects, amount of time spent with doors, and mouthing of objects. However, without a good deal of specific stimulation, he reverted to his former patterns of behavior with objects and his body. 5. Verbal behavior: There was an increase in vocal sounds, he said a few words, and hummed tunes learned in music.
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6. Changes in environment disturbing to the child : T he child allowed ma ny more changes in h is environment wi thout anxiety reactions. 7. Response to dai ly routines: T he re was no specific effor t to use a shaping program in sleeping, eating, and elimination. As far as scheduled act ivities were concerned, he showed a great deal of interest in music and some interest in drawing. General behavioral changes not specifically attributed to the shaping program that Pete manifested were a willingness to approach other children, staying in a room with his family, and a desire for his mother and father to hold him a great deal. He began to play appropriately with his sister, responding to her directions in play activities. T her e was appropriate response to the emotional state of his mother and that of other children. For example, du r ing a period when his mother was under much pressure and cried in front of him several times, he would go over to her, pull her hand away from her eyes and look with a sad expression into her face, then respond with a smile when she would cease crying. On one occasion when the counselor had the children in a group and most of them were saying " H ello," Pete did not respond. The counselor said to him, "Pete, aren't you ashamed of yourself? All the other children can say 'Hello,' and here you are not saying it." In a few seconds Pete said "Hello." In h is response to daily routines he began to sleep the night through, goi ng to bed at an early hour and not waking up. He now feeds himself a variety of solid foods and is practically toilet trained. Outdoors he plays appropriately with outside toys and plays in the dirt, an activity he ne ver before engaged in. Results with Other Children The results of this study of eight children ar e described in the following outline below. We could not include more th an the general response of the chi ldren to the re inforcements, nor could we include all of the reinforcements tried. The children's responses to the social reinforcements were highly variable from day to da y. Those listed in the outline are the most consistently successful. We learned from this study that some of the children's devotion to their rituals on many occasions was not so strong as their motivation to thwart th e adults. For example, one child (K. S.) played for weeks with cardboard boxes ,
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tearing to shreds any box she could get hold of and crying whenever she saw a box. This kind of behavior during a certain period far eclipsed any other. We purposely did not reinforce her playing with boxes since it was obviously used to withdraw from people and other environmental stimuli. We then decided to use cardboard boxes as a reinforcer because all other reinforcers were failing. On the first occasion that we presented the box as a reinforcer, the child refused it and thereafter showed no interest in boxes. DATA ON OTHER CHILDREN
K. P.) 2% yrs., AutisticBEHAVIOR AT START OF STUDY
1. No eye-to-eye contact. Inspected pocketbooks of women and pockets of men. Otherwise ignored adults. 2. Ignored other children. 3. Toys: played with sand and water pouring it over herself for hours at a time. Little interest in playing with toys, but much mouthing of objects. 4. Stood in one spot rocking sidewise from one foot to another for long periods. Much masturbation. Moaned and twitched on the floor if wants were not met. She did like to rock and sit near adults. Ate paper. Had a frown on her face most of the time. 5. No words. No babbling. Scr eaming and moaning if th warted. 6. Upset in any change of her behavioral pattern. 7. Slept late in th e morning. Eating fairl y good, except th at she would not sit at the table but ran around the tables snatching food from other people's plates. Not toilet trained. No interest in scheduled activities. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. 2.
Holding, rocking, patting. Singing, talking to her, smiling, looking at her directl y.
BEHAVIOR SELECTED FOR SHAPING
I. 2. 3.
Develop eye-to-eye contact. Playing with toys. Toilet training.
1 All children . with one excep tion, were in the program for ten months. T he exception was H. C.• who was in the pr ogram for only five months.
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REINF ORCEMENTS-SOCIA L
1. Half an hour four times every week with O . T . 2. Half an hour three times every week with teacher. 3. Counselor assigned to take care of most physical nee ds and toilet training. 4. All three people held her, praised her, kissed her when she played with toys, looked at picture books, urina ted in toilet, looked at or interacted with other children. RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SH APING PROGRAM
1. 2. 3. 4. child
Played with several toys appropriately. Toilet training nearly accomplished. Looked at books. Patting, looking at, chasing other children; resentful if another took away possessions or attention of favorite adults.
GENERAL BEHAVIORAL CHANGES2
1. More friendly, more outgoing. 2. Smil es often at appropriate times. 3. J abbers, says a few words. 4. Directly conveys her wishes by friendly appropriate actions rathe r than by screaming and yelling.
T . B.}10 yrs., Symbiotic-A utistic BEHAVIOR AT START OF ST UDY
1. Allowed no ph ysical contact. Eye-to-eye contact. Screaming, hitting self and adu lts if thwarted . Often had this sort of reaction without known provocation. Principal response to adults was avoidance. 2. Urina ted in other childr en' s beds. Pulled their toys away from them, destroying them. 3. Toys, in animate objects: smashed anything he could with his hands or under a table leg. Pl ayed with clay, using his urine to soften it. No appropriate use of toys. 4. Use of body: played often in own urine. Some masturbation. Grim, dour facial expression. 5. Verbal behavior: some grunting, screaming. In thr ee years he said three separate phrases. Made no pleasurable sounds. 6. Any change in his behavioral pattern was upsetting to him. • All "General Behavior Chan ges" in all children listed here refer to the period covered by this study, i.e., November 21, 1959 to August 1, 1960.
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7. Slept, ate well. T ook no responsibility for to ileting, exce pt to urinate any place that struck fancy. No in terest in adult-sponsored activities. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT W ITH CHILD
1. 2. 3.
Going swimming. Going for walks outside hospital. Holding him when he was h itti ng himself or banging his head.
BEHAVIOR SELECTED FOR SHAPING
1. 2. 3.
Develop interest in music activity. Color with crayons instead of smashing them. Develop more varied vocalizations.
REINFORCEMENTS--SOCIAL
I . During music period counselor rode child on shoulders in circle when child looked at or came close to children involved in music games. 2. During art period counselor played tumble games after T. B. marked on pap er instead of smashing crayon. 3. Verbal praise, imitating T.'s sounds when he made pleasurable ones. RES ULTS ATTRIBUTA BLE DIRECTLY TO SOCI AL SH APING PROGRAM
1. 2. 3.
Marching in music circle with smile on face. Coloring with crayons consistently. Humming tunes sung during music period throughout da y.
GE NERAL BEHAVIORAL CHANGES
1. 2. them, 3.
Generally appears smiling and relaxed. Seeks both adults and children more often for affection, kisses dances around room with them. Fewer tantrums and self-destructive acts .
B. S.) 8 yrs., Symbiotic-A u tistic BEHAVIOR AT START OF STUDY
1. Grabbed adults' glasses, dug fingernails into their ears , gritted her teeth and smiled when an adult displeased her, smelled adults' hair, pinched adults. Sought out men more than women. Most of her response to adults was aggressively tinged. She had eye-to-eye contact. 2. R an from older boys crying. Pushed and pulled hair of other ch ildre n . Grabbed toys. Knocked children. Knocked children off riding toys.
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3. Put clothes in toi let. Drank from toilet. Clutched toys to her; did not play with them, but tore them up. 4. When thwarted she would roll, hit her head on the floor, hit and scratch self, and pull out her hair. 5. No speech, just grunting and grimacing. 6. Any forced change in behavioral pattern was upsetting. 7. Sleeping, eating good. Some smearing of feces. Not consistently responsible for toilet. No interest in scheduled activities. METHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Giving physical and verbal attention before she could pinch or dig in adults' ears or hurt herself. 2. Hold her hands and smi le and talk wit h h er. BEHA VIOR SELECTED FOR SHAPING
1. Develop interest in rock-a-boat. 2. Play face-and-hand games. . 3. Develop new methods for expressing h er anger other than selfmutilation, gritting teeth, and smiling. REINFORCEMENTS-SOCIAL
1. One hour each day with nurse who took her to snack bar; after one half hour of playing face-hand games, encouraging her to frown when angry. 2. Ball-and-paper throwing on ward wi th adult. RESULTS ATIRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Self-destructive activity ceased. 2. For a while great interest in face-hand games and said few words. This activity ceased when Mrs. M- absent for long period; it was never regained. 3. No longer smiles when other actions show she is angry. GENERAL BEHAVIORAL CHANGES
1. Little general change in behavior except improved physical status and disappearance of self-destructive behavior. 2. Few adults could work comfortably with her.
R. M. ) 8 yrs., Symbiotic BEHAVIOR AT START OF STUDY
1. Never wanted to be left alone. Pinched arms, twisted fingers of adults .
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2. Pushed peers down, twisted their fingers, pinched them. When with bigger boys trembles and puts hands over ears. 3. Small toys, sticks, pencils, he knocked together furiously, mumbling to himself. This was a favorite activity with little acceptable social interaction with peers. Could color well, but difficult to get him interested in any activity but the hitting of small toys and objects together. 4. Often stamped feet, trembled, put his hands over ears when upset. Overly neat and clean. Not much large-muscle activity. 5. He has a large vocabulary. Speaks in sentences, but with most people he speaks so rapidly in a high breathless way that they cannot understand him. 6. Is particularly upset if he has to take responsibility for a largemuscle activity on his own or with a change in any scheduled routine. 7. Often sleeps poorly. Eats poorly. Urinates in pants with responsibility for fecal elimination. Goes along with all scheduled activities. METHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Verbal reassurance when trembling or running to adult for protection. 2. Coloring or pasting with him. 3. Close attention during music period. BEHAVIOR SELECTED FOR SHAPING
1. 2. 3.
Interest in rough-and-tumble games. Converting pinching to throwing, boxing, running. Decrease neatness and cleanliness.
REINFORCEMENTS-SOCIAL
1. One half hour each day with recreation person who praised him for each effort to playa jumping or roughhouse game and verbally discouraged pinching. 2. Praise, attention by adult whenever he gets in sandbox or becomes dirty; was dressed in old clothes. RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Pinching, pushing nearly replaced by acceptable roughhouse games. 2. Decrease in neatness, greater comfort when dirty. GENERAL BEHAVIORAL CHANGES
1. Began to relive, with mother, days before and after "break" (period of great anxiety and hallucinations at age of five), going over
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things said and done then, getting reassurance from her that he is not a bad boy, getting her permission to be dirty. 2. Taking dancing lessons with his sister. 3. Roughhousing often with his father. 4. Much conversation at home.
K. K' 7 yrs., Symbiotic J
BEHAVIOR AT START OF STUDY
1. Fearful of physi cal closeness, demanding of adults. Refused to accept any set limits. Often ignored adults by engaging in repetitive, purposeless, stereotyped play. Laughing and crying inappropriately. Misidentification of people, particularly men. 2. Did not play with other children. Fearful of the children. Aggressive toward smaller children. Misidentification of children. 3. Pla yed constantly with shoes. Wandered from one toy to another, playing with none. 4. Ritualistic finger flipping. Constantly washing her hands, masturbating, self-destructive (butts head, hits chin with fists). 5. Usuall y spoke in sentences with a reversal of pronouns or using third person. 6 & 7. Eating: large appetite. Sleeping: demanded lights be on until she went to sleep. Elimination: went after activities. No response over changes. METHOD OF ATTA IN ING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. Allowing K. K. to be a little baby with her own bottle. 2. Joining in her play with inanimate ob jects (shoes, pures). BEHAVIO R SELECTED F OR SH APING
1. En couraging doll-house play, painting, water play. 2. Encourage her in doing things for others, such as getting cigarettes and matches out of purse, running small errands. 3. Developing proper use of pronouns. REINFORCEMENTS-SOCIAL
1. Praising child for appropriate response, such as playing with doll house, referring to self as "I." (She was particularly responsive to praise from one teacher.) 2. Reassurance and encouragement. RESULTS ATTRIBU T A BLE DIRECTLY TO SOCIAL SHAPING PROGRA M
1. K. K. plays with doll house for fifteen-minute periods. Paints. 2. She is able to carryon a conversation using "I" and without reversing pronouns.
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1. No longer needs light on until asleep. 2. Talks about going to activities, able to discuss a change in schedule, plays with shoes and body less, plays occasionally with other children, not aggressive to little children. 3. Differentiates people properly. 4. Eats less. 5. Compulsive hand washing ceased.
H . C,) 6 yrs., Autistic BEHAVIOR AT START OF STUDY
1. He believed each new woman coming on the ward was his mother. He believed this for a period of about two weeks, then believed some other new person was his mother. He constantly felt the elbows of women; called them breasts. Often hit out at women when upset. 2. Some appropriate interaction with peers. However, he often pretended he was Superman and that he was flying. . 3. Used large-muscle toys appropriately. 4. Constantly in motion, screaming, yelling, hitting head when displeased. 5. Some speech for expressing immediate needs and some of his thoughts, often quite bizarre. 6. Any change in routine upset him, particularly if he was pl aying alone that he was Superman. 7. Some sleep disturbances. Ate fairly well. Responsible for own elimination. Music period especially upsetting to him. Cried, hit, screamed; hit his head during this period. He would respond by drawing to art activities. Played outdoors. METHOD OF ATTAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
1. 2.
Holding him. Reading simple stories to him.
BEHAVIOR SELECTED FOR SHAPING
1. To help him attain pleasure in an adult woman even after he had decided she was not his mother. 2. Focus on drawing activities. REINFORCEMENTS-SOCIAL
1. Reading to him, sitting beside him in his quiet moments. 2. One half hour four times a week with nurse to draw with him and try to observe other reinforcing social stimuli.
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RESULTS ATIRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Less hyperactivity. GENERAL BEHAVroRAL CHANGES
I. During the period his father brought him irregularly to the day-car e program he changed little. J ust as he was beginning to be less hyperactive, he contracted measles, developed measles encephalitis and died. C. S.) 5 yrs., Autistic BEHAVIOR AT START OF STUDY
I. Played with adults' hair, face, and elbows. Avoided adults, walking away when they approached her. Shunned adults' affection. 2. Avoided all peers. Showed no interest in their activities and never looked at them. 3. Looked at TV frequently and at self in the mirror. Looked often at magazines. Play with other toys extremely limited. 4. Hit herself. Slapped arms and h an ds on wall and her legs on the floor. Kicked and scratched her face. Often put hands behind ears. Lies on the floor often. 5. Jabbered TV commercials at a rapid rate so that words nearly unintelligible. Whined and fretted often. No language for communication. 6. Upset with an y change of her routine. 7. Poor sleeper. Finicky eater. Responsible for own elimination. No interest in adult-sponsored activities. M ETHOD OF ATIAINING PLEASURE-PRODUCING ADULT CONTACT WITH CHILD
I. Sitting beside child, pointing out objects in magazines, reading slogans and pointing to words (she would take adult's hand and indicate she wanted this) . 2. Repeating understandable words, an action which brought a smile to her face. BEHAVIOR SELECTED FOR SHAPING
1. Using her speech and interest in magazines to develop closer physical contacts and more verbalization with adults. REINFORCEMENTS-SOCIAL
1. Half an hour, four times every week with counselor in room. Counselor praised her for playing appropriately wit h doll house, read to her when child allowed counselor to sit beside h er or pick her up.
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RESULTS ATTRIBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1.
2.
Child learned to recognize words, in a sense to "read." Allowed adults to pick her up, approached them for affection.
GENERAL BEHAVIORAL CHANGES
1. Sleeps better. 2. Approaching neighborhood children and talking to them; e.g., child offered her a rose and C. S. said, "My, that's pretty." Noticing her peers on dorm. 3. Fewer tantrums, less destructive to self and to others. 4. Joins music and art activities on ward.
P. K.) 4 yrs., A utistics BEHAVIOR AT START OF STUDY
1. If adult failed to set stage for his routine behavior, he butted or bit the adult. Wide ambivalence. No response to name or emotional reaction of others. No eye-to-eye contact. 2. Behavior with children essentially same as with adults. 3. Spent most of day flipping, sucking, or spinnnig toys, positioning doors, turning and sucking door knobs. 4. Looked often at hands and feet while putting them in strange postures. 5. Cried, screamed, yelled with changes in routine or denial of wishes. Frequently emitted high-pitched sounds. No words, except at home occasionally sang snatches of songs with mother. 6. Poor sleeper, would not feed self; diet consisted of milk and strained baby food; not toilet trained. No interest in scheduled activities. Refused to play in dirt and finger paints. METH OD OF ATTAI NI NG PLEASURE-PRODUCING ADULT CO NTACT WITH CHILD
1. Adult stood close and talked to him while playing wi th doors. 2. Later holding him and riding him on shoulders. BE H AVIO R SELECTED F OR SHAPING
1. Appropriate use of toys. 2. Listening to music. 3. Pl ay with art media and dirt. 4. De veloping words. REINFORCEMENTS-SOCIAL
1. Verbal encouragements, carrying him, kissing. • P. K. is Pete , more extensively described abov e.
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RESULTS ATllUBUTABLE DIRECTLY TO SOCIAL SHAPING PROGRAM
1. Responded to adults' approach by kissing them, looking at them, holding out arms to be picked up; appropriate response to verbal directions. 2. Used several toys appropriately and decreased amount of ritualistic use of body, toys, and doors. 3. Babbling, saying a few words, humming tunes. 4. Allowed several environmental changes without anxiety reactions. 5. Interested in music. GENERAL BEHAVIORAL CHANGES
1. Approaches other children and staying in a room with family. Sometimes plays with sister. Responds to other's emotional expression. 2. Sleeps night through, feeding self a variety of foods, nearly toilet trained, plays in dirt. DISCUSSION OF RESULTS
The evaluation of the effectiveness of any psychotherapeutic intervention is a difficult problem (Eisenberg, 1957). These troubles are compounded in a residential treatment unit because so many things are done with the child and so many people come in contactiwith him. Thus the study in no sense could be rigidly controlled. Because the group of children was small and because there were no attempts at quantification of data, only general impressions can be given. With all of the children, it was possible It Ochange their behavior by the use of social reinforcements in a predicted direction. There appear to be two important elements in limiting the range and variety of behavior that can emerge from this technique as it was utilized in this study. The older children were more difficult to deal with in all steps of the process. We relied heavily in the first stages on physical contact, such as kissing and picking up the children, playing rough -and-tumble games, and cuddling them. In the case of the older children, it was more difficult for the workers to use such methods, partly because of size considerations, and partly because this activity was not so rewarding to the adults as it was with the younger children; thus they did not put as much energy into this process . In the cases of the two younger children, ages two and four, the results seemed to be most far-reaching. Perhaps the changes in the oldest boy, a ten-year-
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old who before this program was introduced had responded little, were the most amazing to the staff. T he boy changed from a child who always appeared dour and angry to a smiling one, often humming a tune, and seeking both adults and children for affection . In terms of age appropriateness, however, his activities ar e still at a much younger level, whereas with the three younger chi ldren, the changes have resulted in the total pattern of behavior reaching a more n early ageappropriate level. This result is to be expected, of course. Another observation in two of the children (B. S. and H . C.) with whom the program had little success was that there were many interruptions during the procedures. It is not possible to evaluate whether the technique used by an individual can be transferred successfully to another person without the child losing the new behavior he has gained, because in general there has been excellent daily attendance of the workers, and th ere have been no re signations among the people working on the project. From this initial study it is possible to say that the technique of social reinforcements to teach new social behavior to autistic and sym. biotic children is one that can be learned successfully by professionally untrained psychotherapists, that some changes in behavior directly attributable to the reinforcement program can be predicted, and that cha nges are more likely to be closer to age appropriateness in the very young children th an in those older than six . We cannot state that these results ar e more likely to be permanentl y successful th an approaches based on other theories. Nor can we state tha t all improvement in this group of children resulted [Tom thi s teaching process since other techniques, such as interpretation based on other theories, were used, and most of the childr en had many contacts with changing parents in treatment.
REFERENCES
BETZ, B. J. (1947), A study of tactics for resolving th e autistic barrier in th e psychotherapj of th e sch izophre nic personali ty. Amer, ] . Psychia t ., 104:267-273. E ISENBERG, L. (1957). T he course of childhood sch izophrenia. A .M .A . Arch . Neurol. p $)' chia t., 78:69-83. EKST EI N, R . (1954), The space child's tim e machine: on " reconstru ction" in th e psychoth erapeutic treatment of a schizoph renoid child. A m er. ] . Orthopsychiat ., 24:492-506 FERSTE R, C. B. (1958), Reinforcement and pu nishment in th e control of human behavior by social agencies. Psychiat , R es. R ep ., 10, 12:101-118.
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_ _ & DEMYER, M. K. (1962), A method for the experimental analysis of the behavior of
autistic children. Amer. ] . Orthopsychiat ., 32:89-98. KANNER, L. (19·14), Early infantile autism. ]. Pediat., 25:211-217. _ _ (1943), Autistic disturbances of affected contact. Nero. Child, 2:217-250. IIIAHLER, M. (1952), O n child psychosis and schizop hrenia: autistic and symbiotic infantile psychoses. The Psychoanalytic Study of the Child, 7:286-305. New York : International Universities Press. - - & GOSLINER, B. J. (1955), On symbiotic child psychosis: genetic, dynamic and restitutive aspects . The Psychoanalytic Study of the Child, 10:195-211. New York: International Universities Press . RABiNOVITCH, R . D. (1954), Discussion of child schizophrenia. Res. Nero. & M ent, Dis. Proc., 34:468-469. SKINNER, B. F. (1953). Science and Human Behavior. New York : Macmillan. WAAL, N. (1955), A special technique of psychotherapy with an autistic child. In: Emo tional Probl ems of Early Childhood, ed . G. Caplan. New York: Basic Books, 431-449.