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sn#031623 filedate 1973-03-27 generic text, type T, neo UTF8
00100 REMARKS ON THE TREATMENT OF NONSPEAKING CHILDHOOD AUTISM AT
00200 THE FRIEDA FROMM-REICHMANN AWARD LUNCHEON, MAY 5,1973, HONOLULU.
00300
00400 KENNETH MARK COLBY
00500
00600
00700 In searching through Frieda Fromm-Reichmann's publications I
00800 could not find any discussion of childhood autism and its treatment.
00900 However there is ample evidence in her papers and book that she was
01000 not reluctant to take on difficult problems and use imaginative
01100 methods. It is in this spirit of innovation and willingness to
01200 undertake the hitherto discouraging, that I would like to tell you
01300 something about a computer-based method for stimulating language
01400 acquisition in nonspeaking austistic children.
01500
01600 No one person invented and developed the method I shall
01700 describe. Hence let me first acknowledge my indebtedness to my
01800 co-workers at Stanford University- Horace Enea, David Smith, Malcolm
01900 Newey and Maxine Colby, each of whom has put years of effort into
02000 this project.
02100
02200 We began about seven years ago with a working hypothesis and
02300 two well-known facts about childhood autism. The hypothesis was that
02400 nonspeaking child's primary difficulty lay in an inability to process
02500 symbols, language being of course the most important symbolic system
02600 used in human communication. The first well known fact indicated
02700 prognosis was highly correlated with speech, the outlook for
02800 nonspeakers being poor. The second fact was the common observation
02900 that these children played for hours with machines but remained
03000 indifferent to interactions with people.
03100 There is now increasing evidence in the research literature
03200 supporting this hypothesis of a primary difficulty in symbol
03300 processing. [Churchill,1972; Frith,1972; Hermelin and O'Connor,1970;
03400 Rutter, Bartak and Newman,1971]. A dysphasic or developmental aphasic
03500 child also has difficulty with language but he can acquire usage of
03600 other symbolic systems such as gesturing and drawing. But the
03700 nonspeaking autistic child has great difficulty with all symbolic
03800 systems, not just language.
03900 The cause of this condition remains unknown. Nowadays few
04000 experts in the field defend a strictly psychogenic etiology since the
04100 supporting evidence is weak and the disconfirming evidence is gaining
04200 in strength [Rutter et al.,1971]. Regardless of the original cause,
04300 if we believe we understand the crux of the child's difficulty, we
04400 can try to devise a remedial treatment which takes advantage of the
04500 child's fascination with machines. Our idea then was to create a
04600 machine a nonspeaking child could play with in which the play process
04700 involved the use
04800 The system we developed consists of a television-like screen
04900 and a typewriter-like keyboard in front of which the child sits or
05000 stands. There is no computer visible since it is located in another
05100 part of the building. Pressing a key on the keyboard causes a letter,
05200 word, phrase, or picture to appear on the screen accompanied by the
05300 sound of a human voice saying the linguistic expression or something
05400 else which might interest a child. It is much like having one's own
05500 Sesame Street to play with. But instead of being a passive recipient
05600 of what the television show provides, a child in our situation is an
05700 active instigating agent who controls the machine. The merits of such
05800 a machine are that it is untiring, predictable, always saying the
05900 same thing the same way, never angry, never bored and controllable-
06000 properties which are notoriously lacking in humans.
06100 This audio-visual-tactile experience is directed by a
06200 computer program running on a PDP 6/10 time-shared system at the
06300 Stanford Artificial Intelligence Project. The program is divided into
06400 games intended to provide a child a variety of opportunities at
06500 playing with and interacting with symbols. For example, in one game
06600 when the child presses the key showing the letter "H", an "H" appears
06700 on the screen and a voice says "H". In another game pressing this key
06800 produces a horse on the screen accompanied by the sound of running
06900 hooves. There exist over 1000 such experiences on the system. The
07000 games are organized at various levels of complexity and are designed
07100 to show a child how English is put together from sounds and letters
07200 into words and expressions. The idea is that in playing he will begin
07300 to copy or approximate the sounds he hears associated with what he
07400 sees on the screen. I shall not go into the details of the games here
07500 They are throughly described in the literature,[Colby and
07600 Smith,1971]. Instead I shall try to sketch the rationale or major
07700 principles underlying this approach.
07800 First, consider how normal children acquire language. They
07900 are not taught formally as are adults learning a second language.
08000 Children are simply exposed to members of a linguistic community and
08100 given an opportunity to explore language usage in everyday
08200 communication with other humans who encourage and sometimes correct
08300 them. From this exposure, exploration, and corrective feedback they
08400 come to associate the sounds and meanings of words. They come to
08500 grasp that certain that certain sounds, human voice sounds, are not
08600 just sounds in themselves like wind in the trees, but that they are
08700 about something else, that is, they are symbolic. Human voice sounds
08800 are perceptual invariants about other invariants. Between the ages
08900 of roughly 2 months and 4 years normal children spend thousands of
09000 hours listening, practicing and playing with language. Mastery of a
09100 language, that is getting most of it right, does not come until far
09200 into adolescence, if ever. A normal child can make an interpretation
09300 of expressions he has never heard before. A nonspeaking autistic
09400 child does not show this course of development.
09500
09600 The problem is not simply the development of language skills but also
09700 the acquisition of concepts necessary for a comprehensive enough
09800 model of how the world works, especially the human world. The
09900 conceptual or cognitive deficits shown by nonspeaking autistic
10000 children involve those concepts which are normally acquired through
10100 language or other symbolizations. Take the abstract concept of
10200 `danger'. To prevent a child from becoming hurt, a parent must
10300 identify certain concrete objects and situations as dangerous until
10400 the child grasps the abstract concept of danger. All this is done
10500 linguistically and through pointing. By way of language, objects and
10600 situations can be referred to and warned about even when they are not
10700 present, and referred to without pointing when they are present. An
10800 important socialization function of language is to mark off for a
10900 child what to pay attention to and what is to be done and not done.
11000 Many of the characteristics of autistic children, for example, the
11100 lack of empathy, can be viewed as a consequence of an inability to
11200 form regular conceptual patterns about the world because the
11300 necessary concepts acquired through language are absent or poorly
11400 developed. As one perceptive mother said about her autistic child, `a
11500 screw is not loose, a screw is missing'.
11600
11700 A poorly developed ability to process symbols has further
11800 consequences besides conceptual deficits. Without language a human
11900 has no awareness of being aware. He lacks the ability to
12000 self-monitor and to self-control by talking to himself. He cannot
12100 use symbols reflexively, that is, to give himself orders and to
12200 comment on himself to himself. Having language, a normal child comes
12300 to realize the self is really two which can talk to one another.
12400 Finally to become a person, one must be recognized as a person by
12500 other people who treat you as if you had self-awareness and
12600 self-control. This recognition is virtually impossible for a child
12700 without language skills and probably represents the greatest tragedy
12800 in his life.
12900
13000 Thus far I have spoken of autistic children as if the
13100 nosological label stood for a single homogeneous group. Thirty years
13200 ago it seemed that night be the case. Now it appears as if there
13300 exist several autistic syndromes, none of which should be confused
13400 with childhood schizophrenia since they differ in onset, course,
13500 symptoms, family history and prognosis. There are speaking and
13600 nonspeaking autistic children. Among the nonspeaking group there are
13700 those whose linguistic development is normal until some time in the
13800 second year when they lose their language abilities. The other major
13900 group are those children who, from the start, have trouble with
14000 language, understanding little and saying even less, perhaps one
14100 'mama' or `no' a year. In our experience the most difficult
14200 problem for differential diagnosis lies in deciding whether a
14300 nonspeaking child suffers from dysphasia {developmental aphasia},
14400 autism or perhaps both. Over time the correct diagnosis can be made
14500 when it becomes clear that the dysphasic child can mimic, draw
14600 pictures and signify greetings while the autistic child cannot.
14700
14800 Taking a cue from the normal child who treats language as a
14900 toy, our first principle was that the treatment should provide an
15000 opportunity for exploratory play. The treatment situation is not one
15100 of forced drill, instruction or training but one of play with the
15200 keyboard and video display. Operant conditioning methods reward the
15300 child with candy or food for his actions. We do not, believing that
15400 food rewards inhibit exploratory curiosity, as has been shown in
15500 animals both by Harlow and by Nissen. From our own experience and
15600 that of workers in computer-aided instruction, food rewards are
15700 distracting and disrupting. Exploratory learning requires a situation
15800 which invites exploration, and provides time, security and minimal
15900 interference by adults.
16100
16200 In each of the sessions the child has a `sitter', an adult
16300 whose main task is to sit and not interfere. The sitter's task is
16400 difficult, especially if he has been trained to DO things. We want
16500 to give the child an opportunity to freely self-select those symbols
16600 which interest him, rather than to have an adult instruct him or quiz
16700 him about those symbols which he `should' learn. The sitter's
16800 behavior is crucial to this treatment method if the spirit of play
16900 rather than drill is to be provided. Of course the sitter offers
17000 social approval and encouragement when it is fitting.
17100
17200 An ideal treatment session results when the child is in a good mood,
17300 is interested in working the keyboard display, enjoys imitating the
17400 sounds and is successful in getting the machine to do what he wants.
17500 The principle of success is important here because, in our view, many
17600 nonspeakers have given up on language. They have failed over and
17700 over and hence withdraw from trying. We do not let them fail. As
17800 one normal child said about the experience "It's fun, you can't
17900 lose". There are students of autism who consider nonspeaking
18000 autistic children to be innately withdrawn from people and hence not
18100 acquiring language. We feel it is the other way around; they have so
18200 much difficulty with language they withdraw from people who
18300 unwittingly flood and overwhelm them with meaningless noises. No
18400 wonder they do not call, address, ask or answer questions of these
18500 giants who immediately spout gibberish. Autistic children are not
18600 aloof and indifferent to all people -- only to those who talk. I
18700 have often wondered if it is not eye-to-eye contact they avoid but
18800 eye-to-a-mouth which, as far as the child is concerned, simply
18900 jabbers. If you say little or nothing to a nonspeaking child on
19000 first meeting him, you will more than likely find him in your lap, as
19100 affectionate as any other child.
19200 As with any treatment method, we have had successes and
19300 failures. Every treatment of autism has reported its dramatic
19400 successes with one or two children. What is needed are long case
19500 series before we can sensibly compare methods and decide which is
19600 more effective relative to the effort and cost required. Thus far our
19700 series of nonspeaking autistic children totals 17 with 13 of the
19800 children improved. By improvement we mean that the child begins
19900 voluntarily to use speech for social communication. We do not claim
20000 the method results in normal language ability with full comprehension
20100 and correct articulation and grammar. Our aim is to kindle a child's
20200 interest in using speech, to get him to try again and again, to
20300 catalyze his damaged or slow-developing natural process of language
20400 acquisition.
20500 Our non-random sample of 17 is too small to arrive at firm
20600 conclusions about the method. However our improvement rate at this
20700 point in time represents the best reported in the literature. Some
20800 cautions are in order. Language improvement represents only a first
20900 step. These children still need a lot of help and have a long way to
21000 go to reach whatever is their potential.
21100
21200 Why haven't other workers tried this zero-risk and
21300 potentially promising method? Aside from the inertia which all new
21400 methods must face, there are two reasons. One is that everyone has
21500 his own preferred method which he believes in and may wish to
21600 improve. The other involves people's beliefs and misconceptions
21700 about computers. I have come across people with the following fantasy
21800 about our situation -- that we have a small, cowering, bewildered
21900 child sitting in front of a towering bank of flashing lights {the New
22000 Yorker-cartoon concept of a computer} while cold scientists in white
22100 coats observe him thru one-way mirrors. They say "the child is
22200 already too interested in machines, he needs relations with people --
22300 you are making him into even more of a robot". I hope from my brief
22400 description you can see this is a misconception of our situation.It
22500 may sound paradoxical, but some nonspeaking children can become more
22600 human, i.e. become language users, by way of a machine which talks
22700 and which they find more acceptable on their own terms than they do
22800 talking humans.
22900
23000 A more realistic objection to computers is their cost. Few
23100 people in the world have access to million dollar computers for this
23200 sort of work. But a large computer is not necessary to carry out
23300 this method. Mini-computers costing only a few thousand dollars are
23400 adequate. It may be that we do not need a computer at all if someone
23500 found a way to rapidly random-access both sounds and pictures. We
23600 are investigating this possibility. Once we can get the unnecessarily
23700 Satanic image of the computer out of the picture , I hope others will
23800 join us in discovering more about this technique for treating
23900 nonspeaking autistic children.
24000
24100 REFERENCES
24200
24300
24400 [1] Churchill,D.W.,1972. The relation of infantile autism and early
24500 childhood schizophrenia to developmental language disorders
24600 of childhood. Journal of Autism and Childhood Schizophrenia,
24700 2,182-197.
24800 [2] Colby, K.M. and Smith, D.C., 1971. Computers in the treatment of
24900 nonspeaking autistic children. In Current Psychiatric Therapies,
25000 Masserman, J.H.(Ed.), Grune and Stratton, New York.
25100 [3] Fay, W.H., 1969. On normal and autistic pronouns. Journal of Speech
25200 and Hearing,36,242-249.
25300
25400 [4] Frith, U., 1972. Cognitive mechanisms in autism: experiments with
25500 color and tone sequence production. Journal of Autism and
25600 Childhood Schizophrenia, 2, 160-173.
25700 [5] Hermelin, B. and O'Connor, N., 1970. Psychological Experiments
25800 With Autistic Children, Pergamon Press, London.
25900 [6] Rutter, M., Bartak, L. and Newman, S., 1971. Autism- a central
26000 disorder of cognition and language? In Infantile Autism,
26100 Rutter, M.(Ed.), Churchill Livingstone, London.