Journal of Consulting and Clinical Psychology 1978, Vol. 46, No. 3, 586-587
Early Childhood Autism and Structural Therapy: Outcome After 3 Years Alan J. Ward Henry Horner Children's Center, Chicago, Illinois The effect of 3 years of structural therapy on 21 inpatient cases of early childhood autism (EGA) is examined. Treatment resulted in the discharge of 12 patients. Details of treatment procedure, therapeutic progress, and their effects on diagnostic and prognostic conceptualizations are presented. Comparisons are made among previous reports of attempted treatment of EGA, as well as the results of two other treatment units in the same setting. Results support the hypothesis that the high stimulation, physically intrusive, gamelike, novelty filled, and developmentally oriented treatment approach of structural therapy is capable of producing a significant improvement in cases of EGA.
This article is a preliminary report on the outcome of the application of structural therapy to the residential treatment of early childhood autism. The term early childhood autism (ECA) is used to include both the classically denned rare cases of early infantile autism (EIA), as well as the much more common cases of organic autism and the variously handicapped and/or disturbed children who are mistakenly labeled as suffering from EIA. The treatment of EIA is a topic that has usually aroused great feelings of futility. Examination of outcome data reported by both Bettelheim (1967) and by Eisenberg (1956) revealed strongly contrasting findings. Eisenberg's follow-up evaluation was divided into the three categories of poor, fair, or good outcome. Bettelheim has reported outcome figures on a group of 40 "autistic" children and has used the categories devised by Eisenberg. A good outcome was reported for 17 children (42%); a fair outcome, for 15 children (38%); and a poor outcome, for only 8 patients (20%). These outcome figures are in marked contrast to those reported by Eisenberg of 5% for a good outcome, 22% for a fair outcome, and 73% for a poor outcome. A new therapeutic approach labeled structural therapy (Ward, 1970) was used in the development of a treatment program for EIA children. Evaluation of the 21 original children in this
Requests for reprints and for an extended report of this study should be sent to Alan J. Ward, Henry Horner Children's Center, 6SOO West Irving Park Road, Chicago, Illinois 60634.
program revealed only 4 children who met the research definition of EIA, which was (a) lack of the development of object relations from birth; (b) lack of the use of speech for communication; (c) maintenance of sameness via stereotypic behavior with a rage or withdrawal reaction on interruption, and (d) no major neurological dysfunction. The behavioral characteristic of "lack of affective response" is one that was evaluated and agreed on by both me and the co-director of the program, H. Allen Handford. This evaluation was based on clinical interview, play observation, family interview, and review of clinical referral material that included social history, psychological evaluation, psychiatric evaluation, and pediatric neurological evaluation. The other children fell into the diagnostic categories of childhood schizophrenia (S) primary retardation ( 7 ) , secondary retardation (3), and developmental retardation associated with diffuse brain damage ( 2 ) . However, all of these children were found to display the behavioral characteristics of a "lack of affective response," whereas children from all five of the above diagnostic categories were found to display the characteristics of "lack of object relationships," "lack of the use of speech for communication," and of having come from an "unstimulating mother/infant relationship." The 4 EIA cases were distinguished from the other disturbed children by their combination of (a) lack of neurological dysfuncition and their (b) maintenance of sameness via stereotypic behavior. The total research unit was organized according to the precepts of structural therapy. The milieu emphasized spontaneous physical and verbal stimulation applied to the children in a playful and gamelike fashion. The goal of this approach
Copyright 1978 by the American Psychological Association, Inc. 0022-006X/78/4603-0586$00.7S
586
BRIEF REPORTS was to increase the amount of varied and novel stimulation received by these children and to use this increased stimulation to make them more aware of their external environment and to help them to progress from their positions of early developmental fixation. The physical stimulation was used to develop body image and bodily awareness and to help provide the body ego, which appears to be necessary for the development of higher ego functions. Twelve of the 21 children were seen in individual therapy on a twice weekly basis, although often the children were seen on an informal basis five times a week. Selected children were seen for sessions in speech therapy on a twice weekly basis for periods ranging from 3 months to 2 years. Families were contacted on a weekly basis by the social workers. Group counseling was provided on a biweekly basis for all of the parents, and the majority of them had a weekly day visit, overnight visit, or weekend visit with their child. The 'basic goal of this structural therapy treatment program has not been "cure" but development. EIA and EGA are viewed as severe developmental disorders of the same kind as are often observed with the rubella child, the blind child, or the deaf child. The basic etiology is considered to be rooted in a deficit of novel and varied stimulation for multiple reasons. This treatment program attempted to help these children to progress to the point where they achieved the goals of (a) relationships with people; (b) self-care such as toilet training, feeding, and dressing; (c) communication of simple needs in a consistent manner; and (d) the capacity to follow simple directions. The achievement of these goals revealed a child who was still functioning below age-appropriate level in regard to cognitive and affective behavior. The child was now at a point in development in which more conventional play therapy, speech therapy, and/or special education could be used. It was felt that these children should be viewed as being in the midst of their therapeutic course at the time of discharge. They were discharged at this point because the institution was no longer able to provide the needed therapeutic level of stimulation. Those children who were discharged to their homes in the community seemed appropriate for placement in Eisenberg's category of fair outcome. Each child was used as his or her own control in this research, but some comparisons will also be drawn with two other treatment units, in the same setting, that have attempted to work with autistic children (EGA). The application of 3 years of structural therapy
587
to the original group of 21 cases of EGA resulted in the discharge to homes in the community of 12 of the original 21 children (57%). These children were placed in normal nursery schools, special classes for the retarded or the emotionally disturbed in public schools and private schools, and sheltered workshops run by the local association for retarded children. The families were referred to the appropriate agencies for continued counseling. The experimental unit was Unit A, which had a population of boys and girls with a mean age of 8.9 years and 10.2 years, respectively, at admission and whose mean length of prior hospitalization was 1.08 years and 1.92 years. Inspection of comparable data on Comparison Units B and C revealed little difference as to mean age but a great difference as to length of prior hospitalization. These data suggest that the children on Unit A were more severely disturbed than those on Unit B or Unit C. The boys on Unit B had a mean age of 7.2 years on admission and a mean length of prior hospitalization of 6.5 months, whereas the girls on Unit C had a mean age of 8.9 years on admission and a mean length of prior hospitalization of S.9 months. Between September 1966 and September 1969, Unit A discharged 12 cases of EGA to home in the community, whereas Unit B discharged 2 boys and Unit C discharged 5 girls. A comparison of the outcome figures of Eisenberg and Bettelheim, vis-a-vis Units A, B, and C, revealed that Unit A exceeded both Eisenberg's and Bettelheim's results in regard to the percentage of children who achieved a fair outcome. Unit C's outcome rate of 25% approximated the outcome rate reported by Eisenberg (22%), but Unit B's outcome figure of 9% fell markedly below that. A classical, psychodynamically oriented psychotherapy and play therapy treatment was used in both Units B and C. The outcome figures of this preliminary study appear to support the hypothesis that structural therapy is capable of producing significant therapeutic change in children classified as having EGA. References Bettelheim, B. The empty fortress. New York: Free Press, 1967. Eisenberg, L. The autistic child in adolescence. American Journal of Psychiatry, 1QS6, 112, 607-612, Ward, A. J. The application of structural therapy to the residential treatment of early infantile autism. Schizophrenia, 1970, 2, 92-102.
Received October 3, 1977 •
Early Childhood Autism and Structural Therapy: Outcome After 3 Years Alan J. Ward Henry Horner Children's Center, Chicago, Illinois The effect of 3 years of structural therapy on 21 inpatient cases of early childhood autism (EGA) is examined. Treatment resulted in the discharge of 12 patients. Details of treatment procedure, therapeutic progress, and their effects on diagnostic and prognostic conceptualizations are presented. Comparisons are made among previous reports of attempted treatment of EGA, as well as the results of two other treatment units in the same setting. Results support the hypothesis that the high stimulation, physically intrusive, gamelike, novelty filled, and developmentally oriented treatment approach of structural therapy is capable of producing a significant improvement in cases of EGA.
This article is a preliminary report on the outcome of the application of structural therapy to the residential treatment of early childhood autism. The term early childhood autism (ECA) is used to include both the classically denned rare cases of early infantile autism (EIA), as well as the much more common cases of organic autism and the variously handicapped and/or disturbed children who are mistakenly labeled as suffering from EIA. The treatment of EIA is a topic that has usually aroused great feelings of futility. Examination of outcome data reported by both Bettelheim (1967) and by Eisenberg (1956) revealed strongly contrasting findings. Eisenberg's follow-up evaluation was divided into the three categories of poor, fair, or good outcome. Bettelheim has reported outcome figures on a group of 40 "autistic" children and has used the categories devised by Eisenberg. A good outcome was reported for 17 children (42%); a fair outcome, for 15 children (38%); and a poor outcome, for only 8 patients (20%). These outcome figures are in marked contrast to those reported by Eisenberg of 5% for a good outcome, 22% for a fair outcome, and 73% for a poor outcome. A new therapeutic approach labeled structural therapy (Ward, 1970) was used in the development of a treatment program for EIA children. Evaluation of the 21 original children in this
Requests for reprints and for an extended report of this study should be sent to Alan J. Ward, Henry Horner Children's Center, 6SOO West Irving Park Road, Chicago, Illinois 60634.
program revealed only 4 children who met the research definition of EIA, which was (a) lack of the development of object relations from birth; (b) lack of the use of speech for communication; (c) maintenance of sameness via stereotypic behavior with a rage or withdrawal reaction on interruption, and (d) no major neurological dysfunction. The behavioral characteristic of "lack of affective response" is one that was evaluated and agreed on by both me and the co-director of the program, H. Allen Handford. This evaluation was based on clinical interview, play observation, family interview, and review of clinical referral material that included social history, psychological evaluation, psychiatric evaluation, and pediatric neurological evaluation. The other children fell into the diagnostic categories of childhood schizophrenia (S) primary retardation ( 7 ) , secondary retardation (3), and developmental retardation associated with diffuse brain damage ( 2 ) . However, all of these children were found to display the behavioral characteristics of a "lack of affective response," whereas children from all five of the above diagnostic categories were found to display the characteristics of "lack of object relationships," "lack of the use of speech for communication," and of having come from an "unstimulating mother/infant relationship." The 4 EIA cases were distinguished from the other disturbed children by their combination of (a) lack of neurological dysfuncition and their (b) maintenance of sameness via stereotypic behavior. The total research unit was organized according to the precepts of structural therapy. The milieu emphasized spontaneous physical and verbal stimulation applied to the children in a playful and gamelike fashion. The goal of this approach
Copyright 1978 by the American Psychological Association, Inc. 0022-006X/78/4603-0586$00.7S
586
BRIEF REPORTS was to increase the amount of varied and novel stimulation received by these children and to use this increased stimulation to make them more aware of their external environment and to help them to progress from their positions of early developmental fixation. The physical stimulation was used to develop body image and bodily awareness and to help provide the body ego, which appears to be necessary for the development of higher ego functions. Twelve of the 21 children were seen in individual therapy on a twice weekly basis, although often the children were seen on an informal basis five times a week. Selected children were seen for sessions in speech therapy on a twice weekly basis for periods ranging from 3 months to 2 years. Families were contacted on a weekly basis by the social workers. Group counseling was provided on a biweekly basis for all of the parents, and the majority of them had a weekly day visit, overnight visit, or weekend visit with their child. The 'basic goal of this structural therapy treatment program has not been "cure" but development. EIA and EGA are viewed as severe developmental disorders of the same kind as are often observed with the rubella child, the blind child, or the deaf child. The basic etiology is considered to be rooted in a deficit of novel and varied stimulation for multiple reasons. This treatment program attempted to help these children to progress to the point where they achieved the goals of (a) relationships with people; (b) self-care such as toilet training, feeding, and dressing; (c) communication of simple needs in a consistent manner; and (d) the capacity to follow simple directions. The achievement of these goals revealed a child who was still functioning below age-appropriate level in regard to cognitive and affective behavior. The child was now at a point in development in which more conventional play therapy, speech therapy, and/or special education could be used. It was felt that these children should be viewed as being in the midst of their therapeutic course at the time of discharge. They were discharged at this point because the institution was no longer able to provide the needed therapeutic level of stimulation. Those children who were discharged to their homes in the community seemed appropriate for placement in Eisenberg's category of fair outcome. Each child was used as his or her own control in this research, but some comparisons will also be drawn with two other treatment units, in the same setting, that have attempted to work with autistic children (EGA). The application of 3 years of structural therapy
587
to the original group of 21 cases of EGA resulted in the discharge to homes in the community of 12 of the original 21 children (57%). These children were placed in normal nursery schools, special classes for the retarded or the emotionally disturbed in public schools and private schools, and sheltered workshops run by the local association for retarded children. The families were referred to the appropriate agencies for continued counseling. The experimental unit was Unit A, which had a population of boys and girls with a mean age of 8.9 years and 10.2 years, respectively, at admission and whose mean length of prior hospitalization was 1.08 years and 1.92 years. Inspection of comparable data on Comparison Units B and C revealed little difference as to mean age but a great difference as to length of prior hospitalization. These data suggest that the children on Unit A were more severely disturbed than those on Unit B or Unit C. The boys on Unit B had a mean age of 7.2 years on admission and a mean length of prior hospitalization of 6.5 months, whereas the girls on Unit C had a mean age of 8.9 years on admission and a mean length of prior hospitalization of S.9 months. Between September 1966 and September 1969, Unit A discharged 12 cases of EGA to home in the community, whereas Unit B discharged 2 boys and Unit C discharged 5 girls. A comparison of the outcome figures of Eisenberg and Bettelheim, vis-a-vis Units A, B, and C, revealed that Unit A exceeded both Eisenberg's and Bettelheim's results in regard to the percentage of children who achieved a fair outcome. Unit C's outcome rate of 25% approximated the outcome rate reported by Eisenberg (22%), but Unit B's outcome figure of 9% fell markedly below that. A classical, psychodynamically oriented psychotherapy and play therapy treatment was used in both Units B and C. The outcome figures of this preliminary study appear to support the hypothesis that structural therapy is capable of producing significant therapeutic change in children classified as having EGA. References Bettelheim, B. The empty fortress. New York: Free Press, 1967. Eisenberg, L. The autistic child in adolescence. American Journal of Psychiatry, 1QS6, 112, 607-612, Ward, A. J. The application of structural therapy to the residential treatment of early infantile autism. Schizophrenia, 1970, 2, 92-102.
Received October 3, 1977 •
