Professional Documents
Culture Documents
l97l
F","fi:,tt point is rhat autistic children are very wary of approaching other
pgol]..'^Jf they approach they usually do so withoui looking at 'tlie other "p.rson.
I hey
-attempt to break .away as soo_n as the slightest hitch or pause interrupts Ltr-
easy flow of the social.interaction. In agonistic'(aggressive) enJount"rs ttrey'neaiiy
always .lose, and usually act to avoid s[ch encouiilrs. Thiy are at the udttom oi
the social dominance h_ierarchy. In ethological languge they may be described ai
being_.Predominantly _ffjght niotivated" (eurrie arid -Branriigan, tbTol ti"u.ig."
and Tinbergen, l97l; Richer, a; and see Hutt, 1970).
Flight behaviours are attempts to escape from or avoid a social interaction.
The most common examples are "moving gwy.y,-" "turning away" ot ..tooiing away;;
from the other person. The autistic chi-ld's "hloofness"-and
"'abnormal belivioirr
,.withdrawal,,
lgry?.rdr people as persons" (Creak et at, l96l) and his (O'G;;;;;,
1964) are the impressions we, as socially interac.tive individ.uals, get on_ i..ing ifr"i.i
behaviours. (To put it loosely, the chiid is giving us the impression he is iot in-
terested in us, because, at that particular m-omeit, he wantj to be left aronet. in
fact, autistic children are very vigilant for the aqproaches of orhers ano urii ,o
active to what-is going,on around them. They di'ffer from normal children in that
they react predominantly by trying to escape or avoid, rather than approacl,.
.The second- point is closely related to the first. It is that autistic children are
muSh-more^"-"^tilv_ frustrated and over-aroused compared to normat Ctritaren-iffuit
and Hutt, 1968; Richer, a & b), j.e., t!e^y are made'tense and anxious more eisily.
ld_tny.kinds of event may lead to this. Some of the more important are the
following:
(l) Being thwarted.
(2) Being near others and in an approach/avoidance conflict.
*The previous articles in this series were:
,I-"Progres_s in_Building for-the..Mentally Handicapped" (J. M. pedersen, Denmark), Dec. 70
Il-"From Ward to Living U.nit" (Coldeest Uospitat'nesign f"^rn, U.X.), lune 7i.
III-"A Test Ward for Mentally Retarded,'(K. GrunewelA, S".a.il, lunl Zf .
(3) pelng near others and unable to get away, being overciowded.
({) Being looked at,, or in some way approached by another person.
(ll P"jng reprimanded by an adult, of lttacked oi threatened by another child.
(6) Being subjected to a lot of extraneous unpredicrable stimulaiion.
(7) Being required to do somerhing too difficrjlt.
(8) Having very little to play with.
All these situations are potentially frustrating and arousing for normal children,
and conversely autistic children do not, on all-occasions, bJhave as if frustrated
and overaroused in them. The difference lies in the degree and exient of the autists'
reactions.
The degree of the autist's frustration and overarousal may be assessed from:
.
(i).the degree to.which he peiforms "cut-off" acts (chance, isozl, such as putring
his hands over his ears or looking away. These are behaviours which cui dowi
noxious stimulation;
(ii) the degree to which he otherwise tries to escape from the situarion.
and
(iii) the frequency and intensity with which he performs stereotyoied behaviours
such.as rocking,.tgtrling, fi_4ger play, twiddling pieces of string, sfiinning, erc., or
certa in stereotypied postures.
These are thought to be the same as displacement activities (Hutt and Hutt, 1968).
All these behaviours, and in_particular, stereotypies, are probably attempts to
reduce frustration and arousa! (Hutt and Hutt, 1968; Williams, 1969; Delius;1967
and 1970: Richer, b). Normal children perform almost all these behaviours, the
diffeience again lies in the much reduced frequency and intensity rvith which they
perform them compared with autistic childien (Hutt, 1970).
These two characteristics we have mentioned seem to be closely related insofar
as when the autist is overaroused and frustrated he is less likely to approach and
interact with another peison, than when he is less aroused. This is iuegested by
the obse;vation that thi frequency of stereotypies is lower, the greater thdirequency
of the child's approaches to, and interactions with. another person, and vice versa
(Greenbaum, 1970 Richer, a).
It is thought that autistic children are retarded and have difficulty acquiring
skills, especially social skills, which includes speaking. for two main reasons.
(a) They find being with, and interacting with, people stressful, and do not tolerate
being with and attending to people for long enough to imitate and learn skills, es-
pecially language skills.
(b) They are often too frustrated and overaroused to be able to explore (Hutt, 1969)
let alone play, or to be able to concentrate on a learning task. In such a state they
manage to do only the simp_l-est and mos! practised activities, such as stereotypies
(Yerkes and Dodson, 1908: Hebb, 1955: Bindra, 1959; Hutt and Hutt. 1968).
Goals
We have ourlined our general position on autism, since it seems essential to
have some idea of the nature of the group one is designing for, before one can
assess what is needed. The ethological approach lends itself well to this, since a
large amount of time is spent observing subjects in their everyday environments.
For a classic discussion of the aims and methods of ethology the reader is referred
to Tinbergen (1963).
Inextricably bound up with a project such as this are the ideais or goals we
have relevant to it. Changing an environment usuaily changes behaviour, and since
we want to change it, we must have some notion of what we want to change it to.
When designing for "normai" people this involves tricky problems of morality.
politics, etc., bul here the issue is relatively clear cui: autistic children are regarded
2
as ill and so our goal is health or normality. In particular we want to increase
soctal approaches and interactions and reduce the child's frustration and arousal.
As we have hinted at earlier these states are regarded as basic in the autist's illness;
if these.are improved then many other improvlments follow in their train. For in-
stance, if the child is less motivated to avoid another person, and more motivated
to app.roach, there is good evidence to suggest that he will, spontaneously, also begin
to imitate,. play and-try to speak; thi;gs which, visibly,'autists do only rare'ly.
Agaln, rf the autlst is more relaxed he is likely to learn things quicker and to be
able to tackle more difficult tasks. This approaih, in which wJatGmpt to influence
the basi: motivations and, states of the child, in the belief that many dther improve-
ments will come naturally, may be contrasted with, say, behaviour modif'action
techniques. which work away at one behaviour pattern afier another without much
consideration for the state of the child or the frjnction of the behaviour pattern. It
remains to be seen which is the more economical and the more effectivi.
General Means
We tried to achieve the two basic goals of increasing approaches and decreasing
arousal, in the following general ways.
1. Reduction of frustration and arousal.
(u) The room is subdivided into connected parts. This cuts down overstimula-
tion (which is worse in_autists than normals) due, in part, to the presence of others.
compared with normal children autists have a much larger "soiial space," which
is the area around them they do not like others to enter. A moie draitic cut-down
of stimulation is achieved.by the."retreat box"-a dark area the child may shut
himself in. As we have. s_aid, autists,frequently perform "cut-oft" acts, they also
try to buiry themselv-es_little enclaves (as d^o noimlt children but in a slightlyiitrer-
ent way). By cutting-off areas one from another we are reducing the aro[sing effects
of other people, and reducing the need for "cut-off' acts.
(b) Autists are agile, dextrous. and cautjous, they rarety hurt themselves by
accident. Moreover they seem to enjoy activities such is climbing, sliding, etc. pro'-
vision has been made for this. If he is absorbed in activities such-is thesel the autist
is less likely to be overaroused and mo:e likely to interact with others.
(c) It has been said that many autists fre{uently engage in stereotypied activi-
ties' No attemp_t i-s made to stop these since they aie thlight to servi -an arousal
reducing -role.. Indeed, "toys" which, like stereoiypies, provide simole predictable
or-unchallenging and sometimes repetitive feedbaik ar-e included in air eftort to
reduce arousal more effectively.
(d) All structures are robust, safe, and most are fixed down. This avoids the
noise and confusion engendered by breaking, knocking over or pushing big things
around the room.
2. . Re.duction of flight behaviours and facilitation of approaches and rewarding
social interactions.
(a) Since all structures are robust, safe, and easily cleaned, staft do not have
c-ontinually. to stop children doing things for fear they might hurt themselves or
damage.things in the room. Their role can change from a-negative custodial one
to a positive therapeutic one.
(b) The contact and interaction autists usually seek is of two sorts. They may
seek close tactile contact, sitting on the lap of an adult clinging closely and avbiOin'g
eye contact; or alternatively, thgv may solicit rough and tumute play and want t5
be thrown around, lifted uo, tickled, etc. Areas are provided in whici the children
-
may be given these sorts of contact and interaction.
(c) There are areas where the physical confines of the structures mean that, if
two children are there, they are-close together and. as in the activity house (see
below), are likely.to be eng.aged in a rewarding activity. This may'increase the
frequency of positive social inte:actions.
'I retneot box
soft seots & p\cd
octivitY nouse
wo lkwoy
3 stimulus wsll
m m i rrons
blockboo rd
lN. \N
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I fixed tobles
ond benches
Y drinking fountoin
lllil- 10 tv / rodio/r€coi d
T ploye r/ storoge
serving hstch
I
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f iq.1 PLANSTPLAYROOM & WARD
oxono metric
of ployroom
tor key. see
The Playroom
The project had three main con'
stralnls.
(i) The site. This was far from ideal
(see Fig. l).
(ii) The amount of money available.
This was just over f1,000. It was
donirted by the League of Friends of
Smith Hospital.
(iii) The nature of the nursing care
siven and how the use of the room
frtted into the life of the hospital as a
whole.
The staff-child ratio varied from
between1-l to l-10.
The room was intended as the chil-
dren's home room. in which no for-
mal training was to be given, since
this took place elsewhere. The child
was free to do what he wanted (if the
room provided the means) and free
from adult intervention. This con-
trasts markedly with the accommoda-
Activity House tion before conversion. Then the
children were continually being
stopped from doing things for fear
they would hurt themselves or destroy
furniture, etc. The result was that
there were few toys around since
those put out, berng inadequate, were
soon smashed, and the room was fur-
nished with chairs and tables whose
play possibilities were severely limit-
ed. It was difficult for a child even to
sit with someone since most of the
chairs were narrow and had hard
arms. In the dining room the chairs
and tables were easily moved around,
which made a lot of noise. and a child
sitting at table might have it pushed
into his stomach by the child opposite
him. In this srtuation the children
quickly became frustrated, over-
aroused, they were eftectively over-
crowded, and people were mainly
sources of frustration. This does not
improve the autist child's condition,
neither is it a particularly easy or re-
wardins environment for staff to work
in. Th; new design attempted to
remedy these faults and construct a
Retreat Box positive therapeutic environment.
we shall now describe the structures in the room and say something abour
their intended functions (see Figs. I and 2).
L Retreat box. This is a dark enclosed area that the child may shut himself in.
It is intended as an extreme de-stimulation/de-arousal area. In thlre the child miy
shut himself away from other people and other arousing stimulation.
6
Fixed tables and continuous bench, hatch and drinking fountain in background
Results
A time samoling study of four categories of behaviour was carried out in the
old playroom a few months before conversion, and in the new playroom a few
weeks after conversion. The categories of behaviour were as folldws:
(i) Stereotypied activities and postures.
(ii) Sociat approaches to another clrild or adult. Behaviour such as lookine at
another person could not be reliably assessed and so was not scored.
(iii) Interaction with another person. In this category one person must not be
merely passive, each must react to the other.
(iv.) Obiect manipulations. This includes a non-stereotypical manipulation of the
.
physical environment such as toys, fixtures, structures, eii.
Each child was observed for 10 consecutive l5-second periods. and it was noted
whether or not the behaviour in each category occurred at ieast once in that period.
8
Thus for each category there was a maximum score of 10. The children were ob-
served in the free play sessions once after lunch and once before tea. The observa-
tion periods for a child were randomly determined, This procedure was repeated
at least four times for each child, so that a child's maximum score for each category
was at least 80.
The average score out of l0 for each category and for each of the autistic chil-
dren was calculated. Scores achieved in the new playroom were compared with
those achieved in the old (Fig 3).
The results were as follows:
__ (i) Stereotypied behaviours were less frequent in the new playroom (p{.025,
Wilcoxon matched pairs signed ranks test).
(ii) Interactions were more frequent in the new playroom (pq.025, Wilcoxon).
(iii) Approaches and object manipulations showed no significant change, how-
ever these were the less reliable measures.
These results were interesting in view of the instructions given to staff, namely,
not to approach the children and not to stop stereotypies. The results were in the
direction we predicted.
The time sampling measures also differentiated between the six children in
the autistic group anj the other chrldien, i.n the following ways:
(i) ltereotypigd behaviours were more frequent in the autistic group (p<.01,
Mann-Whitney U Test).
- (ii) Interactions were less frequent in the autistic group (p<.033, Mann-Whitney
U test).
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10
autistic child's retardation, dearth of social skills, his wariness of people, and his
propensity to become very tense and highly aroused. We wished to let the child
grow slowly from what he can do, from how he can interact with others, to more
normal behaviour; rather than assuming that if we put him in a "normal" or "home-
Iike" physical environment (whatever that is) he will adapt, if he is left in for long
enough. This may sound trivial, but it is often forgotten in practice by people
anxious that the autistic child should learn to deal with the "real" world, despite
the fact that the child is severely mentally crippled.
Once the child has become less flight motivated and tolerates people more,
attends to them more, and so on, we can begin to use social reinforcers (instead
of the very inconvenient smarties) as part of programmes to teach the child certain
things, just as they are used with normal children. We can also use the child's in-
creased propensity to imitate, play, try to speak, and so on. This approach demands
of staff that do not do what is, perhaps, their first impulse to do, namely to try and
interact with these "stand-offish" children. This is the most straightforward and
socially acceptable way of showing concern and affection, but it is probably not
the most productive.
Judging the success of a project such as this is extremely difficult since it is
impossible to control'-a sufficient number of factors. However, it seems, from the
measuies taken, and from the observations of one of us (J.M.R.) and members of
the staff, that some considerable advances have been made, which are sufficient
to warrant considering expanding the project. But it is only after a few years that
we shall see how successful we have been.
Acknowledgements
The authors would like to thank the League of Friends of Smith Hospital, who
paid for the playroom. The playroom was constructed by Golden Hill Workshop,
Bristol.
We are indebted to Mrs. M. Clarke, the ex-matron, and Mrs. M. Souleyman,
the ward sister, for their invaluable help and ideas; to Dr. O'Gorman, the physician
superintendent, for his permission and help; and to Mr. Mason, the St. Birinus
Group Chief Engineer, who sped the work on its way.
J.M.R. would like to express his thanks to Professor and Mrs. Tinbergen for
allowing him to read a pre-publication draft of their paper, and for very helpful
discussions, especially for clarifying many treatment ideas.
Further Information
A model of this playroom was shown at the Exhibition of Playthings
for the Handicapped Child at the Royal College of Art in Aptil 1971. Parts of this
exhibition, including the playroom model, are to tour the countrY in the winter of
l97ll2, under the auspices of the National Fund for Research into Crippling
Diseases.
Enquiries about the playroom should be directed to John Richer, Smith Hos-
pital, Henley-on-Thames, Oxon. Henley 2678.
l.l
Relerences
Bindra, D. (1959). An interpretation of the displacement phenomenon' Brit. l. Pqclrcl'' 56'
263-268.
Chance, M. R. A. (1962). An interpretatio_n of- some ago,nistic postures: the role of "cut-off"
acts and postures. Svmp. Zool. Soc., London, 8' 7l-89.
crcak. M. et al (1961). Schizophrenic syndrome in childhood. Progress report of a working
pirty (April, 196l). Cerebral Palsy Bull" 3, 501-504.
Currie, K. H. and Brannigan, C. R. (1970). Behavioural anall-sis an!-modification in an autistic
--^'i,-fiiiA. 7i Eiioiio"7 Sl"iii ii Piycttiatry, eds. Hutt, S. j. and Hutt, C. Pergamon' Oxford'
Delius, I. D. (1967). Displacement activities and arousal. Ncture, 214, 1259-1260.
Delius, J. D. (1970). lrrelevant behaviour, info.rmation processing, and arousal homeostasis.
Psychol. Forsch., 33, 165-188.
with
Graziano, A. M. and Keen, I. E. (1968). Progra-mmed relaxation and reciprocal inhibition
psycliotic children. Behav. Res. 7'lter', 6, 433-437.
Hebb, D. o. (1955). Drives and the c.n.s. (conceptual nervous system). Psychol. Rev.,62,
243-254.
Hutt, C. and Hutt, S. L (1968). Stcreotypy, arousal and autism. Human Developntent, 11,
277-286.
Hutt, C. (1969). Exploration arousal and autism. Psychol' Forsch',33' l-8'
Hutt, C. (19?0). Autistic children. New Society.
O'Gorman, G. (t964). The nature ol childhood autism. Butterworth'
Richer, J. M. (a). The social behaviour of autistic children-an ethological study. In manuscript.
Richer, J. M. (b). Frustration behaviours of autistic children' In prep'
Tinbergen, N. (1963). On the aims and methods of ethology. Z. Tierpsychol.,20,410-433.
Tinbcrgen, E. A.6nd Tinbergen, N. (1971), Social interactions in normal and autistic children.
In Tinbergen, N., r/ie animal in its world-fort\')'ears ol exploratory behaviour of an etholo-
grst. Allen & Unwin. In Prcss.
Williams, C. (1969). Unpublished M.Sc. Thesis. Univ. of Birmingham'
yerkes. R. M. and Dodson, J. D. (1908). The relation of strength of the stimulus to rapidity
- of 'nabit formation. t. Comp. I'ieurol. Psychol., 18' 459-482'
t2