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Reprirtted lrom'British Iournal ol Mental subnormalit;.,, vol. xvlI, parr2, No.33, Dec.

l97l

THE PHYSICAL ENVIRONN,IENT OF


THE MENTALLY HANDICAPPED
*lv-A PLAYROOM FOR Au1gg1la CH|LDREN, AND tTS
COMPANION THERAPY PROJECT
synthesis of ideas from ethotogy, psychology, nursing
-a and design
,^_,!lr, l^ou\1h paper in this series is an example ol environmental manipulation
ctesigned.to_change the behaviour of children who are notoriously dillicult eiiilio
1lp^i?!i!. !,!.:: q good exampte of a mutti-disciptinary approiii''to i'r"ry difficuit
probtem which is treated lrom a new point of view._Thb fanr.

Research p,v.r, oro J9Hif; [::fi :l Henrey-on-rhames


and Department of psychology, Reading University

rnterior Design or Art, London


l. Autistic Childre4.
",o",lJ:"1,"fil"it:?:*
.^-, this paper.we shall say that two things importantry charac-
terlseI9ll.t:.puJp.,o,ses.of
autlstrc chlldren. They are the result of extensive ethologicil observation of
these children.

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
\.\.
I fixed tobles
ond benches
Y drinking fountoin
lllil- 10 tv / rodio/r€coi d
T ploye r/ storoge
serving hstch
I

il

ll o
il-
-JL-
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.

? Soft seats and pad.siton


dren may lie, cu.rl
the PVC covered foam rubber soft seats and pad chil-
with adults and other children. These sorts of ve;y simple
|p,
rnteractions, and what may arise from them, may be achieved in comiort and ease,
which tends to lower arousal and facilitate inie:action. This eflect is further en-
hanced by soft_cushions and olc fur coats-the value of soft things to young chil-
dren being fairly well accepted.
The solt area also provides a good alea for rough and tumble play, the children
may be thrown on the pad, etc.
3. Activity house. Tiris has iivo levels. On the ground floor there rs an entrance
under the slide and a hole to the uppei floor. The upper floor has four exits: to the
slide, to the slot steps, to the rope ladder, and to the pole, which has a circular
mirror above it so that the,children may see themselves going away from themselves
as they slide down the pole on to the PVC covered foam iubbei pad below. This
structure capitalises on the autist's agility, caution and Dropensiiy to engage in
climbing, slidin-g, and other simple but active behaviours. Th6 houie is larglel*y en-
closed, except for the entrances/-exits and a few peepholes, and so, especiall! at the
lower level, provides a barrier to stimulation from outside.
-. -It was hoped that the children, whilst engaging in the rewarding activities of
climbing, etc., would come up against each othei, and that this would' increase the
frequency of rewarding interactions.
4. The walkway. This is another fairly active area. It is a connection between the
two main halves of the room, one of which, since it contains the activity house, is
essentially aclive; whilst the other half is quieter and intended for less active be-
haviour. The walkway has the interest of being a raised area. It may be sat on,
walked alon_e, have things rolled along it, be stood on whilst attendins to the
stimulus wall. etc.
5. Stiinulus wall, mirrors, light box. These were intended to amuse and relax the
chil-{ren b.y providing simple, sometimes_repetitive, unchallenging yet absorbing
feedback, in the same way as, but more effectively than, stereotypies.
6. The blackboard. This was included as autists, like normal children. often seize
the opportunity to draw, especially on a large surface.
7. PVC covered foam rubber building blocks. These were I foot cubes, or 2ft. x
lft. x lft., or cylinders-2ft. lo_!g and lft.diameter. They were large enough to be
built as enclaves, etc., but suftciently light and soft to be throrvn around, pushed
over, sat on, etc., without danger. It was thought that their sheer size would make
them "satisfying" to use.
8. Fixed tables and continuous benches. These are mainly for meals but may be
used for table games, construction toys, etc. Because they are fixed to the ffooi the
children cannot create noise and sudden movement by oushing them around during
meallimes. That the benches are continuous acts as mild disincentive to swivellinl
around and jumping up and running away. Food is served from an adjoining kitchei
via a hatchway. All this helps to cut down unnecessary stimulation and distractions,
and reduces the need for staff to bring children back to their places and reprimand
them for being disruptive. It facilitates the acquisition of the requred tible be-
navlour

6
Fixed tables and continuous bench, hatch and drinking fountain in background

Soft seat, walkvvay, slide


9. Drinking fountain. This was included since autistic children seem to want to
drink freq.uentty. Ie h-opeg.!q remove this possible sourc€ of irritation by having
water available when the child wanted it.
10. General points.-All structures are robust, safe and easily cleaned. Lights are
recessed into the ceiling to avoid their being broken or swung on, they aie fitted
with dimmer switches, out of reach of the ihildren, to allod the room ro be lir
softly..which_helps de-arousal. All cupboards are lockable and do not have hancl:s,
so children do not have to be stopped from rummaging. The television, radio and
record player are housed in such Cripboards. All the Toalm rubbe; ite:rrs a;e coveied
with tough washable PVC. All these factors relieve staff from a mere custodial
role, since, broadly speaking, what the child can do is safe and not destructive.
Behaviour of Staft in fhe Playroom
when it was completed, oue of us (J.M.R.) discussed with staff how the plav-
room might be uied. The essential points we wished to ger across we:e thai tie
children were to be allowed to explore the, room in their own time, and they were
to be allowed to do whatever they wanted regardless of how pointless, absurd or
repetitive it seemed. There is no "proper" way-of using any of ihe structures. Since
the struciu:es weie robust and safe, there would be no nedd to stop children doing
c.erta-i+ things, Inrted if it looked as if a child was about to destr6y somelhing hi
should be allowed to try. If he failed because the stiucrure had 'isucceeded,; he
would be unlikely to. try again and a reprimand had been avoided. If he succeeded
a weak point in the design had been revealed and ought to be remedied.
Staff were asked not to make unnecessary approaches to the autistic children.
However, they should accept any approach the ahild made and interact as far as
possible in .the. way the child seemed to be asking. This does nor imply that they
should not be inventiv.e but merely they- should nof try to foree a child't5 do thingi.
since looking -at a child is an approach behaviour, fhis should be avoided r".."pt
when the child seems very motivated to approach.
Children in the Playroom
The playroom was the "home" room for l0 children resident at Smith Hosoital.
Six conform to Kanner's syndrome, two might be called autistic in a wider iense
of the term, and two were not autistic, but severely disturbed. Their ages ranged
from 4 to ll at the time of conversion. Ail slept in the unit for most oi the wEek
and some went home at weekends. All went to occupational/training sessions from
9.30 to 11.45, and from 1.30 to 3.30. For much of ihe resr of the iime they lived
in. the- playroom. In the summer they weie usually outdoors when the weathLr per-
mitted.

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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BABABABA
sterectypies rnteroctrons opprooches obJectmonipulstions

f rg 3. Results ot time sompling study


B: beto{-e , A:ofter convension
H = outists (6 Ss) o----. = non-outists(4 Ss).
Other observations.
The children's general behaviour in the room was obseived. Some teriitoriaiity
developed. For instance, one girl spent most of her time, for the first three or four
months, lying on the seat in the alcove. When anybody approached she tried to
push them away. She occasonally made forays into the rest of the room, but when
upset retreated-to this seat and, rolling back and forth on her side, soon quietened
dbwn if left alone. She now no longer spends such a lot of time on that seat but
mixes more with other children, gives people much more eye contact than before,
and delighted her parents by greeting them with eye contact and smiling.
Most of the structures were used in the ways we expected. There were some
exceptions. For the first six months the retreat box was hardly used. One girl-would
go in there fleetingly to put things in, but no one stayed for any length of time.
Some just swung on ttre- door. Then one 6 year-old autist took a srnall ,dog on
rockeri in there and stayed in there for a long time with the door closed. He now
quite frequently goes in there for periods of up to half an hour. If the door is
dpened by another child he may be seen sitting on the dog and perhaps rocking.
The only real fgrilure was the drinking fountain, which u'as installed incorrectly
and as a result floijded. Als6-water was splashed around and no provision was made
for floor drainage or protection of the adjacent walls. Consequently it had to be
turned off. The other partial failure was that the PVC covers did not turn out to
be bite-proof, and one was ripped. However, all assaults on covers ceased com-
pletely after one week.
The dining area has been successful in cutting down such behaviours as_jumping
up and runnin-g away, throwing water and food atound, and tantrums. Mealiimes
seem to pass 6ff more smoothly and quietly. This is often helped by playing a
"soothing" record quietly during meals.
The most successful area is the soft pad. This attracts a lot of children, es'
pecially in the evenings when the lights are dimmed or out, and only a.green spot-
iigt't piayr on the pad.from above. and-perhaps.the television is on. They curl up
airongst'fur coats, cushions, adults and each othei. Th-ey aie quiet, close to each
ottrer,"and yet seem relaxed. It is a fair hypothes]s that-they are learning to.be close
to other people and relaxed at the same time. It could even be called relaxation/
desensitisation therapy! (cf Graziano and Kean, 1968).
The ward sister has noted great changes in the behaviour of some of the chil-
dren. Some of the six autists now tolerate being close to other peoOle for long
periods without becoming unduly tense, th.ey sometimes engage in_ eye con:act for
'as
long as ten seconds. ttrey witt play simple tickling and stroking games and
solicit ihese, some will even make apDroaches to other children, with eye contact
(and without the aim of, for instance, snatching something away), .and perhaps
play touching or chasing games or just touch the other child in an exploratory way.
Att'tttit was-virtually unknown before the regime.

Summary and Conclusions


This project constitutes an attempt_ to construct -a "prototype playroom" for
autistic chilOien, which might be copied, with suitable alterations, in other units,
-concerned
eyen those not specifically with autistic children. The design solutions
are not in themselves particularly novel.
When we designed this playroom we viewed it not as a comp.lete therapeutic
environment in its;ff, but rathel-as a neressary precondition-the physical enviro-n-
ment precondition-to successful therapy. The tenor of this therapy is to accept the

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"
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