Language Construction in an Autistic Child .8

“Language Construction in an Autistic Child: Thoughts Regarding Language Acquisition and Language Therapy”: Translation, Update, and Commentary on a 1977 Case Report Hellmut Thomke, PhD* and Katharina Boser, PhDw Abstract: A 1977 Swiss case study is presented in English translation: a mute child with infantile autism is taught to speak starting at the relatively late age of 6. The author, who is the primary therapist and the child’s father, de
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  “ Language Construction in an Autistic Child: ThoughtsRegarding Language Acquisition and Language Therapy ” :Translation, Update, and Commentaryon a 1977 Case Report Hellmut Thomke, PhD* and Katharina Boser, PhD w  Abstract:  A 1977 Swiss case study is presented in Englishtranslation: a mute child with infantile autism is taught to speakstarting at the relatively late age of 6. The author, who is theprimary therapist and the child’s father, details the conditioningprocedure, discusses theoretical considerations in speech acqui-sition, and outlines the limits of the training. The author andtranslator update the child’s status and add commentary. Key Words:  autism, conditioning, language acquisition, speechtherapy, nonverbal( Cog Behav Neurol   2011;24:156–167) INTRODUCTION AND TRANSLATOR’S NOTEKatharina Boser (KB) The core of this paper is KB’s translation of a 1977article by Thomke, 1 then a professor of GermanLiterature and Language at the University of Bern,Switzerland. Dr Thomke was reporting on his use of operant conditioning to teach language to his son,Heiner, who had nonverbal autism. Both father and sonare identified by name here because they were named inthe srcinal publication.At the time that Heiner was diagnosed, manycontemporary accounts of improved speech productionin autism were claiming that if affected children could notspeak by age 5, they would never be able to learn tospeak. 2–4 The perception of a “critical period” forlanguage development has continued despite evidence of older children acquiring speech. In fact, a 2009 literaturereview by Pickett et al 5 documents 14 studies in which 15children aged 5 or older, including Heiner Thomke, weretrained to speak spontaneous multiword or phrasalutterances. 3,6–17 The reviewed studies used many methodsto aid speech/language development, among them signlanguage and special prompting techniques. Higherpretraining intelligence quotient scores, ability to imitate,and other individual characteristics may have given someof the children a potential advantage over Heiner. Pickettet al 5 confirmed that longer therapy generally correlateswith a higher level of language attainment, and specifi-cally that children need at least 3 years of therapy to reachthe highest level, which is spontaneous phrases. (Heinerhad 2years and 3months of intense therapy.) The studyalso showed that longer treatment did not alwayscorrelate with better outcome. What stands out in thearticle is that of all the children studied, only 9 whosediagnosis and treatment were well documented were aged6 or older when instruction began  and   learned to producephrases. Heiner Thomke was one of those 9.Dr Thomke writes in remarkable detail about hisson’s therapy, progression, and results. The author’sbackground as a language philosopher has given himspecial insight into not only his child’s language abilitiesbut his own theoretical arguments for the techniques thathe used to train Heiner. Because a father is writing abouthis own son, the reflections must be somewhat subjective.Further, the lack of a research design precludes scientificproof that the behavioral conditioning was responsiblefor the improvements in Heiner’s speech. But the papergives us a snapshot of therapies for children with autismin Switzerland in the late 1960s and 1970s.The therapies outlined are not intended to beprescriptive or even replicable, but rather descriptive.Several resemble techniques used today. For example, DrThomke’s redirecting therapy in response to Heiner’sinterests is a part of Pivotal Response Therapy. 9 Thefather’s use of pictures and objects to help Heiner learn tocommunicate presages the Picture Exchange Commu-nication System. 18 And his technique of training andreinforcing one small skill until it was firmly learned, andthen building on it in the next skill taught, is known as“shaping and chaining.” 19 Received for publication August 18, 2011; accepted August 18, 2011.*Professor Emeritus of German Literature and Language, University of Bern, Bern, Switzerland; and  w Individual Differences in Learningand Boser Educational Technology, Ellicott City, MD.HT is the author of the srcinal paper, updates, and some commentary.KB is the translator of the srcinal paper and updates, and author of some commentary.This research was supported by the Cognitive Neurology Gift Fund andby the Therapeutic Cognitive Neuroscience endowment andgift funds.The authors declare no conflicts of interest.Reprints: Katharina Boser, PhD, Individual Differences in Learning andBoser Educational Technology, 4120 Sears House Ct, Ellicott City,MD 21043 (e-mail:  r  2011 by Lippincott Williams & Wilkins H ISTORICAL  U PDATE 156  |  Cog Behav Neurol     Volume 24, Number 3, September 2011  Dr Thomke opens his paper by describing theconfusion and hope that he and his wife felt when theywere confronted with the need to teach their 6-year-oldmute son to speak. They are frustrated not just by thedifficulty of the task but by the lack of human and writtenresources available to guide them. Dr Thomke developshis operant training system through trial and error,studying the psycholinguistic and developmental psychol-ogy literature, and recognizing the reasoning behindthings that he does instinctively. He chastises himself fornot starting Heiner’s therapy earlier and not being able togive as much time to it as he would wish. Notsurprisingly, he also has mixed feelings about the successof his effort. But through his work, Heiner gainedfunctional language and kept learning after his formaltraining ended. Although Heiner’s expressive and recep-tive language skills have remained limited and he neverlearned to read or write, his ability to speak has enabledhim to be more independent than he could have beenotherwise, and his receptive language developed to thepoint that he has long been able to enjoy listening torecorded stories. Even this partial success has greatlyimproved his quality of life.Thanks to Dr Thomke’s generous willingness to shareand revisit his paper, we have been able to augmentHeiner’s early history, therapy, and results, and addupdates about him and his abilities over the 37 years sincehis intensive language training ended at age 8. [Newmaterial added within the translated paper is shown inbrackets.] Dr Thomke also approved the addition of severalsection headers to mark natural transitions in the text, andthe deletion of 3 footnotes not considered crucial.In 2011, we still seek best practices to help autisticchildren learn language. In the United States, some schooldistricts have failed to implement evidence-based treat-ments for students with autism spectrum disorder, 20–23 many because of a lack of training. 24 The use of appliedbehavioral analysis for autism in Switzerland has grownonly since about 2001, largely because 2 mothersadvocated for it. Dr Thomke’s 1977 psycholinguisticapproach serves the whole child, using sound, form, andmeaning, based on a profound knowledge of languagestructure and philosophy. If his intense training succeededin enabling a mute older child to speak in sentences, wemay be able to apply his methods to younger children andto children with milder autism spectrum disorders. Language Construction inan Autistic Child: ThoughtsRegarding Language Acquisition and LanguageTherapy 1 (Originally published as: Sprachaufbau bei einem autis-tischen Kind: U ¨ berlegungen zum Spracherwerb und zurSprachtherapie.  Schweizerische Zeitschrift fu ¨ r Psychologieund ihre Anwendungen.  1977;36:1–18. 1 ) Hellmut Thomke Translation from the srcinal German by KB Language acquisition is in many ways still such agreat puzzle that the person who stands before the task of teaching language to a child who has not learned to speakon its own, hardly knows how he might bring this aboutand where he might begin. Professionals and academictexts on language therapy also leave him for the most part“in the lurch.”Similarly, parents of a nonverbal autistic child areleft with feelings of confusion combined with an intuitivesense that if they dare an attempt, perhaps a way willopen itself to them; however, without strong method-ological experience or scientifically supported ideas aboutthe best approach, this is not something achievable for thelong run, something my experience with Heiner, my ownchild, taught me.How intuition and reflection can play a role, andhow I came to draw conclusions about languageacquisition by examining a single case of pathology— my own son—may be illustrated by the followingexample: when in Heiner’s presence, our family decidedquite spontaneously to more clearly stress (intone) themost meaningful words, increasing the importance of sentence melody. It was only after quite a period of timethat we began to realize that Heiner might perceive ourspeech more easily through this change of sentence stress.This thought was based on ideas in the newer medicalliterature about early autism, in which such children werefound also to have a higher probability of perceptualimpairments, which make the normal development of symbolic abilities (including language) impossible. Withthis notion arose the idea that perceptual abilities mightactually be a prerequisite for language acquisition. Later,I became convinced of the importance of auditory stressand sentence melody by studying the psycholinguisticliterature, in which the stress of the tonal gestalt of sentences and the intonation of utterances are hallmarksof the preverbal phase of language acquisition (references25 and 26, among others). In addition, I determined thatby overemphasizing intonation, we created in Heiner apreference for so-called “content” words over “function” Cog Behav Neurol     Volume 24, Number 3, September 2011  Language Construction in a Mute Autistic Child  r  2011 Lippincott Williams & Wilkins  |  157  words. [“Content” words are words with a real-worldreferent: nouns, verbs, adjectives, adverbs. “Function”words have no real-world referent; they have meaningonly within syntax, eg, “if,” “and,” “but,” and “that.”]“Content” words not only stood out most prominentlythroughout Heiner’s language instruction, but they alsotake priority in the early language acquisition phases of nonlanguage-impaired children. Thus, it seemed animportant thought that the sound patterns of languageprovided particular direction for Heiner as he learnedspecific types of speech acts.[Heiner is the youngest of my 3 children. His sister,Elke, was born in 1959. She was healthy until age 22months, when she suffered a serious fall, with a great lossof blood. This led to excessive growth of her tongue,which made it difficult for her to speak. At age 4,probably also related to the fall, she developed temporallobe epilepsy. A seizure at age 15 caused her to drown.My second child, Roland, born in 1962, grew up normaland healthy.][Born in 1966,] Heiner appeared in his first year todevelop normally, both physically and cognitively.Although his babbling phase was not very productive,at 10 months he was able to produce the sound sequences“mama,” “papa,” “tatata,” and “nan.” In his secondyear, however, his development halted [and, by 18months, he could not produce a single sound]. At thetime, there did not seem to be a specific reason forHeiner’s muteness. Soon early signs of autism appeared.He hardly reacted to speech, he avoided eye contact, andhe did not want to be touched. He preferred to watchthings that spun and twirled, like wheels. Only somewhatlater did he show a fear of change. Strangers thoughthe might be deaf, although his hearing was testedmany times and was always normal. He often reactedto very faint sounds, but generally tried to escape fromloud noises. Yet, from an early age, he was engagedby music.He received the diagnosis of “autistic tendencies,mute” at about 2 years of age. Not long thereafter, thediagnosis was revised to “childhood autism.” Later hewas described as a “schwer” (severe) case. [The initialdiagnosis was made in 1968 by Dr Hanspeter Matthys,then the only privately practicing child psychiatrist in theState of Bern. In 1970, the diagnosis was confirmed at thepediatric clinic at the University Hospital of Bern.] It wasa typical case of Kanner’s syndrome. Heiner also haddigestive difficulties resulting from unexplained foodallergies and perhaps a difficulty in tolerating sucrose.(This made it extraordinarily difficult to find an appro-priately motivating reinforcer during the conditioningtraining.) Multiple attempts to modify his behaviorthrough medication failed. However, thioridazine (Mel-laril) and pyritinol (Encephabol) seemed to bring aboutsome improvement at first.[More on medicines and medical care: Startingshortly before Heiner turned 2 years old, and continuinguntil about his third birthday, we tried many medicines totreat his autistic behaviors and severe insomnia. Therewere so many medicines that I can no longer name themall, but I do remember these: the antipsychotic drugthioridazine (Mellaril) and the antihistamine hydroxyzine(Atarax) did not help. The anticonvulsant carbamazepine(Tegretol) did nothing but give Heiner gum infections.Among the benzodiazepines tried, diazepam (Valium)15mg did not calm him or make him sleepy; neither didnitrazepam (Mogadon), which in higher doses led tovomiting. Among the neuroleptic drugs, thioridazine wasonly mildly calming; haloperidol (Haldol) and levome-promazine (methotrimeprazine) were stopped after 2weeks because they not only made him more restlessbut he looked morose and seemed to be suffering.Sedatives such as barbiturates, and a combination of methaqualone plus diphenhydramine, did not help hisinsomnia.The 1 medicine that really seemed to help Heinerwas centrophenoxine (Lucidril). His cheeks turned rosy,he became happy and calmer, and he made eye contactfor the first time. However, after only 3 days the doctorstopped the drug, saying that it was too dangerous. I didnot mention Lucidril in the srcinal article because I wasnot knowledgeable about the drug and could not findresearch on it.None of the medicines we tried improved the severeproblems that Heiner had falling asleep. I would have tolie in bed with him, holding him totally still for about 50to 60 minutes, until he finally relaxed and fell asleep.Often he was back up at about 3 AM , coming into my bed.There he quickly fell back to sleep so that I could carryhim back to his own bed. After a few years of this, hissleeping problems disappeared.After the fruitlessness of our initial attempts atgiving Heiner medicines, we gave up on all of them for awhile. Some years later, the doctor prescribed thepsychostimulant pyritinol (Encephabol), which Heinertook for many years. At first this drug appeared to havesome benefit, but after a time it seemed to wear off. Thebroad failure of medicines led the psychiatrist to concludethat only pedagogical intervention would help. His adviceled to the beginning of the behavior therapy described inthis paper.Initially, I wondered whether Heiner’s autism couldhave resulted from his early digestive problems. In 1970,specialists at the pediatric clinic in Bern thought thispossible but did not have any specific evidence. Theydiagnosed Heiner with a mild chronic intestinal infection,probably caused by a wheat allergy, but they did not findceliac disease. Biopsy showed a secondary sucroseintolerance. Later that year, Heiner’s pediatrician puthim on a special diet similar to one used for patientswith celiac disease: no glutens, very little fat, andavoidance of vegetables known to cause digestiveproblems. Further, Heiner was not allowed any dis-accharide sugars like sucrose or lactose; glucose was usedinstead. He was also given pancreatin (a combination of lipase, amylase, and protease). Used together for about10 years (ages 4 to 13), these measures normalizedHeiner’s digestion. When he was 19, he starting living Thomke and Boser  Cog Behav Neurol     Volume 24, Number 3, September 2011 158  |  r  2011 Lippincott Williams & Wilkins  from Monday to Friday at a group home for adults withautism. The home served such poor and unbalancedmeals that Heiner’s digestive problems recurred and hehad to be restarted on pancreatin. I finally stopped thedrug in 2006 when it caused Heiner an outbreak of eczema. Since then he has not taken any medications orhad digestive problems.At age 3, Heiner began to have recurring tonsillitis.At age 3 years 6 months, he underwent a tonsillectomyand the infections stopped.][Once Heiner stopped speaking (at around 18mo)],he remained mute except for an occasional “mama” and“papa” that seemed to have no real meaning. The dentalsounds “t” and “n” that he had earlier were gone. [He didnot hum or exhibit echolalia. He did not repeat syllablesuntil these were trained, and he did not repeat phrasesfrom songs unless these were specifically requested muchlater on.] At age 2 he tried to make himself understood bytaking either my wife’s hand or mine, and using it to pointto the location where he wanted something. If the objector item was something he could get himself, he would dothis instead. At about 4 years, we realized that hislanguage comprehension was also very constrained. Onlythrough systematic training, which occurred somewhatlater, would this improve. Even before a systematicbehavioral treatment plan was begun, when we tried toengage him Heiner would occasionally try to imitate thearticulation locations of vowels, but he could not producea sound. It seemed very unlikely that he would speakwithout some kind of training. His case showed us thatengaging autistic children in any systematic way requiresa strong, methodologically grounded therapy. The lack of this recognition among local speech professionals, to-gether with most therapists’ practices of bestowinggentleness, love, patience, and “trust in the healthy soulthat has lost its way in a sick body,” really angered us,especially because we received absolutely no useful advicefor years.When Heiner was 5 years old, we took him to aBern University speech disorders clinic in the hope thatthey would begin some kind of language therapy withhim. However, they claimed that unless he could learn toconcentrate and imitate, he could not be helped. Workingwith experienced teachers at a good kindergarten, he hadmade only small steps in this direction. My disappoint-ment was that much greater because I knew fromprevious experience that there was only the smallest hopethat he would learn language at this late age. Theliterature of the time claimed that a child who did notspeak by age 6 years would never speak and wouldremain extremely mentally retarded. The fact that Heinerappeared to be an attentive and intelligent child was weakconsolation, but it motivated us not to give up attempts atspeech just yet. His intelligence per se could not bereliably tested. For example, his Vineland score at 5 yearsand 3 months gave him an intelligence quotient of 56,which put him at a social age of 2;11, an overly favorableestimation of his abilities. Speech Sound (Phonemic) Training The systematic speech training began when Heinerwas 6 years and 5 months old. My wife and I began with aHungarian “behavioral therapist” ( Heilpa ¨ dagogin ) whohad trained in Budapest and had her own clinic for manyyears. She had worked with mute and deaf subjects, buthad little experience with autism. She did have experiencewith the Pavlovian method of behavioral conditioning,and taught us, as parents, a number of its principles. Wehad avoided speaking to Heiner in “motherese”— shortened, simplified words. We decided to train him in“high” German [rather than Swiss dialect German], forseveral reasons: Heiner’s mother spoke high German,Heiner had few relationships with children who spoke thedialect, and articulation in high German is much moreprecise and can therefore be more easily practiced.Finally, early attempts at teaching Heiner to read andwrite high German had shown that this was not animpossibility [although, unfortunately, no further prog-ress was made].[Each week the Hungarian therapist gave Heiner atmost 2 training sessions, each lasting 1 hour. Because sheworked in her home, my wife or I had to take Heiner toher and we sat in on the sessions. In addition to hertherapy, I worked with Heiner for about 6 hours a week,in 12 half-hour sessions. My wife and I became concernedabout the therapist’s rigor and, at times, well-meantfanaticism. Heiner would become aggressive when sheheld him tight and would not let him go, and because shedid not give him a sense of “affectionate engagement”(“ Zuwendung .” There is no equivalent word in English. Zuwendung  is any behavior, verbal or nonverbal, thatengenders affection in another.) Therefore, I increasinglytook her place as the primary therapist. After about 18months, we stopped seeing the therapist entirely, and Iconducted Heiner’s intensive training alone.]The training [with me] seemed to be fun for Heiner,but only when he was in a good mood. [Early on, hewould squeal when he did not want to work anymore anddid not want to sit still. When he was upset, he could noteven cry; he could only manage to pant.] The trainingtime was gradually lengthened. It was accompanied byrhythm exercises and exercises involving body imitation.During the course of the work, I attempted to familiarizemyself with behavioral therapy through readings (un-fortunately, the possibility of undertaking speech traininglike that described by Lovaas et al 3 was as yet unknownto me). At the same time, however, I maintained a criticaldistance from methods of operant language conditioningbecause of my language research knowledge and educa-tion in modern psycholinguistics and the theory of speechacts. [A speech act is a spoken or nonspoken commu-nication, such as a greeting, request, invitation, compli-ment, apology, complaint, or refusal.]There was a certain ethical mistrust of behavioraltherapy among speech-language professionals in Switzer-land at the time, yet I made myself familiar with what werethen considered “authoritarian” training methods, realizing Cog Behav Neurol     Volume 24, Number 3, September 2011  Language Construction in a Mute Autistic Child  r  2011 Lippincott Williams & Wilkins  |  159


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