cognitive-developmental training with elevated boards and sign language

Journal of Autism and Childhood Schizophrenia, 1973, 3, 1, 6 5 - 8 5

Cognitive-Developmental Training with Elevated Boards and

Sign Language ~

ARNOLD MILLER 2 AND EILEEN ELLER MILLER

Language and Cognitive Development Center Boston, Massachusetts

A study is presented to describe cognitive-developmental training involving use of connected boards elevated 3 to 6 feet above the ground together with special language signs. The subjects, 12 boys and 7 girls, were mute autistic children. Thirteen were in residential treatment and 6 attended day school. Signs were systematically paired with appropriate spoken words which all children learned to understand. Also, all learned to initiate signs to achieve desired objects or goals. The day school children, a younger group, achieved significantly greater expressive use of signs and words than residential school children. Two children, whose case histories are summarized, made the transition from signs to expressive spoken language. The training program is discussed in some detail.

Cognitive-developmental training refers to the systematic use of selected procedures to ameliorate the massive language and cognitive deficits which recent investigators (Rutter, 1965, 1968; Rutter & Bartak, 1971; Hermelin, 1968; Wing, 1969; Churchill, 1972) regard as central in childhood psychoses. These procedures are used judiciously depending on the level of deficit manifested by the child. Thus, training of mute autistic children, the focus of the present report, emphasizes both communication and improved contact with the immediate environment, while training of children with some spoken

IThe authors wish to express their appreciation to Dr. and Mrs. Jacques M. May, Directors of the May Institute for Autistic Children, Mrs. Kay Morgenthau, Director of the League School of Boston, and Dr. John F. Scott, Director of the Worcester Youth Guidance Center, for the cooperation which made this study possible. Special thanks are also due to Mr. Roland E. Vandal and Dr. John Murphy, officers of AMIC, Region 2, for their help and enterprise in establishing a pilot Cognitive-Developmental Training Program at the Day Care Unit for Autistic Ctfildren at the Worcester Youth Guidance Center.

2Requests for reprints should be sent to Dr. Arnold Miller, Language and Cognitive Development Center, 25 Huntington Avenue, Boston, Massachusetts 02116.

65

Copyright � 9 by V. H. Winston & Sons, Inc.

66 ARNOLD MILLER AND EILEEN ELLER MILLER

language endeavors to expand their capacity to speak while developing abilities to read and write.

The developmental assumptions on which such training procedures are based merit an introductory mention. To begin with, it is assumed that the

development of language and cognition follows a regular progression (Piaget,

1954; Werner, 1948), and that during such progression children first learn to

direct their body actions, then their distal senses (vision, audition), and finally their language and thought toward objects and events beyond their immediate

reach. A second assumption is that directed body action, the earliest to develop,

provides the foundation on which subsequently developing intentional activity

builds. Thus, a child unable to voluntarily direct his body toward his immediate environment or to make transition from his large body activity to more

sense-dependent contact with his surroundings, should be unable to achieve

more symbolic modes of experience.

Autistic children seem to have serious difficulty with both intentional body

activity and transition from body action to more symbolic functioning. These difficulties seem closely related to the way in which they are dominated by impressive aspects of their immediate experience. Unlike normal children who

act toward and connect one event with another, autistic children become "captured" by their total body response to one event. Once "captured," each sequence of response, whether twiddling or complicated ritual, appears to

harden into a circumscribed sphere of reality (Uexk{ill, 1957; Werner, 1948) detached from every other sphere. Each sphere of reality seems to have its own

integrity and engages the child in a "single-track" manner so that he is quite oblivious to any ongoing event outside that sphere. For example, an autistic

child on a hike might initially adapt his body to broken terrain as he climbs a

hill. However, in the process, he becomes so involved with this particular action

(l~l-climbing) that he loses contact with the reason for climbing the hill (the

hike). Then, unless the child is urged forward, he may begin, endlessly, to repeat his hill-climbing.

We suggest that it is the autistic child's "single-track" involvement within each of a series of such disconnected spheres which seems to preclude his

deliberate disengagement from the preoccupying object or ritual, so that he might relate his body in a more functio,lal manner to the larger situation or to new situations. This form of encapsulation is distinctly different from the conditions that nmst exist before intentional activity is possible. Schilder (1950) characterized such conditions as follows:

There must always be the knowledge that I am acting with my body, that I have to start the movement with my body, that I have to use a

ELEVATED BOARDS AND SIGN LANGUAGE 67

particular part of my body. But in the plan there must also be the aim of my action. There is always an object toward which the action is directed . . . . In order to act we must know something about the quality of the object of our intention. And finally, we must also know in what way we want to approach the object. The formula contains, therefore, the image of the limb or part of the body which is performing the movement.

Unfortunately, the awareness of body and body part in relation to the object, which Schilder considers necessary for intentional action, seems largely

absent among autistic children immersed in their rituals. And, without awareness

of the body as a separate entity in relation to external goals, there can be no

self-directed activity. In a world without awareness that the body is a separate

entity which moves among and acts upon objects and events, the autistic child

cannot distinguish stimulation from his own body from impinging stimulation

deriving from objects and events external to his body. Unable to distinguish

where his body ends and the world begins, the autistic child has no foundation

from which to launch purposeful action. Our observations of autistic children suggest that they themselves may be

aware of the lack of definition between their bodies and the world. Such children may periodically try to compensate for this by seeking "edge"

experiences which dramatize the relationship between their bodies and the

immediate environment. Behavior at the beach by one of our subjects, a

10-year-old autistic boy named Philip, appeared to demonstrate such awareness

and attempt to compensate. Philip would run back and forth across the line

which divided water from sand. In addition, although unable to swim, he would

bob up and down at the greatest depth he could stand with only his mouth and

nose above water. During the course of such bobbing, he would at times breathe

water instead of air, and then bob higher. In another example, 4-year-old Nancy,

an autistic girl quite aware of height, had on several occasions hung by her hands

outside her third-story window until her unsuspecting mother, reacting to the

alarm of people below, discovered the danger and pulled her in. While such "edge" experiences may momentarily provide the child with a

more accented experience of his body, they cannot, by themselves, solve the

problem of his encapsulation. For this to happen, some means of guiding him from his detached sphere of reality to more functional contact with the world

appears to be required. It is interesting to note in this regard that Donald T., one

of Kanner's (1943) original 11 cases who achieved a satisfactory adjustment, did so, at least in part, because the couple who cared for him guided the boy from


his autistic preoccupation to more functional behavior. Kanner (1971) described

this transformation as follows:

They made him use his preoccupation with measurements by having him dig a well and report on its depth. When he kept collecting dead birds and bugs, they gave him a spot for a "graveyard" and had him put up markers . . . . When he kept counting rows of corn over and over, they had him count the rows of corn while plowing them. On my visit, he plowed six long rows; it was remarkable how well he handled the horses and plow and turned the horses around . . . .

Kanner's case, of course, involved a child who could talk and count. Consequently, the couple who worked with him could draw on this cognitive ability to guide the boy from his autistic preoccupations. However, in order to

guide a mute autistic child from his circumscribed reality, the worker has only the child's ritualized body activity with which to work. This he must guide and transform into a more directed contact with his surroundings. Then, for the

achievement of spoken language, the worker must find some means of helping the child relate his newly directed body activity to his utterances. But here, the

child's difficulty lies not only in his encapsulation but also in the remoteness of

spoken words from their referents. Typically, there is nothing in the form of our

spoken words which hints at their inner meanings. Thus, to understand the

intent of a spoken word, e.g., "stop," "come," the autistic child must first

understand that it is possible for utterances to convey meanings, i.e., that they

are not merely noises but noises which intend meanings relevant to what he sees

and does. Accordingly, we suggest that before mute autistic children can begin

to develop language, they must first free themselves from their autistic

preoccupations. They must then achieve awareness of their own bodies in

relation to objects and events in order to deliberately initiate directed action. Finally, they must achieve a means of relating the directedness of their body

actions to spoken language. In order to create conditions that might enable mute autistic children to

resolve these problems, we have established "edge" situations for them at elevations 3 to 6 feet above the ground. These "edges," comprising a variety of connected boards, obstacles, tunnels, and drawbridges to cope with, were designed to both enhance body awareness and guide children from autistic maneuvers to more directed and functional activity. To link directed actions to spoken language, we then introduced manual signs adapted from the American Sign language (ASL) for the deaf both on the boards and in other relevant


contexts. This report describes these procedures in some detail and considers

their effect with a sample of 19 mute autistic children from residential and day

school settings.

SUBJECTS

The 19 mute autistic subjects who part icipated in our cognitive-

developmental training represented a populat ion o f the most severely disturbed

Table 1

Characteristics o f 19 Mute Autistic Children

Name

Mona Hank Nina Thomas Carl Margaret Teresa Kirk Barry Sidney Neal Elliot Bella

Sex

F M F M M F F M M M M M F

CA at com- mencement of training program (months)

Months in Creak

training score program

Residential School Children

144 14 108 11 132 14 180 14 192 11 144 12 108 7 276 14 240 4

72 10 132 14 180 4 120 14

48 50 46 51 56 56 42 50 54 48 52 52 46

Source and timing of diagnosis

Prior to ad- At com- mission to mencement

training of program program

MIAC MIAC PCC PCC MIAC MIAC

MIAC PCC PCC

MIAC MIAC PCC PCC

Karen F 114 Tod M 144 Donald M 84 Larry M 72 Philip M 96 Nancy F 60

Day School Children

12 54 WYGC 12 54 WYGC 18 52 LSB/LCDC 18 50 LSB/LCDC 36 48 LSB/LCDC 14 46 PCC/LCDC

Note . -MIAC = May Insti tute for Autistic Children; PCC = Putman Children's Center; WYGC = Worcester Youth Guidance Center; LSB = League School of Boston; LCDC = Language and Cognitive Development Center.


and unresponsive children from four therapeutic centers. All had little or no

ability to understand or use spoken words when they began the program, and all

but two (Teresa and Sidney) had been diagnosed prior to admission as shown in

Table 1.

The median chronological age of the 12 boys and 7 gifts was 11 years. The

median Creak score, assigned to each child by the authors after some observation

and consultation with appropriate teachers, was 48. 3

Residential (iV = 13) and day school (iV = 6) children differed markedly only

in age. Those in day school who lived at home were significantly (/7 < .05)

younger than the 13 children in residence at the May Institute for Autistic

Children (MIAC); the median chronological age of the day school group was between 7 and 8 years. The two groups did not differ significantly with respect to sex distribution, Creak scores, or time in program.

Three of the day school children (Donald, Larry, and Philip) participated in

the program at the League School of Boston (LSB) and, during the summer, at

the Language and Cognitive Development Center (LCDC). Nancy was trained

solely at LCDC. All residential children were trained at MIAC. The median time in the training program was 13 months.

The Spearman rank order correlation (p) was used to investigate the

relationship between the children's responses to signs and to spoken words as well as that between their diagnostic and training characteristics and achievement of signs and words. In addition, the Fisher test (Siegel, 1956) was used to test the significance of differences between residential and day school children on both diagnostic and achievement measures.

METHOD AND MATERIALS

Enhancing Body Awareness with Boards

The use of boards described in this study was based on preliminary work with several mute autistic children on lO-inch wide boards elevated 3 to 6 feet above the

ground. These boards constituted "edges" highlighting the children's body experience in relation to their immediate surroundings. Autistic children who were

unresponsive on the ground became more aware of their surroundings as soon as they stepped on such boards. This was apparent in the sudden cessation of autistic mannerisms, the steadiness of eye-contact, and the alternating of searching looks

3On the Creak Scale (Creak, 1964) a score of 56 (14 ratings of 4) reflects the most severe autistic state, while scores of 42 or less reflect relatively less severe states.

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at the worker with careful checking of foot placement and the direction in

which the board led. We speculated that this heightened awareness of

surroundings stemmed from the proximity of the body boundaries to the edges

of the boards. As the child looked down the sides of his body and perceived

them in direct relationship to the edges of the plank, he simultaneously

experienced his sides and feet in relation to board edge and distance above ground. In such a situation, there was no need to conceptualize the body's

relationship to the immediate environment since it was given in a glance. Thus, the immediate impact of the experience was to establish a more polar experience

of the body and a greater outward orientation than had previously existed.

As children crossed different kinds of board structures, we noted that their

outward orientation varied in accord with the kinds of structures they confronted. For example, as long as the boards ahead of them were solid they

continued without hesitation. However, if the next connected board was constructed of parallel 2 by 3 inch boards fastened 6 inches apart 4 they hesitated and did not move forward until they learned to place one foot, then

the other, on each 2-inch board and to alternately shuffle each foot foward. When a further complication involving small blocks was introduced on each board, as shown in outline lb of Figure 1, the children did not move forward

until they could shift their weight to one foot so that they could pull back and

lift the other foot over the obstacle. In still another kind of board situation, as

shown in Figure 2, children had to coordinate both hands and feet to find

appropriate space for the footing they needed to move along the board. It seems

clear that autistic children could not solve such board problems unless they gained at least momentary awareness (as they shifted weight) of how one side of

their bodies differed from the other, of the relationship each foot had to its

obstacle, and the way in which hands and feet could work together to make

progress on the boards possible.

Establishing Intentional Acts

Earlier, we suggested that "edge" experiences by themselves could not solve

the autistic child's encapsulation. For this to occur, he had to be aware of his moving body as he was guided into more functional activity. We found that the boards helped achieve both goals. They not only induced heightened body awareness, but also enabled us to guide the child into more functional activity. The boards helped achieve this, in Lewinian (1935) terms, by exerting a "pull"

4See outline la in Figure 1.


FIG. 2. Child picking his way by coordinating hands and feet on a parallel board with varied block obstacles.

(positive valence) on the child's body to move in accord with the manner in

which they were organized. For example, an autistic child's presence on a

10qnch board, situated 4 feet above the ground, which went from point A to

point B 8 feet away, helped induce him to walk from A to B. If an obstacle (a

foot-high box) were placed in the middle of the board, the child would walk

from A to the obstacle, stop, step on or over the obstacle, and continue to B.

Thus, in order to induce the child to perform various intentional acts it was

necessary to construct board situations that he must solve in order to go from

one point on the boards to another. Situations constructed on the boards

included doors that had to be opened, bridges that had to be crossed, drawbridges lowered, and positions from which he had to slide down, push-pull, or pick-up something and jump. At first, the children required assistance and

support from staff or parents who worked with them under supervision. Later,

they would go through the course with little or no assistance.

In each instance, the boards contributed toward the intentional act because

they prevented the child from avoiding the directly confronting problem while

at the same time making it difficult to lapse into one of the autistic maneuvers

readily available on the ground. Nevertheless, as the children repeated the same

act several times, it would tend to lose its intentional quality and become a


ritual. To prevent this from happening, we constantly changed both the configuration of the boards and the tasks built within them. With each such

change we found that the child's activity again became purposeful.

Sign Language

The body awareness course which the boards evolved into demonstrated that it was possible to encourage an unsuspected range of intentional behavior among autistic children. Our task now was to transform this intentional activity into meaningful language. We chose sign language to link action to spoken language after preliminary research (Miller, 1959, 1963; Miller, 1968)indicated that body

gesture could facilitate spoken language. We reasoned that children who could not understand spoken language but could perform intentional actions on the boards might be able to transfer the meanings of such actions first to signs

(which resembled them) and then to the spoken word which accompanied the manual signs. Until signs transferred their meanings and function to spoken language, they could provide them with a means of understanding and

communicating with us. To facilitate the transfer of meaning and function from action to sign we

selected 50 functional signs closely related to everyday activities of the children. Then, to make the signs relevant, we introduced them in three different contexts. The first context involved the use of signs on the boards. The second

taught signs with training films, and the third sought to generalize the learned

signs to everyday contexts.

Signs on Boards

We found that autistic children could learn signs more readily on the boards because many such signs closely resembled or could be related to the intentional

acts that they performed on the boards. Thus, the sign open (hands parting) was taught by the worker saying "Open" and interposing his parting hands in front of the door the child was opening. In similar fashion, he would say "Walk," and walk his hands (sign for walk) in step with the child as he walked from place to place on the boards, or say "Push," and "Pull," with the appropriate push or pull signs as the child performed these actions. Signs for come (beckoning fingers), stop (the edge of one palm meets the other and simulates a barrier), up and down (index finger pointing in the appropriate direction) were taught somewhat differently because they related closely to board vectors. To teach the sign come, the worker would say the word while beckoning to the child from the end of the board's length. In this way the utterance, sign, and board vector


mutually supported each other in the common "pull" they exerted on the child

to move toward the worker. The sign stop required a similar strategy;just as the

child met an obstacle in the middle of the board the worker would say "Stop!" and interpose the manual sign so that real barrier, sign barrier, and utterance

again shared the same vector. We suggest that it is the sharing of common vectors

that made it possible for the spoken word to assume, by itself, the significance initially shared by all three factors (board vector, sign, and utterance).

After establishing receptive understanding of a certain group of signs, the varied problem situations built into the course were used to encourage the

children to initiate signs. Then, a child poised 5 feet above the ground and

wishing to get through a box enclosure with doors on each end had to make the sign for open (hands parting) before the teacher would open the door and let the child through. In the same fashion, he had to perform a down sign before a drawbridge would be lowered, or a pick-up sign before an obstacle would be removed from his path. Once children could respond to and use signs effectively above ground, they were trained to generalize this understanding to everyday situations on the ground.

Training Films

In alternation with the awareness course, signs were also taught with the help of carefully prepared training films. In using films, we drew upon strategies described elsewhere (Miller & Miller, 1968, 1971) designed to accent the relationship between many signs and the objects or events to which they related. The utility of motion picture films becomes evident when one notes how directly many of the manual signs may be related to their referents through careful film editing. For example, the hand sign for jump (two fingers of the right hand jump off the left palm) blends readily with and thus assumes the meaning of a child jumping off a stool,just as the hand sign for break (two hands

simulate breaking something) readily blends on film with two hands actually

breaking a stick. Similarly, manual signs for eat, drink, fork, knife, spoon, pour, plate, and many others are juxtaposed on film with their objects in such a way that the sign and its meaning become intimately related. Other dusters of signs relate to tofleting (wash, toothbrush, comb) and to actions directed toward objects (push, pull, pick-up, drop, open-close). These f'rims first presented signs from the child's subjective view and then gradually shifted the sign orientation to a fully objective angle so that the child could see the signs as they would be presented by a person opposite him.


Procedure

Although the intensive work with boards and signs averaged about an hour a

day (5 days a week) at both residential and day school settings, the hour was

integrated differently within the two settings. For example, within the

residential setting a teacher and an aide would work intensively with two or three children at a time in a classroom, first with boards (20 to 30 minutes), and for the remaining time, with sign films, 2-concept phrases, etc. Then, to facilitate generalization of learning, kitchen staff as well as day and night workers were instructed in sign-word-procedures to enable them to respond to and also encourage the children's use of signs and words at meal times, bed times, and in the course of dressing, toileting, or washing. However, because the residential school operated on a 24-hour basis, teachers could not directly observe nor supervise the institution staff during this phase of the program.

In the day school setting, on the other hand, teachers' work with boards and signs was carefully integrated within the child's school day. This permitted them to directly control the important generalization of signs from training to real life

situations. A typical school day began with a few minutes of orienting and body play and continued with 10 to 15 minutes of board work concerned with body awareness. This was followed by another 10 to 15 minutes of board work during which concepts like come, go, stop, up, or clown were developed. During the outside walk which followed, teachers actively generalized these board-developed concepts in a more natural setting. On their return, children had a 10 to 15 minute intensive training session with sign films concerned with eating and drinking. Then, during the immediately following snack period, these food-related signs (eat, drink, pour, glass, etc.) were used and elicited by

teachers. After snack time, the children participated in small group games which encourage interaction. They then toileted themselves and washed in preparation

for lunch. During the lunch period, each of the children helped set table, prepared food (usually with assistance), moved chairs to table, dined, and then cleared the table. Each of these activities was guided and accompanied by the appropriate sign-word combinations. Following a brief rest period, the children experienced another 10 to 15 minute training period with another group of sign films (e.g., push-pull, pick-up, and drop), after which the teachers systematically provided opportunities for generalizing these concepts. Thus, teachers were able to work intensively with the children and control generalization of concepts during much of the school day.

In both residential and day school settings the relevant adults were taught to understand, elicit, and use the 50 signs designed for the children. They were


taught to speak economically and directly (waiting for eye contact) to the children as well as to pair each sign with the appropriate spoken word so that the meaning inherent in the sign might transfer to the spoken word. To facilitate this transfer both staff and parents were also taught to vary their utterances both rhythmically and in intensity. Thus, as a worker beckoned to a child she might say "Come" in a loud, urgent manner and then abruptly shift both gesture and utterance to a soft, genre pattern. Wherever possible, the rhythmic pattern of

the gestures was closely related to the relevant spoken words and to the child's total body involvement. For example, as a child went up a ladder or went up on a seesaw, the worker would, in the course of performing the relevant sign (upward gesture), utter the word "Up" with a rising vocal inflection timed to coincide with the child's upward movement. Conversely, a downward gesture and vocal inflection were paired with the child's downward body movement. When a sign was paired with a hyphenated phrase like "Get up" or "Sit down," the worker would "hyphenate" the sign (palms moving upward or downward) to correspond to both parts of the phrase.

Conventional speech therapy procedures (mouth manipulation, etc.) were not

used initially because of our impression that the children became so preoccupied with the therapist's manipulation of their mouths that they lost referential contact with the objects or events to which their articulations were supposed to relate. However, when a child produced a relevant utterance in context of the appropriate situation, workers would mimic this utterance with the relevant sign and express delight with the child's new achievement.

Once a child had grasped 20 or 30 signs, he and the adults who cared for him were taught 2-sign 2-word combinations, e.g., pick up ball, bring hat (or spoon), etc. As part of the training, children would bring desired objects from one end of

a board to the worker waiting at the other end. After the child in response to a

signed and spoken request could bring an object to one person, he was taught to bring the same object to another person, etc. Then, relative positions were

reversed so that the child could learn that his response to signs and words was completely independent of his starting position. As soon as these cognitive tasks could be performed at both higher and lower levels on the boards, the child was trained to perform them on the ground, in different rooms, or outside.

RESULTS

Receptive Language

Table 2 indicates that all children could respond appropriately, first to signs paired with spoken words, and later, to spoken words without signs. The


Table 2

Achievement of Signs and Spoken Words by 19 Mute Autistic Children

Signs paired with Name spoken words

Spoken words without signs

Receptive Expressive Receptive Expressive

Residential School Children

Mona 44 Hank 27 Nina 39 Thomas 24 Carl 7 Margaret 11 Teresa 27 Kirk 33 Barry 6 Sidney 13 Neal 22 Elliot 15 BeUa 28

Karen Tod Donald Larry Philip Nancy

12 6

19 6 3 4 4

12 1 7 2 7

11

40 28 39 25 9

12 26 29 17 14 23 21 31

Two-sign plus two-word combinations

Day School Children

36 40 20 37 50 40

10 12 8

25 50 25

40 40 20 40 50 45

Receptive Expressive

yes [ no yes [ no

1 x x

0 x x 0 x x 0 x x 0 x x 0 x x 3 x X 0 x x 0 x x 2 x x 0 x x 0 x x 0 x x

3 x x 0 x x 0 x x 4 x x

50 x x 7 x x

median number of receptive signs achieved was 27 while that of receptively

understood spoken words was 26. The rank order correlation (p .66) between

signs and words achieved is consistent with the view that pairing signs with

spoken words in the manner described enabled the spoken words to assume

significance for the children. The children seemed somewhat less able to

understand and respond appropriately to 2-sign (paired with 2-word)

combinations (e.g., pick up fork, bring hat, etc.) since only 12 of the 19 could

respond correctly to these combinations. These 12, however, demonstrated their

understanding of the 2-concept combinations by responding appropriately to

interchanged verb-noun pairs.


Expressive Language

The children used significantly fewer signs expressively than they did receptively. The median expressive use of signs was 8. Nevertheless, even the most profoundly autistic children (Carl, Margaret, and Barry) could initiate a few signs (usually for eat, drink, open). It is of note that signs learned and used were not restricted to the context in which they were learned. For example, children would use their eat, drink signs not only in conventional eating situations at dining hall or dinner table, but at picnics and restaurants as well.

This was also true for signs open, come, etc. when these were mastered. Only 7 of the 19 children produced some spoken words related to the signs they

learned. And, thus far, only one of the 19 (Philip) has learned to both

understand and use appropriate syntactical spoken language.

lntercorrelations

Table 3 indicates that the duration of a child's participation in the program, his Creak score, and chronological age were highly correlated With his language achievement. Thus, the number of months in program was significantly (p < .01) correlated with 3 of the 4 language scores. The longer the child participated in the program the more likely was his achievement of higher levels of receptive and expressive use of signs and increased receptive understanding (although not expressive use) of spoken words. Creak scores, on the other hand, were negatively correlated with language achievement. Thus, the more profoundly disturbed children with high Creak scores did significantly worse (p < .05) on 2 of the 4 measures (expressive signs and receptive words) while the less disturbed

Table 3

In te rcor re la t ions be tween Chronologica l Age, Dura t ion o f Training. Creak Score and Ach ievemen t o f Signs and Words

Signs and words

Receptive signs Expressive signs Receptive words Expressive words

CA

P pt

-.15 -.41 < .05 -.36 -.45 <.05

Creak score

P Pt

-.36 -.47 < .05 -.46 < .05 -.26

*Months in program; tone-tailed test.

Duration of training*

P Pt

.57 < .01

.66 < .01

.55 <.01

.36


children with lower Creak scores did significantly better on those measures. The chronological age of the children, another important factor, was negatively

correlated (p < .05) with the expressive use of signs and spoken words. Thus, the younger the child at the start of the program, the more likely his achievement of both the expressive signs and words.

Comparing Residential and Day School Children

A comparison of the residential with day school children reveals a more

vigorous response to the program among the latter. This difference was most striking in the expressive use of language. The day school children's median expressive use of signs (about 18) was significantly greater (p < .05) than the median of 8 expressive signs for residential children. Similarly, in appropriate use of spoken words only 3 of the 13 residential children uttered words, while this was true for 4 of the 6 day school children. Further, the group of day school children included the boy (Philip) who achieved syntactical language and the girl (Nancy) who is currently adding about a word a week to her vocabulary; the two children are briefly described below.

CASE ILLUSTRATIONS

Case 1

Philip, a handsome, sturdy-looking boy, began the program 3 years ago at the age of 8. At that time, he was completely mute except for periodic staccato emissions of strings of vowel sounds. The child was also given to bursts of activity during which he would hurl himself back and forth against the walls of his room. At other times, he would spend hours humming, lining up blocks, sniffing and piling them in rows of two and three before he would break them

up and start all over. Philip would not respond to verbal commands, screaming piercingly when required to interrupt an activity.

The boy's parents reported normal development until 12 months of age, when, on the occasion of a viral infection, he suffered a grand real seizure. At 18 months, following a vaccination, Philip experienced a prolonged series of convulsions which were subsequently controlled with Dilantin. Since then, no further seizures were in evidence. EEG examinations have shown no abnormalities during the past 5 years and Philip was taken off medication at the

age of 6. During the 3 years we have worked with Philip he has moved from a

comprehension and use of manual signs to an understanding and use of spoken


language. As words became meaningful and useful, he has gradually given up

the use of signs. Currently, he can understand and use sentences 6 to 8 words in

length with proper use of pronouns I, you, he, she, we, they. The boy is oriented

in space and time. He can read at early second grade level, s and perform arithmetic at late first grade level. Philip's parents report that most of his bizarre

mannerisms have disappeared (as language developed) and that his increasing interest in people during the last 6 months is evidenced by play contact which he initiates. Special class placement in a public school within a year is a realistic possibility.

Case 2

Nancy is a delicate, blonde little girl who began our program 14 months ago,

2 months before her fifth birthday. Before this she had been at a therapeutic nursery school which, at the end of two years, recommended Nancy's

institutionalization. A teacher describing her first contact with Nancy at the school reported that

She rocked almost constantly, screamed when brought into the playroom, banged her head, ground her teeth . . . . stared at lights, showed bizarre finger movements and arm-flapping, had no eye contact, wandered aimlessly . . , toe-walked, went into a panic if touched by other children, had no speech, wasn't weaned or toi let- trained. . , had no conception of walking downstairs, and was so withdrawn that formal testing was impossible.

Nancy's mother reported that there was no unusual illness during the gift's

first 2 years of life. Neurological and EEG examinations revealed no

abnormalities. Developmental milestones followed normal progression (walking at 15 months) and her mother was unaware Of any problem until the child, a very quiet baby, never crying and not at all demanding, had reached the age of

1�89 and did not talk. Great concern was expressed about Nancy's persistent

efforts to climb out of a third story apartment window; on several occasions she was found hanging by her fingertips from the window's outer ledge.

Although somewhat improved when we first saw her (some eye contact was evident as well as fragments of organized behavior as she responded slightly to

sphilip learned to read with the help of Symbol Accentuation (Miller, 1968), a reading program which systematically helps children to link body gestures as well as speech to printed language.


peek-a-boo games), the essential features of her behavior were the same. After 2 months of training, Nancy could respond to receptive signs for come, stop, and jump (first on the boards and then on the floor), and within 3 months she could appropriately initiate her first expressive signs (open, eat). Currently, she understands 40 signs and can initiate 25 in appropriate situations. Her understanding and use of signs is not limited to one situation and she has

spontaneously begun to generalize them to related situations. For example, the

sign open no longer applies only to a door, but is used by her to get someone to open a jar of peanut butter, etc. The integration of signs within cognition is evident in the girl's signing to herself before she performs a particular act. Thus, Nancy will make a covert jump sign to herself before she jumps off the boards or a quick run sign before she begins to run. Most encouraging is her recent utterance of spoken words "Up," "Down," "Eat," (she no longer requires the sign with "Eat,") "A-ke," (for jacket) "Ma," "Ball," "Baby," and the fact that for the past few weeks she has been adding about a word a week to her vocabulary.

Autistic rituals and mannerisms both at our Center and at home have

dramatically decreased while her awareness of surroundings and people (particularly for games of "chase-me") have steadily increased. The mother reports that Nancy now seeks out and plays simple games with children. The girl also "panhandles" candy by standing in front of a child with candy and, while gazing at him steadily, performing the eat sign toward her mouth. She also helps set table and is beginning to assist her mother with house chores. She has not attempted to climb out the window for the past 6 months, a report which correlates well with our observation that Nancy has become quite cautious, even fearful, as she walks the boards at our Center. Presumably, having become more aware of her body in relation to her immediate environment, she no longer requires "edge" experiences of such desperate nature.

DISCUSSION

Since none of the children could respond to and use signs when they began the program and all could respond and use some signs when retested, it appears that even severely autistic children can benefit from the present approach. The results also indicate that the ability to respond to signs can contribute to the understanding of spoken language. The procedure of pairing signs and spoken words both on the boards and in other relevant situations seems to have facilitated the transfer of meaning to spoken words so that mute autistic children can understand them even without the accompanying signs. Further,

ELEVATED BOARDS A N D SIGN L A N G U A G E 83

the results with several children suggest that training with signs may, at least for some, stimulate the development of expressive spoken language.

These fmdings, however, leave several important questions unanswered. For example, how important are the elevated boards in accounting for these results? Might not the presentation of manual signs and spoken words without the boards have been sufficient to teach the children? We cannot answer these questions decisively because we have not conducted a controlled study in which all factors but the use of boards are held constant. Our clinical observations, however, support the importance of elevated boards. We found that some

children could not begin to learn signs until they were first presented within a board context. Other children could learn certain signs without the boards (e.g.,

eat, drink), but could not grasp action signs (come, stop, etc.) until they were first taught with boards. Some demonstrated the importance of the boards quite concretely by transferring certain aspects of their board experience to the ground. Nancy, for example, had to use a wide stance as she shuffled on a parallel board (as shown in outline la of Figure 1) toward her mother in her

initial response to mother's "Come". When the procedure was repeated on the ground (without the board) Nancy could at first respond to her mother's "Come" only by assuming the same wide stance and shuffling feet movement that she had used on the boards. Several days later, she could respond to her

mother's call without having to use this board gait. These and similar

observations with other children are consistent with the view that the boards facilitate a directed body response to signs and words.

The program's overall effectiveness seems implicit in the findings that the longer a child participated the greater his achievement of receptive and expressive signs and receptive understanding of spoken words. The fact that duration of training in the program did not correlate significantly with expressive use of spoken words suggests either that the children were not in the program long enough, or that they had passed a critical period during which expressive spoken language could develop. Support for the latter view is inherent in the finding that the younger children were more likely to achieve some capacity for expressive use of both signs and spoken words.

If this is correct, the greater achievement of expressive signs and spoken words by day school children (in contrast to residential school children) may be largely due to their relative youth. The median age of 7 to 8 years of the day school children is significantly below that of the residential school children. It seems likely that younger children with less entrenched autistic patterns may be more responsive to cognitive-developmental training than their older counterparts. An additional factor which may have helped generate more


expressive language among day school children is the greater involvement of parents in the school program. Parents of the day school children worked

directly with their children under supervision in a manner similar to that

described by Schopler and Reichler (1971), while parents of residential school

children did not have this opportunity. We found that the more parents are

involved with their children's training the more likely is the children's

functioning to generalize to home and other settings.

One further issue concerns the desirability of teaching manual signs to autistic

children. It has been argued that if these children are unable to use signs as a transition to expressive spoken language, then the manual signs may merely

add another set of mannerisms to their bizarre behavior. We suggest that the

inability of a mute autistic child to attain meaningful speech via signs does not

invalidate their use. The signs offer such children the means of understanding

both signs and spoken language as well as the possibility of communicating with other people. Without such human contact, most mute autistic children tend to

lapse into states in which they pass their days rocking back and forth and twiddling objects.

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cognitive-developmental training with elevated boards and sign language

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