Nikolaas  Tinbergen (1981) - An Effective Therapy of Childhood Autism

Mr. Prime Minister, Count and Countess Bernadotte, Mr. Chairman, ladies and gentlemen. This talk is a sequel and in a sense an end piece to the talk I gave here three years ago, when I discussed the results of a study over about eight years that my wife and I together have conducted. That study was characterised by the application of some methods developed in animal ethology to abnormal children, disturbed children who do not speak and therefore had to be studied by the non-verbal behaviour just as animals have. I reported on what our studies, the application of this method made us conclude or rather interpret about the autistic condition about what it was like to be autistic. And also about its ontogeny, the genesis, what could make children autistic. And I want to report today on what I call the end piece, on how it might be possible to cure them, how we have found since that we can cure against expectation a number, and perhaps a high proportion of these unfortunate children. Now, when I speak of autistic children, then I don’t care too much about this label but I’m speaking of children that you can recognise by the following observable behaviours. One is what we call social avoidance, they do not want to make any contacts with any other human being, not even their own mother. Second, a reluctance to explore unfamiliar physical world. They do not explore, they shrink back from anything that is unfamiliar to them. They do not develop speech, or if they begin to develop it, it regresses again and they become totally mute. They resist any change in space or in time, any new situation, any slight change in a familiar situation creates tantrums and also changes in routine, so changes in what is done in time. They show a continuous repetition of very simple, often very bizarre, strange mannerisms or stereotypies, time after time the same, they may scratch their ear, they may make curious movements with their hands, half looking at them. They may spin pirouette around and similar very simple and very monotonous repeated movements. They become in general retarded, although almost all of them, and perhaps all of them have what are called islets of good performance. In some things they can be very good. And further they usually show sleeping difficulties, they sleep very poorly, they are generally very over-aroused. And some of these points have to do with each other. Our conclusions about being autistic can be summarised in an expression of a few words. They live in a continuous emotional imbalance which is dominated by hyperanxiety, they’re anxious, they’re apprehensive of almost everything. If this is seen as central to the whole syndrome that I have described, then the syndrome becomes very clearly understandable, it’s a very plausible way of looking at the syndrome. You find that part of the behaviour consists of insipient, half-hearted social and exploratory approaches. But at the same time they swing back and the behaviour consists of equally insipient and not complete withdrawal from persons and from new situations. And you also see in the behaviour the direct expressions of the motivational conflict between these two incompatible things. You can’t approach and avoid at the same time. And whereas with normal children the avoidance is initially there, but gradually wanes, in these autistic children it stays there. And they are in perpetual conflict, they are not just merely anxious, they are at the same time very willing and even want to approach situations and persons, but they can’t bring themselves to do it and they are in this internal balance between the two, which we call an emotional imbalance. As to becoming autistic, which is a quite distinct question, how does a child become autistic. We claim, without being able now to elaborate that, but we can do that in our informal discussions, that there is only a very minor genetic component, it is possible that there are genetic differences between children connected with this, and that some children are more vulnerable than other children, but that is all. And we know that from the beginning study of identical twins of whom some are autistic, one may be autistic of a pair and the other not autistic. To that extent this point to a non-genetic component and are more concordant, there are more discordant identical twins with regard to autism than there are concordant identical twins. And even those that are concordant can be partly genetically determined, can be partly determined by the environment, as I can also argue but not now. That I did last time. Secondly there is no evidence at all for gross structural damage, for instance gross brain damage, not even for minimal brain damage. If there is minimal brain damage, it’s quite equally possible that that is a consequence of having been autistic for a long time as that it is the cause, it’s a correlation that is sometime found. But even the minimal brain damage, which is a fashionable word nowadays, has been inferred, not found. But there are, contrary to what is at the moment quite widely held among the circle of experts, there is quite some evidence of very early traumatisation of external environmental influences in early youth, which may undo the normal development of a sense of security, which controls both the approaches to other people as the approaches, the exploratory approaches to unfamiliar environments. From both of which a normal child learns so much. We have traced together some, over 20 of possible early influences that may happen, some before birth, some during birth and some shortly after birth, usually well before the child is 30 months old, which can make a child derail into this autistic deviation of the normal development. What they have in common is that these early conditions hinder the early affiliation between mother and infant. All socialisation, all development of social relationships in any human being begins with the formation of a strong emotional bond by which the child is tied to the mother and the mother to the child and in which mother and child interaction build a kind of upward spiral for both, for the child mainly but also for the mother. The second thing we find about these external traumatising influences is that they are all characteristic of modern social conditions, at least in our type of modern industrialised urbanised societies, societies where many people work under great stress which extrapolates itself, radiates onto the mother-infant and the father-infant and the family-infant and ultimately the community-infant relationships. Now, these conclusions ran counter to prevailing opinion. Even at the moment most, almost all people, all experts on autism have come to a standstill, they all believe in what they call organic or structural damage, which is irreversible and they believe in the impossibility to rehabilitate these children. These children are given up and they end up in mental institutions and are often then diagnosed suddenly schizophrenics. And that is still true, the latest summaries, as late as the British Medical Journal in late 1980 said there is no known treatment. And now I am going to turn to this problem of treatment. Since we spotted that there was a possible environmentally controlled ethology, origin of the disorder, and also having seen a number of recoveries of autistic children, which should not happen if they were ineducatable, we began to believe in the educatability and the rehabilitation of autistic children and we began to think of the possibilities of therapies from two ends. First of all we looked at our own analysis of our understanding as we saw it of what makes a child autistic and what autistic situation is like. And, deducted from that, what could be expected to cure an autistic child. But then of course what you expect is very much dependent on what theory, what hypothesis you adhere to. So our hypothesis could be wrong and we had to look in the empirical, typical medical way, the proof of the pudding is in the eating, other autistic children that do recover, and if so, how, what has happened, why have they, what has made them recover? And for that we had two sources of information, one was we looked at the quite considerable number of autistic children who had recovered without doctors ever knowing about it. We studied what we call the “do-it-yourself mothers” and how have they proceeded. And we have seen in a number of cases, these had to be studied in depth, that these procedures of the do-it-yourself mothers had quite a lot in common. What they did was actually what you would expect that would cure autistic children, namely they made this anxiety wane. And how did they do that? By being super mothers. But we hadn’t got beyond that, we had seen, yes, these children must lose this anxiety and once they begin to feel as secure as normal children, they will explore, they will accept instruction, they will even seek instruction, they will practice, they will do all kind of things. And you need not then to teach special skill, they teach so to speak themselves in their interaction with the environment. But that’s where we had got stuck. And the breakthrough came when we got in touch with a New York psychiatrist, Dr. Martha Welch, who had in a rather empirical way come to a conclusion that we at the beginning would have shrunk back from. She said to the mothers, she persuaded the mothers of autistic children to go back to square one, so to speak, and to treat the children, even if the child were 10, 12 years old, in the same way you treat a baby or a toddler in distress or overtired or ill or an obstreperous child, by holding the child, if necessary forcibly but lovingly with all the non-verbal expressions and verbal expressions that belong to that, until the child gives up its initial struggle, it does struggle originally. But you must go on until the child turns around and becomes socially positive to the mother again. And then, in the course of one session which in the beginning may last a couple of hours, then the child will begin to socialise. It will also feel that it has a secure home base and it will set out and explore. And now I would like to show you a few slides in which I show you two sequences of two sessions, supervised by Dr. Welch. The first shows the beginning and the end of a session. Here you see the beginning of a session, the boy resisting very much, furiously, the therapist, Dr. Welch sitting in the background rather unconcerned, because she knows this is the beginning of many sessions, you have to repeat these sessions. And that is the end of the session where the boy and the mother do socialise with each other. I needn’t point out how different the facial expressions and the body expressions are. Now, the next six slides show six stages, successive stages in a treatment, one session of a series of sessions in another child. You see the child, the mother and the mother’s mother. Now, in the first you saw the child in a very resistant condition. Here the child is still not very happy but begins to look at the face of the mother. The therapist begins now to study what has happened because after the familiar beginning, now it begins to be interesting. Now the child begins to explore the face of the mother, first it looked only at the face of the mother, but now begins to touch, expression in both child and mother and interestingly therapist change. All the details of this we can discuss in detail in our informal discussions. Now, the child begins to interact with the mother’s mother who has been supporting the mother morally. And you see again the face of the therapist, shows delight in this development. Next is the child, having got a secure home base, ventures forth away from it and socialises with the therapist. And you see again typical non-verbal expression of this friendly interaction. And the last slide, the next one shows the child ventures out into the room and begins to explore objects in the room. That shows the typical course of one session. These sessions have to be repeated a number of times at reducing and increasing intervals but the mother is taught how to do this. And the interesting thing is that as soon as the child begins, and it’s usually the child who begins to react first to this force holding. As soon as the child begins to react in a friendly way to the mother, then the mother receives that as a reward that reinforces her maternal behaviour which may have been suppressed for a long time, because having an autistic child is, as you can imagine, a very miserable experience. And that makes the mother behave in a more motherly manner, that again encourages the child and the downward spiral which is normal is reversed into an upward spiral. I put it now in very simple words, I needn’t stress that this is a very complex set of interaction. So complex that even in the quite exhaustive literature on child behaviour, even on non verbal child behaviour, a great number of the behaviour patterns that you see in autistic children and in recovering autistic children haven’t even been described yet and yet you see them repeated time and again. What is interesting in this is that, since the autistic child has become more and more retarded, the longer it has been autistic, the more and more it has to catch up on and the longer the interaction must become normal between mother and child. And in the run of this upward spiral, the child runs very rapidly through a process that a normal child takes five, six years for. And the autistic child in this way catches up on its retardations very fast. Showing partly how much it has learned latently by unobtrusively observing what's going on around him. And partly, by now wanting to learn and learning with such an incredible rapidity that they often end up well above the average normal child. That’s another interesting point which we may discuss informally. So many of these autistic children who have recovered show that they are in some way special children. They have a very special social sensitivity, perhaps a little more timid than other children but they usually have very special gifts, either intellectual or artistic or social gifts. One thing, for instance, by which the do-it-yourself mothers have helped autistic children to recover even faster is to engage their help for even more unfortunate children. Suddenly the autistic child who has always felt anxious and closed in, is given the message ‘you can help somebody else’ and that does a great deal to the self esteem and that gives a boost to this emotional development on which they have to catch up. I use the word ‘emotional’ in the subjective sense, more or less as equivalent to what we call motivational in the more objective sense. What fascinates us is the success rate. We have studied now together with Dr. Welch and Dr. Zapella of Siena in Italy, and in the case of do-it-yourself mothers, about 29 cases on which we can report. And of these 29 cases, 25 have recovered fully or practically fully, not quite fully because the treatment hasn’t been going on for a long time. There are four failures, two of them are because the mothers gave up. And it’s very interesting but also very worrying that when the child makes the first friendly approaches to the mother, that there are some mothers who have been so traumatised themselves, either by having had an autistic child for so long, or by earlier conditions, such as their own early childhood, that they shrink back from the friendly early approaches of the child which they have so rejected by then, that they find it difficult, if not impossible to bond again with them. The other two failures were due to sheer physical circumstances, the patients live too far from the psychiatrist that they could see him only a couple of times, not enough times for the psychiatrist to teach the mother and then the parents more fully how to conduct these sessions. And it’s quite possible that they will still recover, if this difficulty will be overcome. What worries us about this whole story is that it has become more and more clear that, although we can now cure autism, we don’t know what proportion of children can be cured, but the indications are, and we have information way beyond these 29 children, that it may well be possible for the majority of children or rather child-mother diets. Is that, since all the autism inducing factors that we have been able to find, are in the social environment, in the modern social environment, that what is a real cure for autism is seen in wider context a symptom cure for our society. If autism is, as we believe, a consequence of psychosocial stress, to use the word that is widely used, then it is a societal disease, and then the treatment of autism alone would be a symptom disease in this wider context. And, although I speak of children with this particular syndrome of autism, we suspect and are fairly sure that there is a much, much larger proportion of children who are labelled in a different way. And you know, labelling diagnosing in psychiatry is still very much an art and no two psychiatrists really agree on a diagnosis, except in such rare cases where the syndrome is well described. We consider this a kind of test exercise of the application of ethological methods to emotional disturbances. And we begin to sense that emotional disturbance, particularly in childhood, are very common at the moment and may very well be on the increase. One indication of that is that the country where autism causes the most worry and most attention is not a Western country but a westernised country, it’s Japan. The news we get from Japan is just frightening. And it looks very much as if these mental disorders in childhood, which will lead, if not cured, to mental disorders in adults, for those who have to take part in adult life and even have to take part in running our society, that that may well be on the increase in the very countries who believe or have believed until recently that they are making great progress in civilisation. There is a heavy price obviously to pay for the modern industrialised, competitive, anonymous society. I have no time to elaborate, as I have said, but we have fortunately at last been able, my wife and I, to write up this whole story in the form of a book which is in the press now, and there we take our time not only in explaining these methods which take some explaining to psychiatrists who have been raised in such a totally different way of thinking than biologists, but in which we also have to describe in detail the case histories on which inevitably we have to base our conclusions. I would like to point out in conclusion that, although as an experimental zoologist I love to be able to run experiments with proper controls, that is in this case absolutely impossible. A, because of the fantastic complexity of the phenomenon of which most of the aspects haven’t even been described yet. B, because the cures take such a long time. And from the moment on you even suspect that you have spotted the factors that may bring on or perpetuate such a disorder, you are in the same position as the pharmacologist who begins to suspect that this or that drug may help in the curing of this or that disease. You are very reluctant to deliberately withhold treatment from a whole population and you would have really have to have enormous samples of thousands or tens of thousands of children, whom you would deliberately expose to these terribly damaging, fatal external influences. What we have learned from this, we think, from this little intrusion in a little corner of psychiatry, is that psychiatry as a prescience, in many respects a pseudoscience, is very much in need of an injection from even such a primitive science as ethology still is. Thank you for your attention.

Nikolaas Tinbergen (1981)

An Effective Therapy of Childhood Autism

Nikolaas Tinbergen (1981)

An Effective Therapy of Childhood Autism

Comment

This is the second of the two lectures that Nikolaas Tinbergen held in Lindau. Tinbergen pioneered experimental investigations on top of the “watching and wondering” which characterized most of ethology during the first half of the 20th century. But both lectures concern what can be learnt concerning autism by applying the methods of ethology, i.e. watching animal behaviour. In his first lecture at the Lindau Meeting 1978, he described the research project that he and his wife Elisabeth had started around 1970 and which was reported on already in his Nobel Lecture in Stockholm 1973. The main conclusion was that autism is not connected with the genes or is an effect of a brain damage. Instead a more psychoanalytical hypothesis was put forward, that autism derives from a hyperanxiety developed in the child through early loss of contact with the mother. In his second lecture, the present one, Tinbergen reported that they now had found a cure for autism. This cure originated with an American psychiatrist, Martha Welch, who had pioneered a therapy where the mother holds the autistic child for extended periods of time and thereby establishes contact with it. Tinbergen refers to an investigation where he and his wife found that almost all autistic children responded to the cure. Inspired by this result, they wrote a book together entitled “Autistic Children: New Hope for a Cure”, published in 1983. As of today, a detailed understanding of autism is still missing, but it seems clear that the hypothesis of the two Tinbergens is not the whole story and that there may be some genetical aspects of autism. Concerning their optimism of having found a cure, this seems also to have been somewhat premature.

Anders Bárány

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