Principles for Directing Both

Educational Treatment and Research

ERIC SCHOPLER

This chapter is based on 25 years' involvement with children diagnosed with autism or
related developmental disorders. During this period of time, my colleagues and I have
developed a statewide, community-based system located in our Psychiatry Department at
the University of North Carolina School of Medicine: The Division for the Treatment and
Education of Autistic and Communications Handicapped Children (fEACCH). Described
in detail elsewhere (Reichler & Schopler, 1976; Schopler & Olley, 1982; and Schopler,
MesiiX>v, Shigley, & Bashford, 1984), TEACCH is North Carolina's statewide system for
providing children and adults with autism and related developmental disorders with
comprehensive service, relevant research, and training of professionals. Home and family
adjustment is facilitated through six regional TEACCH Centers. Individualized educational
programming is developed through 92 TEACCH-afTiliated public school classrooms under
our program direction. Community integration is facilitated through parent groups attached
to Centers and classrooms and affiliated with state and national parent organizations.
Parental perspective is implemented at each program level.
In this discussion, I will review both the primary obstacles to the development of
our community-based system, and also the most useful and important concepts and
principles that have made it viable for this relatively extended period. By now, it is quite
widely recognized that following Kanner's (1943) publication of autism, psychoanalytic
theory was the primary and mistaken basis for explaining and treating that condition. The
children were said to be withdrawn from pathological parents - "refrigerator mothers" -

167

C. Gillberg (ed.), Diagnosis and Treatment of Autism

Springer Science+Business Media New York 1989

whose unconscious attitudes and wishes produced the autistic symptoms. Treatment was
primarily a parentectomy, or placement away from parents in a residential institution
(Bettelheim, 1967).
Our own research (Schopler, 1971; Schopler & Loftin, 1969, a & b) and that of
others (Cantwell & Baker, 1984) produced a consensus of empirical data showing that
parents were not the primary cause, but victims of autism much like their children. On the
strength of these data, we began helping these children through their parents as cotherapists (Schopler, 1971). We evolved a parent-professional collaborative relationship
in which we developed an optimum individualized teaching and behavior management
program for each child.
We found that we could accept parents' statements of concerns, without
reinterpreting them according to theoretical assumptions about their unconscious motives
and attitudes. In those cases where parents misunderstood their children or how to manage
them, we made it the staff's burden to show evidence for such misunderstanding or
mismanagement, rather than the parents'. We incorporated parental experience into our
diagnostic formulations, and incorporated parental perspectives into our individualized
educational programming, research, and professional training. The resulting TEACCH
system for the study and treatment of autistic children has been used as a model in many
states and countries, and has been shown effective in several outcome studies (Marcus et
al., 1978; Short, 1984; and Schopler et al., 1982). Figure 1 shows long-range outcome
(Schopler et al., 1982) for our children compared with six other studies. In these six
studies, between 38% and 76% of the autistic children were institutionalized in mental
hospitals after they reached adulthood (Creak, 1963; DeMyer et al., 1973; Lotter, 1974;
Mittler et al., 1966; and Rutter, 1970). In the TEACCH sample, on the other hand, only
7% of the sample was institutionalized, including 4% placed in group homes. The
remainder stayed in the community. This study confirmed what we believed clinically: that
autistic and similar children can remain with their families, function better, and at a lower
cost to the community when there is a viable community support system.

BACKGROUND APPRAISAL
Looking back over the past 25 years, it is intriguing to identify some of the
factors contributing both obstacles and progress to the understanding and treatment of
autistic children. In the field of mental health and education, Freudian theory and
psychodynamic variations had achieved pre-eminence during the post World War II
period. Both specific etiologial explanation and specific treatment techniques were
frequently overused or misapplied. Theoretical justification, rather than empirical evidence,
168

Rate of Institutionalization
of Autistic People

80

"0

Q)

60

.!::!
Oj

c:

.5

40

"EQ)

e
Q)

a..

20

Creak
1963

Mittler
1966

Rutter

1967

Rutter

1970

DeMyer

1973

Lotter

1974

Schopler
1982

Follow-Up Studies

Figure 1

169

was considered sufficient for guiding intervention. Empirical research was of interest to
only a few scientists, and they were not primarily involved in education or treatment.
During this same period from 1940 to 1960, there appeared an increasing proliferation of
specific therapies or educational techniques. These were sometimes introduced by
untrained people, or representing special interests. No doubt the professional
establishment's preoccupation with treatment based on theory rather than empirical
evidence contributed to the proliferation of specific techniques.
From the field of autism alone, I have compiled a list of specific treatment
tedmiques that have appeared in the literature during the past 20 years. This list is intended
to be suggestive rather than all inclusive:
TABlE 1 Specific Treatment Techniques for Autism
Aversive therapy

Goldfine treatment

Patterning therapy

Behavior therapy

Holding therapy

Psychical therapy

Dance therapy

Interactive therapy

Speech therapy

Deinstitutionalization

Logo therapy

Pony therapy

Developmental"therapy

Megavitamin therapy

Play therapy

Fenfluramine treatment

Mainstreaming

Music therapy

Electroconvulsive shock
therapy

Phenothiazine
treatment

Sensory integration

Extensive comparisons between these specific techniques or concepts could be made. But
for the purpose of this discussion, it is sufficient to identify some of the features they all
seem to share in common with each other:
(1) Each seemed like a reasonably good idea to the initiator. Sometimes it bad
been known to correct a similar problem or to add a corrective element. Sometimes it was
based on a coincidental observation or intuition. But regardless of source, the initiator was
convinced it was reasonable to try this technique with someone in this clinical population.
(2) By the time a particular treatment technique or concept bas appeared in print, it
has invariably appeared effective for one or more cases. The resulting improvement was
convincing to one or two observers. But because it was a single case observation, the
reason for the observed improvement could not be demonstrated. It may have been caused
by any number of other related factors, including spontaneous fluctuation of behavior.
Nevertheless, even single case improvement claims attract attention, inspire hope, and are
considered worthy of media coverage. This increased interest sometimes promotes further
trials or even controlled study.

170

(3) The third aspect shared by these specific techniques is that they are studied
with additional cases in controlled studies. These replications are sometimes based on low
probability hypotheses without adequate theoretical justification, but born from desperate
clinical frustration. Regardless of the replication method, none of the specific techniques
listed has been effective with all children.
(4) Moreover, continued use also shows that each technique has costs or negative
side effects not predicted in the flush of pilot study drama. The specific treatment concept
or technique in question becomes a short-lived fad which often produces unnecessary
disappointment and unintended harm.
The above limits to the use of specific techniques and concepts appear to warrant
pessimism or hopelessness. This is not the case. Compelling evidence has been presented
(Frank, 1961) that non-specific treatment factors have precedence over specific techniques.
These are based on the faith found in the relationship between doctor-patient, parent-child,
or teacher-student. It is such a relationship that allows access to the best understanding of
the more dependent individual's problems or learning difficulties, along with the best
knowledge of the currently available techniques. It is the therapeutic aspirations of this
non-specific relationship that permits determining the most favourable technique, evaluated
from a cost-benefit ratio for the individual involved. This determination is fmally less a
scientific decision than one based on the art of treatment or education; that is, knowing the
individual with his complex history, and matching it with the best available treatment.
From my perspective as an educator, it appears that any of us can become
unwittingly involved in extending a treatment technique or concept beyond the limits of
supporting evidence. In so doing, we may caricature that reasonable idea and tum it into a
short-lived fad, which can do harm or cost more than it is worth.
In our experience with developing the TEACCH system, we are often pressed to
over-extend one of the relevant treatment concepts. For example, we had spent a good deal
of research effort on the hypothesis that parents of autistic children can function as cotherapists with professionals (Schopler & Reichler, 1971; Short, 1984). Both clinical
experience and empirical data supported a positive answer to this question. However,
some tried to interpret these findings to mean that parents' educational priorities should
always be given priority, or that the same type of co-therapy relationship should be
implemented without modification to parents of psychopaths, suicidal depressives, or
schizophrenics.
I am pleased to report that with the TEACCH system so far we have avoided better, resisted - this fad development, by adhering to certain administrative priorities.
These enabled us to develop some viable and lasting guiding principles of treatment and
education. Our first administrative priority grew out of our commitment to parent
collaboration. It required providing the best treatment and education permitted by the state
171

of the art. Concurrently, we made a commitment to study and support research into
problems that were obstacles to understanding the disorder of improving the child's
adaptation. In case of conflict between these two priorities, we would be inclined to resist
having research interfere with treatment. Our next priority was to develop training and
development of staff to implement both service and clinically relevant research.
Given the above priorities, it is not surprising that the most enduring principles
and concepts that we have identified are seven capable of generating both clinical and
empirical research data. These principles evolved at a time when an accumulation of
research indicated that autism was not a single-cause emotional illness induced by parental
pathology. Instead, it was a multiply-caused chronic developmental disorder. And
although biologically based, the adaptation of individuals with autism could be greatly
enhanced through special education.

PRINCIPLES AND CONCEPTS GUIDING TEACCH SYSTEM

Improved Adaptation
The firSt principle is that the child's adaptation can be improved in two ways. One
is to improve the child's skills, especially for communication and social interaction.
Second, when the child's deficit prevents the acquisition of a new skill, then the
environment can be modified to accommodate the deficit. Either of these two ways will
improve the child's adaptation.
Clinically, this principle is important because it acknowledges that both skill
enhancement and environmental modifications are needed for children with developmental
disorders like autism. It recognizes that even in the absence of specific cures, optimism can
be maintained because two intervention approaches are available that will improve
adaptation, rather than only one.
From the perspective of empirical research, this principle was consistent with
of
some our outcome studies. For example, we studied the effects of parent training on
their own children (Marcus et al., 1978) and found that the children showed significant
improvement in attention to task and cooperation with adults. In another outcome study,
we measured the effects of structured teaching versus unstructured teaching (Schopler et
al., 1971), and under structured conditions we found significantly better social relatedness
and attentiveness, and also a significant decrease in bizarre behavior, over the unstructured
conditions.
172

Parent Collaboration
Our second principle is that d:rildren are best helped through and with their parents
as co-therapists or collaborators with professionals. At the clinical level, this principle has
had too many applications to summarize easily. However, implications can readily be
found in our organizational structures, clinical procedures, and parent-professional
relationships (Schopler et al., 1984).
Central to our clinic operation is the one-way observation room. After completing
the evaluation, the therapist demonstrates certain teaching or behavior management
techniques. These are written out in a home teaching program, and implemented by parents
and/or siblings at home. Parents frequently introduce new procedures from their own
observation and experience, which become a meaningful component of their child's
optimum individualized educational program. Such programs were compiled in Schopler,
Lansing & Waters (1983). The parent-as-co-therapist model was extended into
collaboration with the child's teachers. Parent-teacher collaboration occurred along a
continuum of intensity, ranging from parent functioning regularly as an assistant teacher in
the classroom, to monthly telephone contacts. This relationship played a central part in
mediating the children's central difficulty in generalizing learned skills from one place to
another.
Parent-professional collaboration involves four types of relationship (Schopler,
1987): ( 1) When professionals are the trainers, and parents are trainees. This approximates
the traditional authority dependent interaction. (2) In the next interaction, the traditional
roles are reversed: Parents are the trainers, and professionals are trainees. This comes from
more recent recognition that parents usually have both the capacity and the motivation to
understand their own children. Their experience, observation, and educational priorities
are incorporated into the treatment plan. (3) Mutual emotional support from professionals
to parents and vice versa. This important interaction comes from the recognition that
children with developmental disorders are often slow to learn and can be more frustrating
to parents and teachers than other children. (4) The fourth relationship involves social
advocacy, in which parents and professionals collaborate to develop community
understanding of their children's special needs, and cost effective services not currently
available.
Relevant empirical research regarding parent collaboration in our system has
included disproving the notion that parents produce their d:rildren's autistic symptoms with
their own disordered thinking. Our studies showed that parents of autistic children show
no more thought disorder than other kinds of parents, and that thought disordered
behavior can be induced by test anxiety from professionals' psychodynamic judgments
(Schopler & Loftin, 1969, a & b). In a related study, we questioned the conventional
173

professional wisdom of the time that parents misunderstood their severely disturbed
children. We compared parental estimates of their children's developmental levels before
diagnostic evaluation. with test results of the same functions after formal testing. We
found that parents' estimates correlated significantly with test-based estimates, and that
parents with mildly disturbed children were relatively poorer estimators than parents with
more disturbed children (Schopler & Reichler, 1972). Not only could parents usually
estimate their children's level of function reasonably well, they also were effective as
trainers and co-therapists (Marcus et al., 1978).

Assessment for Individualized Treatment

The third enduring principle is that individualized educational program and
treatment are based on developmental diagnostic evaluation and assessment. The
importance of this concept comes from the frequently systematic professional
misunderstanding of autistic children. During the early history of the autism syndrome,
professionals frequently considered these children untestable (Alpern. 1967). Moreover,
some behaviorists have de-emphasized or ignored assessment or testing of autistic children
for the purpose of distinguishing the differences between behaviors that can be shaped and
modified, versus those whose rigidity was linked to a developmental deficit. More
recently, a new treatment ideology has emerged under the banner of "mainstreaming".
Some of the fervent mainstream enthusiasts advocate that all handicapped individuals are
habilitated by placement in a "normal" environment without appropriate education and
assessment.
In the TEACCH system, we have found that both formal and informal diagnosis
and assessment are needed in order to determine an individual's educational program,
implemented in the least restrictive environment, and safeguarding each individual's right
to optimum treatment. At the clinical level, this has meant training staff and students in
naturalistic observation and how to make informal assessments of each client in different
life contexts (Mesibov, Troxler, & Boswell, 1988).
Empirical research involved the development of a number of assessment
instruments. These have included the Childhood Autism Rating Scale (CARS) (Schopler et
al., 1980; Schopler et al., 1988). This instrument is used for making the diagnosis of
autism from systematic observation. This diagnosis, however, is not sufficient for the
individual assessment needed for defming an optimum treatment program. To accomplish
this, we developed the Psychoeducational Profile (PEP) (Schopler & Reichler, 1979),
currently revised for a more thorough inclusion of the preschool population (Schopler,
Reichler, Bashford, Lansing, & Marcus, in press). This assessment instrument was
174

extended to the adolescent and adult population with the Adolescent and Adult
Psychoeducational Profile (AAPEP) by Mesibov, Schopler, Schaffer, & Landrus (1988)
for the purpose of evaluating the client with autism for the best vocational and living
arrangement possible.

Teaching Structures
Our fourth principle is that education is based on structured teaching. Clinically,
the importance of this concept was repeatedly observed and reported during the 1960s and
70s when autistic children were primarily treated in non-directive (Axline, 1947) and
psychodynamic (Ekstein, 1954) play therapy. These frequently seemed to result in lack of
progress and the need for residential treatment, thus giving impetus to the more structured
treatment of operant conditioning, and the educational program developed in our system
(Lansing & Schopler, 1978).
At the level of empirical research, we were able to demonstrate that autistic
children functioned better under structured conditions than they did under unstructured
conditions, and that individual variations in response to structure correlated with
developmental levels. Children of lower levels of developmental function benefitted more
from structure than did children at higher levels (Schopler et al., 1971). This study
demonstrated a fmding that has become more viable with subsequent experience. Since
then, we have evolved more sophisticated teaching structures for different levels of
function (Schopler, Lansing, & Waters, 1983). These have been applied to public school
classrooms throughout our TEAU::H system in North Carolina. This system has been
taught in a fmely-tuned training program under the leadershipof Dr. Mesibov (Schopler &
Mesibov, 1988) and has been applied in different cultures, including Japan, Belgium and
France. The importance of structured teaching is now widely recognized and implemented.

Skill Enhancement
Our fifth principle underscores that the most effective approach is to enhance

skills of children and parents, and to recognize and accept their shortcomings. This concept
follows along with our assessment emphasis. One of the primary purposes of the
assessment instruments reviewed under the assessment principle is to distinguish between
emerging skills which can be enhanced immediately, and deficit areas for which training is
better delayed or treated with environment structures. The emphasis on working with
existing and emerging skills has been reaffmned by clinical experience for the past 20
175

Problem Areas
1. AGGRESSION

Specific
Behaviors

-Pushing
-Hitting
-Spitting
-Throwing

Deficits

- Unawareness of Feelings of Self

- Poor Social Judgement

and others
- Sensory Misperceptions
- Frustration over Communication
Problems

Figure 2

176

years. In fact, it is fair to say that this emphasis has been effective not only with children
and parents, but also with staff and trainees.
The suggestion is sometimes made that such skill development emphasis is most
effective with more able children and parents. Our experience has been to the contrary. For
example, recently a schizophrenic mother of an autistic child was referred to us after being
released from six months of in-patient treatment. She had improved during hospitalization
but felt unable to resume caring for her family and household. After assessment, it was
found that she had some recollection of making Jello, a favorite family dessert. After a
week of intensive training in Jello making, she was able to prepare it on her own. This
gave her the necessary impetus to begin cooking and preparing other meals in the past.
Skill emphasis did not cure her schizophrenia, but enhanced her adaptation.
At the empirical research level, we completed a study of parents' perception of
program helpfulness (Schopler, Mesibov, DeVellis, & Short, 1981). Parents reported
most program helpfulness with problems in their child's social relationships, motor skills,
self-help skills, and communication. Children with higher IQs improved more in language
and self-help skills than did children with lower IQs. In a pre-and post-treatment study
based on observations of children in their own homes, Short (1984) found significant
improvement in both parent involvement and in appropriate child behavior.

Cognitive and Behavior Therapy

Our sixth principle refers to the enduring usefulness of cognitive and behavior
theory for guiding both special education and research, theoretical systems eloquently
reviewed by Gardner ( 1985). At the clinical level, the application of these two theoretical
systems can be illustrated with the management of difficult behavior. Figure 2 outlines an
iceberg to represent problems of aggression. The smaller portion of this entity shows
above the water line, or is visible in the form of specific behaviors like pushing, hitting,
biting, or kicking. Below the water line are possible explanations for the cause of particular
aggressive behaviors. It could be frustration over communications deficit; therefore, hitting
at the teacher rather than signalling for her attention. It could be a child's misperception of
pain or inability to understand behavior rules. Through careful observation and
assessment, the best explanatory cause is identified, and used as the basis for intervention.
If it is frustration over communication, we can teach a word, a sign, or a signal. If the
aggressive hitting behavior decreases, our explanatory theory is supported. If, on the other
hand, hitting continues, a different explanatory mechanism is involved.
At the level of empirical research, we have developed a communications
curriculum (Watson et al., 1989). It includes data collection in four different semantics
177

categories, especially important in the communication problems of autism. See Table 2.

Context in column one refers to the place in which the communication unit was learned or
practiced. Column 2 refers to what student said, using word, sign, picture, or body
language. The third column represents the student's communicative intent, and the fourth
column is for grouping the semantic category used in the student's communication. The
assessment of these four communication dimensions offers both a data base for research
and a basis for teaching strategies with individual children.

The Generalist Training Model

The seventh principle refers to intervention and training in the TEACCH system.
That is, professionals concerned with autism are trained as generalists who are expected to
know the entire range of problems raised by this disorder. Traditionally in the United
States, the field of mental health has emphasized specialization. Psychologists conducted
evaluations, speech pathologists provided speech therapy, social workers specialized in
family work, psychiatrists preferred psychotherapy, and so on. This is an understandable
phenomenon considering the long training required of professionals in various disciplines.
Unfortunately for families seeking help for their handicapped children, specialization
structures professionals to be interested in, or accountable for, primarily their own area of
specialization. This increases the likelihood that parents receive inconsistent or
contradictory opinions on diagnosis and treatment. Moreover, it makes it difficult for
anyone to take professional responsibility for the entire child. The generalist model reduces
these undesirable consequences of specialization. It enables staff to see the child from the
parents' perspective and to work collaboratively with them. It increases staff responsibility,
makes the job more interesting, and improves staff ability to use consultation from
specialists more effectively.
From the perspective of training, we have developed an intensive multidisciplinary training model. It incorporates didactic sessions on the eight topics we have
found basic to the study and treatment of autism and related developmental disorders.
These eight topics, summarized in Table 3, are presented in didactic format during half the
training sessions, and illustrated directly with a group of autistic children during the other
half session. This training program was filmed by a Japanese documentary film group in
1986, and has been effectively applied in Belgium, France, Japan, and the United States.

178

-.J

CD

towel (signs)

finish (signs)

1. Makes mess while

making breakfast

2. Work-folding

X
X

pushes jar away

drink (signs)

R. picks up cola bottle

+ signs drink
bathroom (signs)

6. T. hands R. orange
juice

7. R. opens refrigerator

8. T: "Drink what?"

12. Finishes playing

with cards

11. "-

shoe (signs) + holds up

untied shoe
finish (signs)

10. R's shoe untied; toT. shoe (signs)

X

drink (signs)

5. T: "What?"

9. R. stands up

handst. a cup

FUNCTIONS
Request Getting Reject Comment Give Seek
attention
info info
X

4. "-

touches teacher's arm

3. Free time - R
walks into kitchenette

WHAT STUDENT
SAID OR DID

CONTEXT

Student: Ralph. Observer: Warren. Date: 1/17. Time began: 9:30. Time ended: 11.30.

TABLE 2 Comnumication Sample

Other

object
acted on
object
acted on

wanted

object

object
wanted

object
wanted

own
action

own
action

own
location

SEMANTIC CATEGORIES
Object Action Person Location

Other

TABlE 3 Topics for Generalist Training

1.

Characteristics of autism

2.

Diagnostic assessment, formal and informal

3.

S1ructured teaclJing and reducing behavior problems

4.

Collaboration with parents to expedite client adaptation

5.

Communication issues

6.

Independence and vocational training

7.

Social and leisure skills training

8.

Behavior management

CONCLUSION
In this presentation, I have reviewed some of the specific therapy techniques and
research concepts that have sprung up in the field during the past four decades. Many of

these specific technologies and con~ were used beyond the limits of their supporting
data and have become short-lived fads. They do offer brief periods of hope to parents and
others, frequently with silence about limits, costs, and side effects. In the evolution of the
TEACCH system, we have attempted to reduce overuse of theories and treatment
techniques by adhering to the use of empirical research and the rules of evidence. Towards
this end, we have identified seven principles or concepts found most viable in our
TEACCH system over the past 25 years. These seven principles have remained viable
because they apply both to clinical practice and research, fostering the use of empirical
evidence in bo1h of these areas.

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