Table of Contents

Timeline: Major Historical Developments in the Treatment of Autism
Autism Spectrum Disorders Defined
Autism in the Early 20th Century
Early Treatment Approaches
Autism as a Social and Emotional Disorder
Child Development and Autism
Behavioral Therapies for Autism Treatment
Autism as a Biological Condition
Psychopharmatherapies for Autism
Emergence of Behavioral Therapy for Treating Autism
Autism Spectrum Disorder and Current Treatment Practices
Applied Behavior Analysis

history of autism treatment

Timeline: Major Historical Developments in the Treatment of Autism

  • 1911  – Eugen Bleuler first uses the term autism to describe symptoms of schizophrenia
  • 1920s – Electroconvulsive therapy first used to treat symptoms of autism
  • 1920s – Emergence of dietary restrictions for autism treatment
  • 1943  – Leo Kanner first characterizes autism as a social and emotional disorder
  • 1944  – Hans Asperger publishes article on autism as a communication disorder in children
  • 1950s – Bruno Bettelheim coins the refrigerator mother theory
  • 1950s – Parentectomy is common treatment approach for autism
  • 1970s – Temple Grandin develops a squeeze machine for children with autism
  • 1970s – Shock therapy and aversive punishment mainstream autism treatment approach
  • 1970s – Guy Bérard develops auditory integration training for autism treatment
  • 1977  – Susan Folstein and Michael Rutter publish first twin study on autism
  • 1970s – Pharmaceutical treatments for autism become main treatment method
  • 1980  – Infantile autism is its own category in DSM-III
  • 1987  – Autism is expanded in DSM including diagnostic criteria
  • 1987  – Ivar Lovass develops intensive behavioral therapy for children with autism
  • 1997  – Emergency of special education programs for children with autism
  • 2013  – Autism spectrum disorders classified in DSM-V

Autism Spectrum Disorders Defined

Autism spectrum disorder refers to a range of disorders of brain development. Commonly known as autism, these conditions are characterized by difficulties in social skills, both verbal and nonverbal communication, repetitious movements, delayed child development and other unique strengths and challenges. In the phrase ‘autism spectrum disorder,’ spectrum refers to the variation in presentation of symptoms and assets of each individual with autism.

Also see: What Was It Called Before Autism?

The notion that autism is a spectrum of disorders is a relatively new phenomenon. Before 2013, autism spectrum disorders, such as Asperger’s syndrome and Kanner’s syndrome, were thought of as distinct disorder classes with independent treatments. In the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) in 2013, the American Psychiatric Association combined subcategories of autism and related conditions into one unified category with different characteristics and severity. Autism is now understood to be on a continuum with overlapping symptomology, caused by a multitude of complex genetic and environmental factors. This progression of the classification and etiology mirrors that of evolving treatment approaches for individuals with autism. Treatments have changed in the last century due to changing theoretical conceptions, new philosophies, and research advances in the field, ranging from biochemical to social and behavioral methods.

Autism in the Early 20th Century

The first appearance of autism in historical literature was in 1911 by Eugen Bleuler, a psychiatrist from Switzerland, who used the term to describe a unique cluster of symptoms that were traditionally thought to simply be symptoms of schizophrenia. Coming from the Greek word autos, autism was originally used to describe extreme social withdrawal that was common with psychiatric diseases that presented with psychosis. Although it is now known that autism and schizophrenia are two unrelated disorders, autism was not classified as its own disorder in any diagnostic manual until 1980.

Early Treatment Approaches

Electroconvulsive Therapy

Because of its association with severe psychiatric illnesses, one of the first treatment approaches for autism was electroconvulsive therapy (ECT). Historically an extremely controversial treatment approach, ECT methods have improved and are currently used to treat psychiatric illnesses such as schizophrenia and bipolar disorder. ECT involves passing small electric currents through the brain to intentionally trigger a brief seizure. The resulting seizure episode is hypothesized to change brain chemistry in a way that reduces mental health symptoms such as severe agitation and self-destructive behaviors. ECT is still used in some cases of autism spectrum disorder, although this is becoming increasingly rare as behavioral therapies have demonstrated greater efficacy.

Diet

Originating in the 1920s, one school of thought is that autism is caused by toxic dietary factors and thus can be treated through changes in a child’s diet. Although the exact biochemical dietary factors and nutrition recommendations have changed since then, some autism researchers, physicians, and parents are still utilizing strict restrictive diets in their treatment of autism. A gluten-free and casein-free diet, proteins found in wheat and milk products respectively, has been suggested to improve symptoms of autism in children. Proponents feel that autism may be caused by these proteins leaking from the gastrointestinal tract and reaching the brain. The evidence-base for a dietary treatment approach is mixed and restrictive diets are not a recommended treatment method by most autism research and physician groups.

Autism as a Social and Emotional Disorder

Autism was first characterized as a social and emotional disorder in 1943 by Dr. Leo Kanner, a child psychiatrist in the United States. In a paper published in the journal Nervous Child titled Autistic Disturbances of Affective Contact, Kanner describes a distinct syndrome characterized by children who are highly intelligent but have tendencies towards social withdrawal with emotional limitations.

Resource: Who was the first person to be diagnosed with autism?

Meanwhile, across the Atlantic in Germany, Hans Asperger was defining a different form of autism. Asperger published his autism psychopathology article in 1944, describing autism as a disorder of normal intelligence children who have difficulties with social and communication skills. Later thought of as a milder form of autism and now commonly known as Asperger’s disorder, children with Asperger’s tend to suffer similar challenges with social interactions but do not have the same language development challenges often found in Kanner’s disorder.

Child Development and Autism

Also see: How Does a Child Develop Autism?

The notion that autism is caused by ineffective social and emotional development in children first pointed to the parents as root causes of the disease. This is at a time in history where the contributions of heredity were not fully known, let alone the knowledge that complex genetic and environmental factors may influence mental disorders. Bruno Bettelheim at the University of Chicago was one of the first scientists to develop this theory in the 1950s, stating that autism is a psychological disturbance caused by apathetic mothers who were uncaring towards their children. Coined the “Refrigerator Mother Theory” because it was thought the mothers were especially cold towards their children, the treatment method used was removal of the child from their families.

Parentectomy, the removal of the child from their parents for long periods of time, was thought to reverse the defensive mechanism put it place by children of unloving mothers. Bettelheim was later found to have no psychoanalytic training and his reputation was tarnished. Researchers have found no evidence of a relationship between mother-child detachment and the development of autism, although some psychoanalytic theorists continue to promote Bettelheim’s philosophies to this day.

Holding therapy is another psychoanalytic treatment method stemming from the notion that autism is caused by a dysfunctional parent-child relationship. The treatment entails the caregiver physically restraining the child in a restrictive environment forcing eye contact. The physical restraint and eye contact is thought to promote attachment between the caregiver and child. There is no evidentiary basis for holding therapy as an effective form of treatment and in fact can be extremely dangerous to the child.

Temple Grandin, an individual with a form of high-functioning autism, developed a machine that gave her body squeezing pressure that she was under full control of. This squeeze machine allowed her to have sensory inputs of touch and pressure without having to be touched by another person, which she disliked. This is less dangerous than holding therapy because the child has full control of the machine, however there is no empirical evidence showing it is effective in reducing symptoms of autism.

Behavioral Therapies for Autism Treatment

Aversive Punishment

Forms of aversive punishment are common parenting tactics, such as placing a child in time out when they misbehave. The theory is that by punishing a child for unwanted behavior, the child will associate the behavior with the punishment and no longer perform that behavior. However, this type of punishment can be taken to varying degrees.

In the 1970s, autism was still thought of as a behavioral disorder, not a complex genetic and environmental developmental disease as it is today. Therefore, it was believed using forms of punishment would teach children to no longer exhibit extreme behaviors associated with the disorder such as disassociation and aggression. Shock therapy as a punishment-based treatment for autism was a mainstream treatment method during that period, in which the child was given an electric shock after partaking in an unwanted behavior. The shock administered was painful but not dangerous and theorized to reduce the frequency of that behavior through aversive conditioning. This form of behavioral conditioning has produced strong results in reducing unwanted behaviors with minimal side effects, and many parents are strong advocates for the treatment. However, as recently as 2016 the U.S. Federal Drug Administration (FDA) proposed a ban of the treatment because of ethical concerns regarding potential harm to the child.

Also see: Five Easy-to-Implement Behavior Strategies for Children with Autism

Auditory Integration Training (AIT)

Auditory integration training (AIT) for treating autism was first developed by Guy Bérard, a French physician, in the late 1970s. However, this technique was not commonly recognized until 1991 when a mother of a child of autism published a book, The Sound of a Miracle (Stehli, 1991), citing that AIT had cured her son’s disorder.

AIT is based on the theory that aggressive behaviors in children with autism are caused by hypersensitivity to sound. The treatment involves exposing the individual to a random variation of sounds for half-hour sessions over multiple days. The belief is this therapy will make the individual used to different auditory inputs and therefore perceive them as normal. Proponents of the treatment claim AIT therapy improves aberrant behaviors in children with autism, as well as improves cognition, memory and social behaviors.

There is no empirical evidence to suggest that AIT is an effective treatment for autism spectrum disorders. Multiple studies have been published on the topic, including the most recent in 2000 that compared AIT to ambient classroom noise. The authors concluded that AIT had no positive effect on individual children with autism, either for clinical or educational benefit. In addition, in 1998, the American Academy of Pediatrics’ Committee on Children with Disabilities published a statement on the use of AIT in children, stating “currently available information does not support the claims of proponents that these treatments are efficacious.”

Autism as a Biological Condition

The conceptualization of autism changed course in the later part of the 1970s. In 1977, Susan Folstein and Sir Michael Rutter published a study on twins in which 21 same-sex twin pairs where at least one of the twins had autism were studied. The authors found that there was a 36% concordance rate (also known as the heritability statistic) between twins, meaning that if one twin had autism the probability of the identical twin also having autism is 36%. From this result, the authors concluded there is a significant hereditary component to autism.

In addition to the twin study methodology, the breakthroughs in understanding the hereditary nature of autism occurred due to scientific discoveries in molecular genetics. Scientists had finally answered the question of the physical features of hereditary units, called genes, and how genes are passed from one generation to the next. This concept allowed a greater understanding of a multitude of diseases, such as cancer and autoimmune disorders, but also gave a different explanation to complex behavioral and developmental disorders such as autism.

Also see: Autism and Twin Studies

The emergence of biological theories of autism greatly changed treatment approaches. It was believed that biological conditions were best treated with biological treatments, namely medications. In addition, among psychiatrists there was an increased popularity in using psychotropic medications for behavioral disorders. Concurrently, other homeopathic or alternative medicine interventions were increasing in popularity.

One of these alternative treatments is secretin, a hormone involved in aiding digestion. Secretin injections are used for diagnostic purposes for gastrointestinal problems such as ulcers or pancreatic disease, but are not FDA approved for any other use. Building off the theory that autism is caused by toxic agents leaking into the gut from the 1920s and one mother’s claim of its success in treating her child, secretin became a widely-used treatment approach.

There is no reliable evidence to suggest secretin has any effect on improving any behavioral symptoms of autism spectrum disorder. In fact, the vast majority of research on the treatment has found no clinically significant differences between secretin treatments and a placebo. Despite the lack of evidence, however, secretin injections are continued to be used as a treatment for autism in children, with influential clinicians in the field continuing to advocate for its use.

Psychopharmatherapies for Autism

Pharmaceutical treatments have had increasing success in diminishing some of the behavioral symptoms of autism spectrum disorders, such as aggression, irritability, and self-inflicting injurious behaviors. Additionally, by reducing these intrusive behaviors, pharmaceutical treatments can aid the efficacy of other behavioral therapies such as applied behavior analysis (ABA), the most successful treatment for autism spectrum disorders.

Risperidone (Risperdal) was the first FDA-approved medication for treating symptoms associated with autism spectrum disorders in children. Known to act on dopamine receptors, multiple studies have shown risperidone has significant effects in reducing number of tantrums, aggressive behaviors, self-injury and other problematic behaviors among children with autism. The most common adverse effects of risperidone include dizziness, dry mouth, and increased appetite.

Aripiprazole (Abilify) is another FDA-approved medication for children with autism, specifically used to reduce irritability associated with the disorder. The exact mechanism of action is still unknown, but thought to be a partial agonist to both serotonin and dopamine receptors. Not only does evidence show that aripiprazole improves symptoms of irritability in children with autism, it also has been shown to significantly improve hyperactivity and quality of life. Relatively common side effects of the drug include weight gain and sedation.

Clozapine (Clozaril, Clopine) is an atypical (second generation) antipsychotic and was commonly used for the treatment of symptoms of autism before FDA approval for Risperidone and Aripiprazole. Clozapine is extensively used for treatment of schizophrenia, including reducing suicidal behaviors and aggression. Clozapine as a medication for autism spectrum disorders has been found to significantly reduce the number of days with aggression in children, and reduce the amount of psychotropic medications necessary to treat adverse behaviors. However, clozapine has significant side effects including excessive weight gain and metabolic syndrome and is infrequently used as a first-line treatment in children.

Haloperidol, commonly known as Haldol, is a dopamine antagonist used to treat a variety of neurological and mental disorders, including schizophrenia, Tourette’s syndrome and hallucinations. In addition, several studies have should Haloperidol is effective in improving social withdrawal and hyperactivity symptoms of autism in children. However, long-term administration of Haloperidol can have severe side effects of tardive dyskinesia (involuntary muscle movements), and should only be used with careful observation by a physician.

Emergence of Behavioral Therapy for Treating Autism

In 1980, infantile autism for the first time was listed in the in DSM-III, separated from childhood schizophrenia. In 1987, infantile autism in the DSM is replaced by a more expansive definition of autism that includes diagnostic criteria.

The Individuals with Disability Act (IDEA) was originally passed by congress in 1975 to ensure all children receive free and public education regardless of any disability. In 1997, an amendment was passed requiring special education for individuals with disabilities that allows students to access the general education curriculum that other students have. For the first time, this allowed children with autism spectrum disorders access to the same level of education as other children.

Special education for children with autism allows children to succeed in an education setting amongst their peers. Children with autism require comprehensive and intensive services, often combining special education, speech and language pathologists, occupational and physical therapy and others, all to work together to plan, problem-solve, and administer a child’s individualized educational program (IEP). These special education programs have been shown to greatly improve quality of life and allow children to succeed.

Related resource: 5 Ways Autism Can Affect Learning

Autism Spectrum Disorder and Current Treatment Practices

The reconceptualization of autism changed the landscape of autism treatment in two important ways. First, the idea that autism is present from birth and thus in part a biological condition paved the way for psychopharmacological interventions, and second, autism is a social and emotional disorder distinct from other mental illnesses and should be treated as such.

The Centers for Disease Control and Prevention estimates that autism spectrum disorders occur in approximately 1 out of every 68 children, and is more prevalent in boys than girls. Although the most obvious symptoms of autism typically appear between 2 and 3 years of age, autism can be diagnosed as early as 18 months in children. Unfortunately, however, the majority of children are not diagnosed until age four.

Early diagnosis and intervention for children with autism is critical and greatly improves outcomes of the disorder. The CDC recommends regular screenings of young children for signs of autism and parents are encouraged to monitor early signs and symptoms and bring any concerns to the attention of the pediatrician.

Applied Behavior Analysis

Applied behavior analysis (ABA) is the most successful evidence-based treatment approach for autism spectrum disorder. ABA is a behavioral learning program with theories from behavioral psychology that reinforces and encourages positive behaviors and discourages negative behaviors in children with autism spectrum disorders. In addition, ABA teaches children important new skills and how to apply those skills to real situations.

Ivar Lovaas, a psychologist from the University of California Los Angeles, is known as the pioneer of ABA therapy after his 1987 article Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children. In the study, children received 40 hours a week of intensive behavioral therapies following Lovaas’s methods and theories for two to six years. The results were striking. More than 90% of children that received ABA had significant improvements in symptoms, including socialization, and had significant cognitive improvements.

Currently, ABA is considered the gold standard for the behavioral treatment of children with autism spectrum disorders. There are multiple types of education programs for individuals interested in a career in ABA therapy at the undergraduate, graduate, and post graduate level. However, regardless of their educational background, all professionals require a certification before practicing in ABA therapy. Certificate programs include Board Certified Behavioral Analyst, Certified Autism Specialists, Registered Behavior Technician, and Autism certificates that complement another type of advanced degree.

Learn more about ABA from the following resources:

Key components of Applied Behavior Analysis
Top 25 Applied Behavior Analysis Programs
Overview of ABA Certification
Introduction to Autism

By Elizabeth Sinclair
Edited by Danelle Wilbraham