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 “Both parents and professionals who work with young children
CHILDR EN AND AUTISM

Cipa ni
with autism should read this book.”
—Temple Grandin, author
Stories of Triumph a nd Hope Thinking in Pictures: My Life with Autism
E n n io Cipa ni, Ph D

CHILDR EN AND AUTISM

“Both parents and professionals who work with young children with autism should read this book.
Many hours of intensive one-to-one behavioral therapy can bring about great improvements,
especially when it is started at an early age. The worst thing that can be done with an autistic 2- or
3-year-old is nothing. When I was two, I had all the full blown symptoms of autism. By age two and
CHILDR EN
a half I was in a therapy program for many hours a week. If my parents let me in the corner at a young
age, I would not be a college professor today.” and
AU TISM
—Temple Grandin, author, Thinking in Pictures: My Life with Autism

“In any discussion or material on autism the mere mention of the word “cure” elicits neck hairs to
rise…Cipani provides substantial and well presented material that demonstrates how early intensive
behavioral treatment (EIBT) has emerged as the most reliable, feasible and evidence based therapeutic
modality in addressing the myriad social, intellectual and communicative maladaptions evident in
children on the autism spectrum.”
—Rick Rader, MD, Editor-in-Chief, Exceptional Parent Magazine Stories of Triumph a nd Hope

C hildren and Autism presents seven heartwarming and compelling stories of children who
have triumphed over the challenge of autism. These are not stories of easy or simple remedies,
and there is no cure for autism. But there are instances of “best outcomes” where in the end the
autistic child is indistinguishable from their same-age peers. These are their stories. Parents can
draw hope and inspiration from these stories while also realizing that dedication, hard work, and
perseverance are key elements to success.

While these seven stories are the heart and soul of the book, Children and Autism offers more than
just that. The book opens with a section on what autism and applied behavior analysis (ABA) are.
It closes with a comprehensive resource section that helps parents locate ABA resources, provides
definitions, and offers advice on applying practices in the home.

Ennio Cipani, PhD is a full professor at National University in Fresno, California.

He is a licensed psychologist in California and works with teachers and families
providing behavioral consultations for children with disabilities. He has written
numerous books, book chapters, and articles on behavioral management and also
has extensive experience in providing behavioral in-home services to families with
children with developmental disabilities.
ISBN-13: 978-1936303014 Groundbreaking
51595
ABA
TREATMENT
11 West 42nd Street
New York, NY 10036-8002
www.demosmedpub.com
$15.95
9 781936 303014
Distributed in North America by Publishers Group West
Cover Design by Steven Pisano
Ennio Cipani
Children and
Autism
Children and
Autism
Stories of Triumph and Hope

Ennio Cipani, PhD

NEW YORK
Acquisitions Editor: Noreen Henson
Cover Design: Steve Pisano
Compositor: S4Carlisle Publishing Services
Printer: Hamilton Printing Company

Visit our web site at www.demosmedpub.com

© 2011 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright.
No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
Medical information provided by Demos Health, in the absence of a visit with a healthcare profes-
sional, must be considered as an educational service only. This book is not designed to replace a
physician’s independent judgment about the appropriateness or risks of a procedure or therapy
for a given patient. Our purpose is to provide you with information that will help you make your
own healthcare decisions.
The information and opinions provided here are believed to be accurate
and sound, based on the best judgment available to the authors, editors, and publisher, but read-
ers who fail to consult appropriate health authorities assume the risk of any injuries. The
publisher is not responsible for errors or omissions. The editors and publisher welcome any
reader to report to the publisher any discrepancies or inaccuracies noticed.
Library of Congress Cataloging-in-Publication Data
Cipani, Ennio.
Children and autism: stories of triumph and hope/Ennio Cipani.
p. cm.
Includes bibliographical references and index.
ISBN 978-1-936303-01-4 (alk. paper)
1. Autism in children—Case studies. 2. Behavior therapy for children.
I. Title.
RJ506.A9C487 2011
618.92⬘85882—dc22
2010031022

Special discounts on bulk quantities of Demos Health books are available to corporations,
professional associations, pharmaceutical companies, health care organizations, and other
qualifying groups. For details, please contact:

Special Sales Department

Demos Medical Publishing
11 W. 42nd Street
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Phone: 800–532–8663 or 212–683–0072
Fax: 212–941–7842
E-mail: [email protected]

Made in the United States of America

10 11 12 13 5 4 3 2 1
 Contents

Introduction vii
Contributors xiii

1. In the Beginning 1
2. What Is Applied Behavior Analysis? 7
3. Diamond in the Rough 23
4. Maggie Mae 57
5. Hey, Look, It’s a Train! 69
6. Good Golly Miss Molly! 83
7. The Case of Nicholas B. 99
8. A Parent’s Story: Jake and Nick 121
9. Why Artie Can’t Learn! 145

Appendix A: Why Is Joint Attention Important? 153

Appendix B: Parent Manual for the Get Me Game 155
Appendix C: Resources 163
Index 167

v
 Introduction

Having a child show symptoms of autism can be both heartbreaking

and scary for a parent. The deep-seated worry is that autism has for
many years been a harbinger of a poor prognosis for living an inde-
pendent life in mainstream society. However, it need not be so. There
is now strong evidence to suggest that in some cases, with early inten-
sive behavioral treatment (EIBT) over a lengthy period of time, their
life can be vastly improved. This book presents the stories of seven
children, diagnosed with autism, who received lengthy EIBT and their
subsequent progress in school and life. In reading each of their
stories, you will be amazed at their language, intellectual, and social
development.
All seven children achieved what is referred to as “best outcome
status” as a result of this treatment. Best outcome status is a child who
does not present the symptoms of autism anymore. That is, they are
indistinguishable from their same-age peers. You could observe them
at home, school, work, or in the community and not see any of the
signs or symptoms of autism. The current ages of these seven children
are from elementary grade level all the way to a college graduate in
economics (see “Chapter 3”). Their progress in skill development is
documented by the behavior therapist who provided the services,
taken from their case notes and data collection systems.

What Symptoms of Autism Are Addressed With EIBT?

Each of these seven children displayed severe learning and behavioral
difficulties at the outset. Make no mistake; these children were diag-
nosed with autism but through EIBT, they began to exhibit behaviors

vii
viii INTRODUCTION

that were age appropriate and socially appropriate. As you will read,
some of the parents of the children in these stories were previously
told by professionals to not expect much in the way of progress. It is
fortunate that these parents did not give up hope but rather proceeded
to find out how their child’s lives could be improved. As a result, these
dire predictions did not come true.
If you have a child with autism, you are probably familiar with the
symptoms and problems that afflict children with this diagnosis. Chil-
dren with autism display the following three major characteristics
before the age of three1:
• A qualitative impairment in social interaction
• A qualitative impairment in communication
• Restricted repetitive and stereotyped patterns of behavior,
interests, and activities
One of the most glaring issues with these children is their failure to
develop appropriate social relations with others. For example, a parent
may notice that their 6-month-old daughter does not smile back at them
when they smile at her. They may also notice that their child does not seem
to experience any joy, as other infants do when intrigued by something or
someone. On the other hand, as a toddler, their son fails to take any
interest in their presence and does not respond to his name by looking
toward the speaker. As a young child, he does not interact with others,
including adults, other children, and even his own siblings. Whereas
nondisabled toddlers and young children show delight when seeing their
parent after a brief time away from them and are delighted upon their
return, such is not the case with parents of children with autism. Upon see-
ing their parent, the child may simply continue with his or her activity or
fascination with an object he or she is engaged with. The child’s response
to his or her parents and others continues to be plagued with unemotional
detachment throughout his or her early and middle development.
Nondisabled children take great joy in sharing events and activities
with others, often saying such things as, “Look at____.” Also, their atten-
tion to someone else who initiates such an attention-getting phrase
immediately engages them. This has been referred to as joint attention
and is noticeably absent in children with autism.

1 Taken from the Diagnostic and Statistical Manual (DSM)-IV-TR, APA, 2000, p. 75.
INTRODUCTION ix

The good news is that an intensive form of early behavioral treat-

ment has demonstrated that such detachment from the social world can
be corrected in some cases2. As you will see in the following heartwarm-
ing seven stories, the children who received this treatment not only
engage in age-appropriate social interactions with their parents but also
have developed an important social network of friends and colleagues.

Leave me alone
Let us say that we have assembled a room full of preschool-aged
children. As we observe these children, some are playing together.
A few are playing by themselves, imagining that the toy blocks
they put together form a castle for the king and queen. All of the
children seem engrossed in their play activity except one child.
This child is alone in the corner. He does not have a toy, book, or
other item used in a play activity. Nevertheless, he is engaged in
something. You watch him closely and you see he repetitively
picks up the carpet corner (which is detached from the floor) and
lets it fall to the terrazzo floor. When it hits the floor, it makes a
sound like “plop.” He is totally engrossed by the sound it makes.
One child comes over to him and says, “What are you doing,” in an
inquisitive manner. He is unresponsive and continues to be
intrigued by the action-reaction produced. Not getting any social
response from this boy, the other child goes off and finds another
child to play with. The boy in the corner continues the repetitive
activity with the carpet for the entire play period.
During story time, this child does not seem interested in the
colorful book or what the teacher is saying. He gets up multiple
times and attempts to go back to the corner of the room where
the carpet corner is unhinged from the flooring. He seems to be
unnerved that the source of his entertainment during the morning
is not available to him. The teacher’s helpers bring him back to
the circle area to be involved in the activity, but to no avail. While
other children volunteer information about the story, this child
seems oblivious to this activity and disinterested as well.

2 Although the overwhelming majority of the children in EIBT efforts improve a number of
behaviors and gain skills in language, social, and pre-academic areas, only a certain percentage
achieve best outcome status and become indistinguishable from their same-age peers, as in the
case of these seven individuals in the book.
x INTRODUCTION

At the end of the school day, parents pick up their children.

Almost every child is excited to see their mother and/or father
and is verbose in the details of their escapades that morning. This
joyous reunion is the case for all the children except this one
child. When his mother comes in, he does not acknowledge her
presence. Rather, he continues to play with the carpet corner. He
seems oblivious to the ending of the preschool day. His mother
calls him several times, but he does not even acknowledge such
verbal requests, as if his hearing was temporarily impaired. She
finally goes over to him and gets him to take her hand. He goes
without comment.

A second prominent characteristic of children diagnosed with

autism is a lack of language and communication skills. In some cases,
vocal language is completely missing. They may use gestures and
nonverbal behaviors when they see a rare need to communicate with
others. In other cases, the child may be vocal but simply repeat spe-
cific words that he or she has heard. This manifestation of vocal
behavior is termed “echolalia.” Echolalia involves immediate simple
reproduction of someone else’s spoken language. Such children are
unable to respond to simple questions such as, “What did you eat for
breakfast this morning?” They will simply repeat the question, that is,
“What did you eat for breakfast this morning?” with perfect imitative
intonation.
Some children have delayed echolalia, where their vocal speech is
simply an imitation of a phrase that they have heard previously, but is
produced arbitrarily (wrong context, without any social function).
Upon observation for a period of time, it becomes apparent that their
vocal fluency does not translate to language competence. Such children
might respond nonsensically to simple questions such as, “What did you
eat for breakfast this morning?” with, “train goes down the tracks.” If
the child does have some basic language skills, it is often at a rudimen-
tary level and certainly not at an age-appropriate conversational level.
A child who is 8 years old may be able to identify three colors (red,
orange, and yellow) instead of 30 different colors.
The seven children portrayed in this book now show usual or
superb proficiency with the English language, in both social and aca-
demic settings. Their current language skills would not seem odd or
INTRODUCTION xi

deficient. Such a symptom of autism has disappeared in each of these

seven cases. Further, their intellectual development has allowed them
to proceed and succeed in life, both socially and educationally and in
one case, in a demanding career.
Children with autism often engage in repetitive movements called
stereotypic or self-stimulatory behavior. This repetitive pattern occurs
to the exclusion of many other behaviors. If a teacher gets out a story-
book with lots of pictures, many preschool children would immedi-
ately flock to the floor area, with excitement as they listen and watch.
For many children with autism, their intrigue with their ritual pattern
would take precedence over such a social activity.
What are some examples of stereotypic behavior? Some children
engage in rocking in a chair back and forth over and over again hour
upon hour in a single day. Other children engage in stereotypic behav-
ior that involves flapping of one’s hands repeatedly again possibly hun-
dreds of times in an hour time frame. Such behaviors are pervasive
over time, and it is often the reason why parents and teachers report
being unable to “reach” children with autism. Although the children in
these stories were initially plagued by a variety of such stereotypic
behaviors, treatment produced dramatic results in this area. Two
resulting phenomena from the children’s treatment are very apparent:
The seven children portrayed in this book do not currently exhibit
such stereotypic behaviors, and they all have a diverse set of interests
and skills in their repertoire.
 Contributors

Audrey Gifford, MEd, BCBA, is a parent of a child who has, through

ABA treatment, received a best outcome diagnosis from autism.
Ms. Gifford has spent many years teaching both regular education and
special education and received extensive specialized training in ABA and
discrete trial training (DTT) as well as other behavioral methodologies.
In 1998, she founded Bridges Behavioral Language Systems in the
Sacramento, California, area to provide intensive ABA services to young
children with autism. She lives in Citrus Heights, California, with her
husband and the youngest three of their six children.
Tamlynn D. Graupner, MS, is cofounder and CEO of the Wisconsin
Early Autism Project. Ms. Graupner is currently completing a doctoral
program in Pediatric Neuropsychology and holds a BS in Psychology
and Behavioral Science from the University of South Florida and an
MS in early childhood development–early childhood administration
from the University of Nebraska. Ms. Graupner’s research interests
include the study of brain differences in children with autism before
and following intensive ABA therapy.
Justin Leaf, MA, is a graduate student at the University of Kansas who
has worked in the field of autism for 6 years. Justin Leaf began his career
working for Dr. Ron Leaf, Dr. Jon McEachin, and Dr. Mitchell Taubman
at Autism Partnership, both as a behavior therapist and as a research
coordinator. His research interests center on improving social skills for
children with autism, developing friendships for children with autism,
and comparing different teaching strategies. He is currently a private
behavioral consultant in the Kansas City and Lawrence area, as well as
the codirector of The Social Skills Group at the University of Kansas.

xiii
xiv CONTRIBUTORS

Ronald Leaf, PhD, is a licensed psychologist who has more than

35 years of experience in the field of autism. At the University of
California, Los Angeles, he served as clinic supervisor, research
psychologist, interim director of the Autism Project, and lecturer. He
is the author of Sense and Nonsense in the Behavioral Treatment of
Autism and It’s Time for School: Building Quality ABA Educational
Programs and coauthor of the book A Work in Progress. Dr. Leaf is a
codirector of Autism Partnership. He is also the Executive Director of
the Behavior Therapy and Learning Center, a mental health agency that
consults with parents, care providers, and school personnel.
Jamison Dayharsh Leaf, MS, is a licensed marriage and family thera-
pist. Ms. Leaf is the director of the Behavior Therapy and Learning
Center. She began working with children with autism in the late 1970s at
the University of California, Los Angeles, on the Young Autism Project,
where she served as a senior therapist, research assistant, and teaching
assistant. Ms. Leaf has worked with Dr. Leaf and Dr. McEachin at the
Young Autism Project, the Behavior Therapy and Learning Center,
Straight Talk, and the Autism Partnership. She has consulted on a
national and international basis to families that have children with devel-
opmental disabilities. Ms. Leaf also coauthored A Work in Progress.
Rebecca P. F. MacDonald, PhD, BCBA, is a licensed psychologist in
Massachusetts and a Board Certified Behavior Analyst (BCBA) who
serves as the director of the Intensive Instructional Preschool Program
for children with autism at The New England Center for Children.
Dr. MacDonald has been at The New England Center for Children as the
clinical director off and on since 1983. Dr. MacDonald has presented her
research at numerous conferences over the past 20 years and published
studies that have appeared in the Journal of Applied Behavior Analysis,
Research in Developmental Disabilities, and Behavioral Interventions.
Glen O. Sallows, PhD, is cofounder and president of the Wisconsin
Early Autism Project (WEAP). He has been working in the field of
autism for more than 25 years. He received his doctorate in Clinical
Psychology from the University of Oregon and trained with Dr. Ivar
Lovaas at the University of California, Los Angeles, prior to starting the
WEAP in 1993 with Tamlynn D. Graupner. Ms. Sallows and Graupner
continue to study the effectiveness of ABA therapy and have brought
this treatment to children in the United States, Great Britain, Canada,
Central America, and Australia.
 1
In the Beginning

As the saying goes, “we have come a long way.” Autism as a separate
and distinct disorder is a phenomenon of the last half century. The
common diagnosis given to children who displayed the bizarre and
unusual behaviors described above was that of childhood schizophre-
nia. In 1943 a psychiatrist, Dr. Leo Kanner, identified 19 children who
exhibited characteristics and symptoms that he felt were qualitatively
different than children diagnosed with childhood schizophrenia. He
characterized these children’s behavior by the presence of the follow-
ing symptoms: (a) an extreme detachment from human relationships,
(b) an excessive demand for requiring sameness (i.e., requiring the
physical environment to be predictable), (c) an inability to use lan-
guage to communicate, and (d) a fascination with objects. Based on his
initial report along with a follow-up report of 120 children by
Eisenberg and Kanner in 1956,1 the identification of children with early
infantile autism was founded. Perhaps the thing that most set these
children apart was their detachment from their social environment. In
particular, the child and its mother seemed to be unresponsive to each
other during psychiatric consultations. It was probably this pattern of
behavior that was a major factor in the formalization of this disorder
and helps explain the theory that first emerged to explain the disorder.
Unfortunately, the child’s unresponsive manner to their parents (and
vice versa) led to misguided theories about why this would be. The term
“emotional refrigerator” was coined in a book by a psychoanalytically

1 Eisenberg, L., & Kanner, L. (1956). Childhood schizophrenia. American Journal of

Orthopsychiatry, 26, 556–566.

1
2 CHILDREN AND AUTISM

trained psychiatrist, Dr. Bruno Bettelheim, to describe the mothers of

these children. His contention was that these children failed to develop
appropriate attachment because of their mother’s nonresponsiveness
to their child. Although the phenomena he observed is a major feature
of autism, it is fairly evident in current views that such behavior is not
the result of the parent’s emotional or behavioral response. Rather, it is
the child’s pattern of avoiding social interactions and not providing the
social cues for attention, affection, and social reciprocity that is more
likely the cause of the parent’s lack of responsiveness.
As a result of this hypothesis, the cause of the child’s autism was
thought to be a result of the mother’s emotional aloofness, and treat-
ment involved psychotherapy for the mother. This prevailing (and inef-
fective2) psychoanalytic view dominated the field of autism throughout
the 1950s and 1960s until two significant changes transpired. In the
1960s, the view that the disorder of autism probably resulted from neu-
rological processes (and not the mother’s response to her child) was
advanced, chiefly by Dr. Bernard Rimland at the University of
California, Los Angeles (UCLA).
The second, and I believe a more significant force, for examining
autism in a different light was treatment research initiated in the mid-
1960s providing positive proof that these children and their behavior
could be changed. Dr. Ivar Lovaas, the founder of comprehensive early
and intensive behavioral treatment (EIBT), developed the instructional
procedures for teaching the basic building blocks of language and
communication to children with autism. Many believe his greatest con-
tribution to the field was his belief that children with autism could
actually improve their language and social skills. In contrast to the
other approaches at the time, treatment involved both the targeting of
problem behavior and the building and development of language and
social skills. The manner in which such skills were developed was
called discrete trial training. His groundbreaking work with children
with autism spanning a five-decade period demonstrated the profound
effect EIBT would have on children.
Educational and language programs up until that time had not
taken into account that some children would need thorough, regular,

2 Brown, J. L. (1960). Prognosis from presenting symptoms of pre-school children with atypical
development. American Journal of Orthopsychiatry, 30, 382–390.
IN THE BEGINNING 3

methodical instruction in acquiring the English language. The develop-

ment of language was assumed to occur by the mere exposure of chil-
dren to a language-enriched environment. Therefore, systematic
teaching of skills that are requisites for more advanced language skills
was deemed to be unnecessary. But that is not necessarily true. Even
today, many preschool special education programs for children with
autism are predicated on the exposure theory of language
development3 and that is not enough for children with autism.
Children with autism in Lovdas’ nationally recognized treatment
program were initially taught to imitate upon command, both nonverbal
and verbal behaviors. Nonverbal imitation involved doing something,
such as clapping your hands and having the child repeat that action.
Vocal imitation initially involved making single sounds or phonemes
and shaping approximations to those sounds. From these initial starts,
the child was taught to come closer and closer to the sound being mod-
eled until it was able to match that sound. From these early matched
vocalizations, the child was then taught to imitate several words and
then develop the skill to match any word produced by the therapist.
After these children were able to imitate behavior and vocalizations,
they were taught words to identify objects, actions, relations, and
possession. Children continued working on these language skills,
resulting in some of them speaking in short sentences after a time
frame of a year.
Why did this effort succeed in developing language where other
efforts had failed? First, in contrast to the psychoanalytic view, Lovaas
and colleagues conceptualized the child’s problems as one of skill
deficit, requiring direct intervention. Providing psychotherapy to the
mother had proved useless in terms of benefit to the child. Second, the
EIBT approach was to directly teach such skills by presenting frequent
opportunities to perform such behaviors until the child mastered them.
The children were no longer expected to develop language from the
natural course of play and interaction with other children and adults.
Even today, this can be an issue in schools. Having children with
autism who do not currently speak (or attend for that matter) in pre-
school activities such as circle time, story time, and so on, makes the

3 Exposure theory should be logically discounted and viewed as inherently flawed because
children with autism often came from families where English is spoken regularly. This theory
would only make sense in families where language is rarely used.
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