Language Construction in an Autistic Child: Thoughts

Regarding Language Acquisition and Language Therapy:

Translation, Update, and Commentary
on a 1977 Case Report
Hellmut Thomke, PhD* and Katharina Boser, PhDw
Abstract: A 1977 Swiss case study is presented in English
translation: a mute child with infantile autism is taught to speak
starting at the relatively late age of 6. The author, who is the
primary therapist and the childs father, details the conditioning
procedure, discusses theoretical considerations in speech acqui-
sition, and outlines the limits of the training. The author and
translator update the childs status and add commentary.
Key Words: autism, conditioning, language acquisition, speech
therapy, nonverbal
(Cog Behav Neurol 2011;24:156167)
INTRODUCTION AND TRANSLATORS NOTE
Katharina Boser (KB)
The core of this paper is KBs translation of a 1977
article by Thomke,
1
then a professor of German
Literature and Language at the University of Bern,
Switzerland. Dr Thomke was reporting on his use of
operant conditioning to teach language to his son,
Heiner, who had nonverbal autism. Both father and son
are identied by name here because they were named in
the original publication.
At the time that Heiner was diagnosed, many
contemporary accounts of improved speech production
in autism were claiming that if aected children could not
speak by age 5, they would never be able to learn to
speak.
24
The perception of a critical period for
language development has continued despite evidence of
older children acquiring speech. In fact, a 2009 literature
review by Pickett et al
5
documents 14 studies in which 15
children aged 5 or older, including Heiner Thomke, were
trained to speak spontaneous multiword or phrasal
utterances.
3,617
The reviewed studies used many methods
to aid speech/language development, among them sign
language and special prompting techniques. Higher
pretraining intelligence quotient scores, ability to imitate,
and other individual characteristics may have given some
of the children a potential advantage over Heiner. Pickett
et al
5
confirmed that longer therapy generally correlates
with a higher level of language attainment, and specifi-
cally that children need at least 3 years of therapy to reach
the highest level, which is spontaneous phrases. (Heiner
had 2 years and 3 months of intense therapy.) The study
also showed that longer treatment did not always
correlate with better outcome. What stands out in the
article is that of all the children studied, only 9 whose
diagnosis and treatment were well documented were aged
6 or older when instruction began and learned to produce
phrases. Heiner Thomke was one of those 9.
Dr Thomke writes in remarkable detail about his
sons therapy, progression, and results. The authors
background as a language philosopher has given him
special insight into not only his childs language abilities
but his own theoretical arguments for the techniques that
he used to train Heiner. Because a father is writing about
his own son, the reections must be somewhat subjective.
Further, the lack of a research design precludes scientic
proof that the behavioral conditioning was responsible
for the improvements in Heiners speech. But the paper
gives us a snapshot of therapies for children with autism
in Switzerland in the late 1960s and 1970s.
The therapies outlined are not intended to be
prescriptive or even replicable, but rather descriptive.
Several resemble techniques used today. For example, Dr
Thomkes redirecting therapy in response to Heiners
interests is a part of Pivotal Response Therapy.
9
The
fathers use of pictures and objects to help Heiner learn to
communicate presages the Picture Exchange Commu-
nication System.
18
And his technique of training and
reinforcing one small skill until it was rmly learned, and
then building on it in the next skill taught, is known as
shaping and chaining.
19
Received for publication August 18, 2011; accepted August 18, 2011.
*Professor Emeritus of German Literature and Language, University of
Bern, Bern, Switzerland; and wIndividual Dierences in Learning
and Boser Educational Technology, Ellicott City, MD.
HT is the author of the original paper, updates, and some commentary.
KB is the translator of the original paper and updates, and author of
some commentary.
This research was supported by the Cognitive Neurology Gift Fund and
by the Therapeutic Cognitive Neuroscience endowment and
gift funds.
The authors declare no conicts of interest.
Reprints: Katharina Boser, PhD, Individual Dierences in Learning and
Boser Educational Technology, 4120 Sears House Ct, Ellicott City,
MD 21043 (e-mail: kboser@gmail.com).
Copyright
r
2011 by Lippincott Williams & Wilkins
HISTORICAL UPDATE
156
|
www.cogbehavneurol.com Cog Behav Neurol

Volume 24, Number 3, September 2011
Dr Thomke opens his paper by describing the
confusion and hope that he and his wife felt when they
were confronted with the need to teach their 6-year-old
mute son to speak. They are frustrated not just by the
diculty of the task but by the lack of human and written
resources available to guide them. Dr Thomke develops
his operant training system through trial and error,
studying the psycholinguistic and developmental psychol-
ogy literature, and recognizing the reasoning behind
things that he does instinctively. He chastises himself for
not starting Heiners therapy earlier and not being able to
give as much time to it as he would wish. Not
surprisingly, he also has mixed feelings about the success
of his eort. But through his work, Heiner gained
functional language and kept learning after his formal
training ended. Although Heiners expressive and recep-
tive language skills have remained limited and he never
learned to read or write, his ability to speak has enabled
him to be more independent than he could have been
otherwise, and his receptive language developed to the
point that he has long been able to enjoy listening to
recorded stories. Even this partial success has greatly
improved his quality of life.
Thanks to Dr Thomkes generous willingness to share
and revisit his paper, we have been able to augment
Heiners early history, therapy, and results, and add
updates about him and his abilities over the 37 years since
his intensive language training ended at age 8. [New
material added within the translated paper is shown in
brackets.] Dr Thomke also approved the addition of several
section headers to mark natural transitions in the text, and
the deletion of 3 footnotes not considered crucial.
In 2011, we still seek best practices to help autistic
children learn language. In the United States, some school
districts have failed to implement evidence-based treat-
ments for students with autism spectrum disorder,
2023
many because of a lack of training.
24
The use of applied
behavioral analysis for autism in Switzerland has grown
only since about 2001, largely because 2 mothers
advocated for it. Dr Thomkes 1977 psycholinguistic
approach serves the whole child, using sound, form, and
meaning, based on a profound knowledge of language
structure and philosophy. If his intense training succeeded
in enabling a mute older child to speak in sentences, we
may be able to apply his methods to younger children and
to children with milder autism spectrum disorders.
Language Construction in
an Autistic Child: Thoughts
Regarding Language
Acquisition and Language
Therapy
1
(Originally published as: Sprachaufbau bei einem autis-
tischen Kind: U

berlegungen zum Spracherwerb und zur

Sprachtherapie. Schweizerische Zeitschrift fur Psychologie
und ihre Anwendungen. 1977;36:118.
1
)
Hellmut Thomke
Translation from the original German by KB
Language acquisition is in many ways still such a
great puzzle that the person who stands before the task of
teaching language to a child who has not learned to speak
on its own, hardly knows how he might bring this about
and where he might begin. Professionals and academic
texts on language therapy also leave him for the most part
in the lurch.
Similarly, parents of a nonverbal autistic child are
left with feelings of confusion combined with an intuitive
sense that if they dare an attempt, perhaps a way will
open itself to them; however, without strong method-
ological experience or scientically supported ideas about
the best approach, this is not something achievable for the
long run, something my experience with Heiner, my own
child, taught me.
How intuition and reection can play a role, and
how I came to draw conclusions about language
acquisition by examining a single case of pathology
my own sonmay be illustrated by the following
example: when in Heiners presence, our family decided
quite spontaneously to more clearly stress (intone) the
most meaningful words, increasing the importance of
sentence melody. It was only after quite a period of time
that we began to realize that Heiner might perceive our
speech more easily through this change of sentence stress.
This thought was based on ideas in the newer medical
literature about early autism, in which such children were
found also to have a higher probability of perceptual
impairments, which make the normal development of
symbolic abilities (including language) impossible. With
this notion arose the idea that perceptual abilities might
actually be a prerequisite for language acquisition. Later,
I became convinced of the importance of auditory stress
and sentence melody by studying the psycholinguistic
literature, in which the stress of the tonal gestalt of
sentences and the intonation of utterances are hallmarks
of the preverbal phase of language acquisition (references
25 and 26, among others). In addition, I determined that
by overemphasizing intonation, we created in Heiner a
preference for so-called content words over function
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
157
words. [Content words are words with a real-world
referent: nouns, verbs, adjectives, adverbs. Function
words have no real-world referent; they have meaning
only within syntax, eg, if, and, but, and that.]
Content words not only stood out most prominently
throughout Heiners language instruction, but they also
take priority in the early language acquisition phases of
nonlanguage-impaired children. Thus, it seemed an
important thought that the sound patterns of language
provided particular direction for Heiner as he learned
specific types of speech acts.
[Heiner is the youngest of my 3 children. His sister,
Elke, was born in 1959. She was healthy until age 22
months, when she suered a serious fall, with a great loss
of blood. This led to excessive growth of her tongue,
which made it dicult for her to speak. At age 4,
probably also related to the fall, she developed temporal
lobe epilepsy. A seizure at age 15 caused her to drown.
My second child, Roland, born in 1962, grew up normal
and healthy.]
[Born in 1966,] Heiner appeared in his rst year to
develop normally, both physically and cognitively.
Although his babbling phase was not very productive,
at 10 months he was able to produce the sound sequences
mama, papa, tatata, and nan. In his second
year, however, his development halted [and, by 18
months, he could not produce a single sound]. At the
time, there did not seem to be a specic reason for
Heiners muteness. Soon early signs of autism appeared.
He hardly reacted to speech, he avoided eye contact, and
he did not want to be touched. He preferred to watch
things that spun and twirled, like wheels. Only somewhat
later did he show a fear of change. Strangers thought
he might be deaf, although his hearing was tested
many times and was always normal. He often reacted
to very faint sounds, but generally tried to escape from
loud noises. Yet, from an early age, he was engaged
by music.
He received the diagnosis of autistic tendencies,
mute at about 2 years of age. Not long thereafter, the
diagnosis was revised to childhood autism. Later he
was described as a schwer (severe) case. [The initial
diagnosis was made in 1968 by Dr Hanspeter Matthys,
then the only privately practicing child psychiatrist in the
State of Bern. In 1970, the diagnosis was conrmed at the
pediatric clinic at the University Hospital of Bern.] It was
a typical case of Kanners syndrome. Heiner also had
digestive diculties resulting from unexplained food
allergies and perhaps a diculty in tolerating sucrose.
(This made it extraordinarily dicult to nd an appro-
priately motivating reinforcer during the conditioning
training.) Multiple attempts to modify his behavior
through medication failed. However, thioridazine (Mel-
laril) and pyritinol (Encephabol) seemed to bring about
some improvement at rst.
[More on medicines and medical care: Starting
shortly before Heiner turned 2 years old, and continuing
until about his third birthday, we tried many medicines to
treat his autistic behaviors and severe insomnia. There
were so many medicines that I can no longer name them
all, but I do remember these: the antipsychotic drug
thioridazine (Mellaril) and the antihistamine hydroxyzine
(Atarax) did not help. The anticonvulsant carbamazepine
(Tegretol) did nothing but give Heiner gum infections.
Among the benzodiazepines tried, diazepam (Valium)
15 mg did not calm him or make him sleepy; neither did
nitrazepam (Mogadon), which in higher doses led to
vomiting. Among the neuroleptic drugs, thioridazine was
only mildly calming; haloperidol (Haldol) and levome-
promazine (methotrimeprazine) were stopped after 2
weeks because they not only made him more restless
but he looked morose and seemed to be suering.
Sedatives such as barbiturates, and a combination of
methaqualone plus diphenhydramine, did not help his
insomnia.
The 1 medicine that really seemed to help Heiner
was centrophenoxine (Lucidril). His cheeks turned rosy,
he became happy and calmer, and he made eye contact
for the rst time. However, after only 3 days the doctor
stopped the drug, saying that it was too dangerous. I did
not mention Lucidril in the original article because I was
not knowledgeable about the drug and could not nd
research on it.
None of the medicines we tried improved the severe
problems that Heiner had falling asleep. I would have to
lie in bed with him, holding him totally still for about 50
to 60 minutes, until he nally relaxed and fell asleep.
Often he was back up at about 3 AM, coming into my bed.
There he quickly fell back to sleep so that I could carry
him back to his own bed. After a few years of this, his
sleeping problems disappeared.
After the fruitlessness of our initial attempts at
giving Heiner medicines, we gave up on all of them for a
while. Some years later, the doctor prescribed the
psychostimulant pyritinol (Encephabol), which Heiner
took for many years. At rst this drug appeared to have
some benet, but after a time it seemed to wear o. The
broad failure of medicines led the psychiatrist to conclude
that only pedagogical intervention would help. His advice
led to the beginning of the behavior therapy described in
this paper.
Initially, I wondered whether Heiners autism could
have resulted from his early digestive problems. In 1970,
specialists at the pediatric clinic in Bern thought this
possible but did not have any specic evidence. They
diagnosed Heiner with a mild chronic intestinal infection,
probably caused by a wheat allergy, but they did not nd
celiac disease. Biopsy showed a secondary sucrose
intolerance. Later that year, Heiners pediatrician put
him on a special diet similar to one used for patients
with celiac disease: no glutens, very little fat, and
avoidance of vegetables known to cause digestive
problems. Further, Heiner was not allowed any dis-
accharide sugars like sucrose or lactose; glucose was used
instead. He was also given pancreatin (a combination of
lipase, amylase, and protease). Used together for about
10 years (ages 4 to 13), these measures normalized
Heiners digestion. When he was 19, he starting living
Thomke and Boser Cog Behav Neurol

Volume 24, Number 3, September 2011
158
|
www.cogbehavneurol.com
r
2011 Lippincott Williams & Wilkins
from Monday to Friday at a group home for adults with
autism. The home served such poor and unbalanced
meals that Heiners digestive problems recurred and he
had to be restarted on pancreatin. I nally stopped the
drug in 2006 when it caused Heiner an outbreak of
eczema. Since then he has not taken any medications or
had digestive problems.
At age 3, Heiner began to have recurring tonsillitis.
At age 3 years 6 months, he underwent a tonsillectomy
and the infections stopped.]
[Once Heiner stopped speaking (at around 18 mo)],
he remained mute except for an occasional mama and
papa that seemed to have no real meaning. The dental
sounds t and n that he had earlier were gone. [He did
not hum or exhibit echolalia. He did not repeat syllables
until these were trained, and he did not repeat phrases
from songs unless these were specically requested much
later on.] At age 2 he tried to make himself understood by
taking either my wifes hand or mine, and using it to point
to the location where he wanted something. If the object
or item was something he could get himself, he would do
this instead. At about 4 years, we realized that his
language comprehension was also very constrained. Only
through systematic training, which occurred somewhat
later, would this improve. Even before a systematic
behavioral treatment plan was begun, when we tried to
engage him Heiner would occasionally try to imitate the
articulation locations of vowels, but he could not produce
a sound. It seemed very unlikely that he would speak
without some kind of training. His case showed us that
engaging autistic children in any systematic way requires
a strong, methodologically grounded therapy. The lack of
this recognition among local speech professionals, to-
gether with most therapists practices of bestowing
gentleness, love, patience, and trust in the healthy soul
that has lost its way in a sick body, really angered us,
especially because we received absolutely no useful advice
for years.
When Heiner was 5 years old, we took him to a
Bern University speech disorders clinic in the hope that
they would begin some kind of language therapy with
him. However, they claimed that unless he could learn to
concentrate and imitate, he could not be helped. Working
with experienced teachers at a good kindergarten, he had
made only small steps in this direction. My disappoint-
ment was that much greater because I knew from
previous experience that there was only the smallest hope
that he would learn language at this late age. The
literature of the time claimed that a child who did not
speak by age 6 years would never speak and would
remain extremely mentally retarded. The fact that Heiner
appeared to be an attentive and intelligent child was weak
consolation, but it motivated us not to give up attempts at
speech just yet. His intelligence per se could not be
reliably tested. For example, his Vineland score at 5 years
and 3 months gave him an intelligence quotient of 56,
which put him at a social age of 2;11, an overly favorable
estimation of his abilities.
Speech Sound (Phonemic) Training
The systematic speech training began when Heiner
was 6 years and 5 months old. My wife and I began with a
Hungarian behavioral therapist (Heilpadagogin) who
had trained in Budapest and had her own clinic for many
years. She had worked with mute and deaf subjects, but
had little experience with autism. She did have experience
with the Pavlovian method of behavioral conditioning,
and taught us, as parents, a number of its principles. We
had avoided speaking to Heiner in motherese
shortened, simplified words. We decided to train him in
high German [rather than Swiss dialect German], for
several reasons: Heiners mother spoke high German,
Heiner had few relationships with children who spoke the
dialect, and articulation in high German is much more
precise and can therefore be more easily practiced.
Finally, early attempts at teaching Heiner to read and
write high German had shown that this was not an
impossibility [although, unfortunately, no further prog-
ress was made].
[Each week the Hungarian therapist gave Heiner at
most 2 training sessions, each lasting 1 hour. Because she
worked in her home, my wife or I had to take Heiner to
her and we sat in on the sessions. In addition to her
therapy, I worked with Heiner for about 6 hours a week,
in 12 half-hour sessions. My wife and I became concerned
about the therapists rigor and, at times, well-meant
fanaticism. Heiner would become aggressive when she
held him tight and would not let him go, and because she
did not give him a sense of aectionate engagement
(Zuwendung. There is no equivalent word in English.
Zuwendung is any behavior, verbal or nonverbal, that
engenders aection in another.) Therefore, I increasingly
took her place as the primary therapist. After about 18
months, we stopped seeing the therapist entirely, and I
conducted Heiners intensive training alone.]
The training [with me] seemed to be fun for Heiner,
but only when he was in a good mood. [Early on, he
would squeal when he did not want to work anymore and
did not want to sit still. When he was upset, he could not
even cry; he could only manage to pant.] The training
time was gradually lengthened. It was accompanied by
rhythm exercises and exercises involving body imitation.
During the course of the work, I attempted to familiarize
myself with behavioral therapy through readings (un-
fortunately, the possibility of undertaking speech training
like that described by Lovaas et al
3
was as yet unknown
to me). At the same time, however, I maintained a critical
distance from methods of operant language conditioning
because of my language research knowledge and educa-
tion in modern psycholinguistics and the theory of speech
acts. [A speech act is a spoken or nonspoken commu-
nication, such as a greeting, request, invitation, compli-
ment, apology, complaint, or refusal.]
There was a certain ethical mistrust of behavioral
therapy among speech-language professionals in Switzer-
land at the time, yet I made myself familiar with what were
then considered authoritarian training methods, realizing
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
159
that these would be indispensable for a developmentally
challenged child. I also had some practical experience in
this method and with speech therapy, since I had tried it
with my daughter to reduce her articulation impairments.
First, I determined that eye contact needed to be
established (although I admit that the necessity of this
came to me only later). I used operant conditioning with
continuous reinforcement. At the table where the training
was conducted, Heiner would receive a primary reinforcer
for every eye contact made. In this case, it was a piece of
salad, his favorite food. We could not give him sweets
because of his special diet. Later he received glucose. He
would also get praise and a fond rub on his back; these
would later become his main reinforcers. The result was
almost instantaneous. Soon, I reinforced eye contact only
if it lasted at least 3 seconds, then 5 seconds, and later 10
seconds. I used the same conditioning method to teach
him quiet sitting and imitating physical exercises. [At rst,
he was unable to sit quietly without some force, such as
an adults hands bearing down on his shoulders.]
The initial language therapy goals were to help
Heiner perceive sounds auditorily in a meaningful way
and to be able to distinguish individual sounds from one
another. Upon presentation of a given sound, he was
asked to imitate a given behavior associated with the
sound. The rst exercise was for him to knock on the
table and be able to distinguish fast from slow knocking.
At rst his hands were led to do this, but this support was
removed in a stepwise manner until he independently
imitated the therapists motions across from him. He was
intermittently rewarded. The next step was for Heiner to
learn to hit a xylophone, a tin drum, and a water glass as
well as ring a bell. Again, we rst used a hand-over-hand
method. Then each of these objects was ordered accord-
ing to its sound, which was then associated with the sound
of 1 of the basic speech vowels, xylophone [a7], bell [e7],
tin drum [o7], and water glass [i7]. First, Heiner learned to
hit the appropriate object when he heard the correctly
associated vowel. After a while, he was asked to say the
vowels while he hit the objects. Soon he was able to hit the
xylophone upon hearing the associated vowel, and then
the tin drum and bell. The [i7] (water glass) took him
longest to learn. Finally, the attempt to introduce a fth
sound [u7] failed. Heiner learned this last [u7] vowel only
much later, once it was used together with the consonants
[g] and [k] to distinguish it more clearly from [o7].
After he consistently responded to 3 vowels, Heiner
had to learn not only to imitate the sound but also
the articulation position of the vowel after observing the
therapists mouth. We worked together for a long time
using a mirror. In this way, Heiner was able to combine
auditory and visual impressions to produce consonants
that were coupled with the vowels (ie, to produce
syllables). Before training, he occasionally produced [p]
and [m] by chance. These consonants were combined
to form pe-pe and me-me, as well as ap-ap and
am-am. After pa-pa he was required to distinguish
ba-ba. After the bilabials, the dentals [t, d, n, l] were
introduced. The back consonants were very dicult for
him. Heiner produced the velars [g] and [k] as well as the
glottal [h] successfully only by using a speech therapy
technique. For example, we initially used a tongue
depressor to ensure proper tongue placement for the [g].
Later, Heiner used his own nger in its place. Finally, it
was enough for him to hold his index nger near his open
mouth, at which point his tongue would retract auto-
matically. New consonants were used and practiced in the
context of syllables. At the same time, we introduced the
dierence between short and long, open and closed
vowels, as well as umlauts and diphthongs. In addition
to [i7] and [u7], the [y7] was dicult, as were [r] and the
fricatives. When Heiner tried to vocalize an [r], it often
made the vowels surrounding it sound wrong. Later he
used [l] for [r]. The [j] was easier to learn, but the [v] was
somewhat more dicult. He could produce [f] only
weakly and when combined with other sounds, but was
aided by blowing out a candle. The ich sound was weak
at rst, but surprisingly strong after exactly 2 years.
Heiner did not learn the ach sound; this seemed to be
replaced by the glottal stop [<]. At the same time, he was
taught voiced and voiceless [z] and [s]. After 4 weeks of
daily practice, using the same method as described for eye
contact, he learned a clean voiceless [s] that was rewarded
stepwise with the salad. We taught him the aricate z
[ts] using a trick, by rst training a strongly aspirated
[t]. He could produce consonant clusters like [pl] and [gl]
only once these sounds were made more distinguishable
from one another by putting a schwa [=] between the 2
consonant sounds and then blending the sound out again.
The [F] was trained by allowing Heiner to bind an
alveolar [n] with a [g].
Training Short Phrases and Word
Comprehension
The sound system or babble training was not
much fun for Heiner. For this reason, we combined words
with their meanings long before the whole sound training
was nished. The training of individual phonemes was
concurrent with learning the production of sentence-
like requests such as Bitte Salat (please salad) and
Ich esse (I am eating). It seemed reasonable to introduce
2- and 3-word phrases once Heiner could produce single
words with reasonable, understandable articulation. The
training of meaning began by our passively showing him
objects and pictures in which these objects were found,
while we spoke the objects names. We asked him to point
to either the object or picture when he heard the word
(eg,Where is the apple?y There!). Pictures were
easier to use at the table. Within the pictures, he was most
likely to recognize objects that he knew from his
environment. Specically, his comprehension was most
accurate for pictures that depicted the object in its most
natural or realistic form (eg, in color and 3-dimensional).
After some time, Heiner became much better at recogniz-
ing more abstract forms of objects, and he was able to
recognize objects in reality that he had learned only from
pictures.
Thomke and Boser Cog Behav Neurol

Volume 24, Number 3, September 2011
160
|
www.cogbehavneurol.com
r
2011 Lippincott Williams & Wilkins
[At rst, Heiner confused such words as tomato
with banana, and donkey with horse. I corrected
such errors through clearly demonstrated speech in front
of the mirror, and later while seated across from Heiner. I
helped him by forming his mouth and tongue for correct
articulation, rst with his ngers and later also with a
tongue depressor, as described above. When Heiner
confused object names, I would set the objects or pictures
in front of him and point to each one, saying the correct
word. Then Heiner had to pick out the correct picture and
was rewarded.]
After Heiner learned to imitate words on his own
during the initial training, the type of question used in
comprehension training was changed from where
questions to what or who questions. Even if he
could not quite articulate it accurately, he was asked to
produce the correct word in response. At rst he was
asked to produce only 1-syllable words; soon thereafter,
we expanded to 2-syllable to 4-syllable words. For
combined word forms such as teakettle and bathtub,
it was dicult for Heiner to deal with the doubled and
hierarchical word stress. After some time, he was required
to produce the associated article (eg, der, die, das).
It was dicult at this point to determine accurately the
degree to which what Heiner produced was merely
imitation of syllable structures rather than speech
production that referred to something substantive and
meaningful. As Heiners vocabulary increased, so did the
incorrect agreement of the gender of the specic article
and noun combination necessary in the German lan-
guage. Heiner generalized and used a universal article
sounding something like de.
At rst we practiced only concrete nouns, because
they often constitute the majority of productions in normal
child language. Heiner learned only very few adjectives.
We tried color terms rst, but it was very dicult for
Heiner to dierentiate colors. In contrast, he learned the
adjectives warm, cold, broken, quiet, and good
(good in describing the taste of his food). Because he had
broken many owerpots while twirling them, the concept
of broken was the clearest of all to him.
After presenting pictures of things to Heiner, we
showed him pictures of actions. Now we asked him
questions like, What is the man doing?ybathing,
eating, etc., or Who is that? What questions were
easier for him than Who. I practiced these with Heiner
in concrete situations. I speculated, however, that he was
more interested in the fact that someone was running or
bathing than who the person was. For this reason, I
decided to focus more on the naming of verbs and actions
than objects and features. I purposefully attempted to set
up most concepts with a focus on the verb, and from the
verb to work on the building of the sentence. The fact that
verbs tend to be less frequent in normal early child
language was not a consideration at this point, but was
probably also not an error since verbs may just not
appear in the surface structure.
Another experience inuenced the focus of the
training and the nature of the practice in these dramatized
situations. My wife and I had tried to force Heiner to
speak by refusing to react to his attempts to point or take
our hands to indicate what he wanted. Now Heiner began
to grab our mouths and open them to show him what he
should say when he could not. After about a year of
teaching, Heiner produced his rst 1-word sentence: an
imperative speech act: Geige! (violin, meaning
Papa, get the violin!). After a few months, he began
to use other words as requests: baden (bath, meaning
I want a bath) or auto (car, meaning I want to
ride in the car), brot (bread, meaning I want
bread), and platte (record, meaning I want to hear
the record). [By this time, his squeals to indicate that he
was nished with a training session were gradually being
replaced by aufstehen (stand up).] The next step was
that he had to say please bath or please car. In this
way he learned to make his rst syntactic connections. We
arrived at this by modeling and speaking along with
Heiner, followed by saying only the rst syllable, then
only the rst sound, and then silently forming the rst
sound. In the end, we were able to eliminate these
instructional aids entirely.
Training 2-Word and 3-Word Sentences
After 18 months of training, Heiner began to use
2-word sentences as they might appear in the adult
language. Three months later, we instituted a systematic
exercise of such sentences. I came up with a list of verbs
that Heiner understood and that he could produce
clearly. The verbs referred to actions that he knew from
daily life and that interested him: eat, drink, sit, stand, lie,
bathe, build, paint, come, cry, laugh, iron, sew, hop, clap,
swing, drive, run, ride, whistle. These were all intransitive
verbs (eg, build would be intransitive if there were no
building built). These verbs could be part of fully
grammatical 2-word sentences created from only a subject
and a predicate. At the same time, I also constructed a list
of nouns that could be combined with these verbs; mama,
papa, Elke (Heiners sister), Roland (Heiners brother),
the man, the woman, the boy, the girl, the doll, the car,
the train. Some of the nouns required an article, so that
now we could practice a 3-word sentence with a specic
article. I presented 3-word sentences in analogical
succession, working with pictures and photographs of
the events. For example: The man bathes, the woman
bathes, etc. The man paints, the boy paints, etc. The
man laughs, the woman laughs, the boy laughs, etc.
Soon Heiner also learned to substitute Bitte
(please) with Ich will (I want). Then, in place of
please, he was asked to use I want (eg, I want
bread or I want stand upthis phrase always
followed working at the table). If he were asked to
imitate a sentence like, I want to have a record, then he
would shorten it to I want record. In this way he
produced a 3-word sentence with a subsequent sentence
part in which he treated the infinitive (to have) and the
concrete noun (an accusative object, eg, record) in the
same way. Next, the third-person singular and first
person were used as subjects in 2-word sentences:
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
161
I bathe, I draw. In this way, Heiner learned 3 inflected
forms of the verb: baden (infinitive), bade (first
person), and badet (third person). The usual difficulty
with personal pronouns demonstrated in autistic children
could be avoided through behavioral conditioning ther-
apy. Heiner began to use the personal pronoun (first
person) on his own. The second person was purposefully
omitted until later in the therapy. The reversal of personal
pronouns by autistic children is usually explained by
echolalia or a disturbed sense of self. At the point of
teaching pronouns to Heiner, he already seemed to have a
clearly developed sense of Ich (I), potentially strength-
ened through the training. Amongst other evidence was
his response of ich (I), and later mir (to me),
when he was asked, To whom does the bed (or do the
toys) belong?, although this response had never been
explicitly trained. To the question of what he had done
one afternoon, he answered several times, Ich will badet
(I want bathed). This was a good sign to us that we
could now introduce Heiner to the perfect verb form.
Discussion
Whatever we may have achieved during the 2 years
and 3 months of training Heiner, the fact remains that
almost all of his production required many prompts
(including questions and requests that specically elicited
speech acts). Many productions were still poorly articu-
lated and Heiner did not reach a normal speech rate or
intonation, that is, sentence melody. Judged against the
accomplishments of a normal childs language, I could be
tempted to conclude that we had achieved very little, but
given Heiners entirely mute state before training, the
accomplishment was great. However, the question of
whether Heiners language development would accelerate
beyond that point would not be answerable. At 8 years
and 8 months, he entered a special boarding school
that stressed perception abilities and cognitive, aective,
and social development in the belief that these would
improve communication. His success at this school was
minimal. At the same time, I tried to continue training
him at home on the weekends. We focused on improving
articulation and sound vocabulary, introducing the
perfect verb form, expanding syntax, and building his
productive and receptive word knowledge. Altogether,
semantic training was more important than syntactic
instruction.
As the description of the instructional practice has
shown, we refocused the original instruction with Heiner
on operant conditioning, using basic principles developed
by behavioral learning psychologists. From the begin-
ning, we also included imitation in the learning process, to
strengthen his imitative behaviors. It was only in this way
that we were able to get Heiner to speak. To my
knowledge, up to this point [1977] there are no other
scientically supported methods of language therapy with
mute autistic children. Our instruction proceeded sche-
matically from sounds to syllables, to words, to simple
sentences. Conditioning and imitation are exactly what an
exemplary representative of modern developmental psy-
cholinguistics deems as not necessary for the natural
acquisition of language.
27
With Heiner, however, we
found the behavioral conditioning method eective in the
phonological, syntactic, and semantic domains. It would
nevertheless be not only presumptuous but also totally in
error to conclude, based on my experiences with Heiner,
that the psycholinguistic controversies about language
acquisition could be decided in favor of a stimulus-
response model, and the critique by Chomsky, the
founder of generative transformational grammar, against
Skinner, invalidated.
28,29
More important to me was my
discovery that independent language acquisition by
nonlanguage-impaired children must proceed quite dif-
ferently in certain crucial ways. Heiner uses almost
exclusively over-practiced speech patterns with a parti-
cular vocabulary, something that obviously does not
happen in normal language communication. (It must be
said, however, that this result was quite a victory for
Heiner, even if he never veered from the learned pattern,
since it was through the help of the ingrained patterns
that a previously unknown method of making himself
understood now became available.) Doubtless, Chomskys
current psycholinguistic theory of generative transforma-
tional grammar has invigorated language acquisition
research with new and fruitful principles. The fact that
conditioning methods lead to language acquisition in
mute autistic children puts us in a better position to
accept the possible inuence of stimulus-response me-
chanisms in language acquisition by healthy children.
Skinners theory of verbal behavior, however, may be too
simple to account for language acquisition. Instead, one
might better adopt a model of representational mediation,
such as that developed by Osgood.
30,31
Although the benets of behavioral conditioning in
language acquisition were demonstrated clearly for me,
I could not ignore the existence of language universals
that result from inborn, biologically grounded human
abilities. This was true also for the universals of language
acquisition. For Heiner, the universal, inborn component
was demonstrated most clearly in the phonological
domain. As we worked on sounds, we probed many
dierent routes of training, depending on which features
Heiner could discriminate and which sounds he could
produce. In doing so, I found that even in this case of
language pathology, Jakobsons rules were upheld to a
certain degree.
32
In the beginning of the training, for
example, Heiner already had [a], [p], and [m], those
sounds that Jakobson mentions as being the minimal
vowel and consonants found in normal speech. The
consonants that Heiner learned could be learned only in
the order that Jakobson claimed was universal. In
contrast, Heiner deviated from normal acquisition of the
production of vowel forms (something that had pre-
viously been shown in other children with autism). These
had to be explicitly taught using behavioral methods. In
Hamblins language development program, as described
by Wendeler,
33
rst the [a7], [e7], and [o7] are practiced.
Before I was aware of this, I found that, before training,
Heiner would produce only these vowels; the rounded [o7]
Thomke and Boser Cog Behav Neurol

Volume 24, Number 3, September 2011
162
|
www.cogbehavneurol.com
r
2011 Lippincott Williams & Wilkins
was more dicult for him than the nonrounded vowels
[e7] and [a7]. Production of the narrow-high vowels was
also dicult, requiring a higher tongue position in the
mouth ([i7], [u 7], [y7], [u7]). Most dicult was the
combination of the phonological characteristics closed,
round, and dark (the vowel [u7]). This diculty was
probably associated with the fact that Heiner had
problems discriminating [i7] from [e7], and [u7] from [o7].
All of these diculties, however, were surmountable
through behavioral conditioning.
Certainly, one needs to be cautious in drawing
general conclusions from 1 pathologic case. Yet after the
experience with Heiner, I believe that neither the theories
developed by the behavioral learning psychologists nor
the psycholinguistic theories stemming from Chomskys
transformational grammar model are sucient to explain
language acquisition. Both attempts at explanation need
to be part of a larger, overarching theory that would
explain the relationships among the forms of sensorimo-
tor, cognitive, aective, and social development that
accompany language acquisition, and that would, in
particular, explain the relationship between language and
thought. Hypotheses regarding these relationships exist in
the so-called area of cognitive linguistics, with the goal
of a mental grammar,
34
and even more in the psychology
of language acquisition that developed out of the
Genevan school of Jean Piaget. In the overarching theory
it would be important, above all, to build on the notion of
speech acts,
35
whereby language acquisition could be
understood in the clearest way by means of functional
action relationships.
The most important result of our language training
with Heiner was that he began to produce 1-word sentences
on his own, he began to use the practiced set of more
complex syntactic patterns as illocutionary and perlocu-
tionary speech acts, and he thus began to use language
functionally.
We tried to force Heiner to acquire functional
language by denying him the things he wanted until he
was moved from silence toward active speech. [For
example, we asked him to say, Ich will baden (I want
to bathe) before allowing him to step into the bathtub.]
Most probably, our experience points to the facts that
language is acquired primarily in connection with actions
and that psycholinguistic research and speech therapy
must take better notice of the importance of the
pragmatic side of language. I am referring to the very
obvious observation that words or symbols referring to
actions and events were more interesting to Heiner and
easier to teach him than were words or symbols referring
to people or objects. It was also clear that Heiner learned
words for objects and people more quickly when these
words were taught in combination with words for actions,
than when the words were just presented repeatedly. In
spite of these ndings, I must also stress that it would
have led to nothing if we had begun with the conviction
that language consists always and from the start of speech
acts and is acquired in normal language interactions
(through the use of speech acts) or through language
immersion. It would not have been possible to achieve
Heiners language independence had he been forced to
speak in normal language contexts. Interaction had to be
reduced to the simplest, extremely asymmetrical, and
articial form of training context. Heiner had to learn
the phonological, syntactic, and semantic domains
through conditioning before he could even partake in
the interactive nature of speech. In the same way, we need
to clarify and incorporate the notion of aectionate
engagement [Zuwendung], a term that is used in the
behavioral therapy and psychoanalytic literatures, so
often with ambiguous or misunderstood meaning. With
Heiner, we had to work on aectionate engagement
through the conditioning of specic behaviors (mostly eye
contact) and through my own behavior that helped to
reinforce them (stroking his back, praise, etc.)
In the transition from single-word learning to the
building of a simple syntax, I was left with the question of
whether it was proper to use as the model for Heiners
2-word subject-predicate sentences the developed child
language and standard language of an adult, or perhaps
instead to imitate early child-like constructions of 2-word
sentences. Only a decision in favor of the fully developed
syntax seemed logical to mein the first place because, in
spite of numerous studies, the syntax of young children
has still not been investigated enough; second, because the
observed forms can be explained in different ways; third,
because there are obvious individual and mother-tongue-
related differences; and, fourth, because for all these
reasons it would not have been possible to determine the
psychologically simplest 2-word constructions to use.
Strengthening my decision was the fact that early child
2-word sentences always include a subject and predicate,
with the possibility of later systematically adding further
sentence constituents to these constructions. According to
Bever,
36
subject-predicate is one of the underlying
relationships that children discover between the elements
of language when the cognitive basis of language
structures develops. This development mirrors itself again
in the mental grammar of adults. According to Bever,
36
most significant is the discovery of the differences
between the subject-predicate and the predicate-object
relationship. For this reason, my next step in training
sentence patterns with Heiner had to lead to the
construction of objects inside the verb phrase. (It
happened first with the verb wollen {want}.) In other
words, we trained sentences with verbs that take either an
obligatory or an optional accusative object. McNeill
27
describes the number of possible patterns in 2-word
sentences, and their corresponding grammatical relation-
ships. The most frequent patterns have verbs and nouns
that stand in an object relationship to one another.
Subject-predicate patterns occur much less frequently.
Perhaps one can draw the conclusion from this that not
only actions but goal-directed events are of particular
importance for young children, so the speech act of
demand stands in the foreground. For the language
therapy with Heiner, I concluded that besides 2-word
sentences with subject and predicate (with verbs that take
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
163
one type of object), we should practice constructions with
the word bitte (as in bitte Brotplease bread).
This was also important because the implicit object
relationship was very clearly the most salient in Heiners
spontaneous 1-word sentences. I also needed to consider
whether we should be training so-called pivot con-
structions.
37
The later version of pivot theory, which
distinguishes between a central (closed) and an open class
of words (Z-O constructions), would have to have been
established first.
38,39
But Z-O constructions make sense
only if children produce them on their own, and many
children hardly use them.
39
In addition, these construc-
tions appear to be incomplete surface reflections of deep
underlying syntactic differences.
27,40
Among Heiners
2-word constructions, we could consider only those with
bitte as being similar to Z-O constructions.
Since it is quite controversial whether language
acquisition is aected more by the deep or the surface
structure of the adult language (if the research into mental
grammar doesnt make the belief in a deep structure
superuous!), there was luckily no other choice for me
than to use the surface structure of the language for
Heiners instruction and just intuitively choose psycholo-
gically simple examples. In doing so, it was very helpful to
refer to the classic research by Stern and Stern.
41
The
importance of the surface structure of the adult language
is supported by the nding that autistic children with
echolalia have a better chance of developing real language
than do children who only comprehend language. The
decision to use the adult forms of the language was also
harder to abandon as Heiner started to be able to identify
variants of utterances in the surface structure, and at
times used these variants himself. The supported notion
that language acquisition depends on a mental grammar
slowly awoke in me the notion that the childs cognitive
development must take priority in the teaching sequence;
thus, it was senseless to keep conditioning syntactic
patterns given Heiners current level of cognitive abilities.
In contrast, I did not want to abandon entirely the idea of
fostering his cognitive development by conditioning
specic sentence patterns through instructions regarding
their functional use. Arguing in favor of continued
syntactic training, one can consider the well-known
phenomenon that children actually use certain language
forms (eg, temporal or causal sentences) before they are
truly able to understand the corresponding logical
relationships. If language and thought depend on one
another, as Vygotsky
42
claimed, then improvement from
usage to understanding should not be excluded. The
Piagetian school, however, stresses that the foundation of
cognitive operations lies not in the language but rather in
preverbal sensorimotor actions. Cognitive development
would therefore only be limited by language training.
43
Because this problem remains unsolved, the dogmatic
adoption of a particular model of language and cognitive
development would be a mistake. Both methods should
therefore continue to be tested, that is, through thinking
to foster language and through speech practice to further
drive forward the development of thinking.
Since I have already spoken in considerable detail
about syntactic considerations, I must prevent a possible
misunderstanding. My decision to use the developed adult
language as the foundation for Heiners practice did not
by any means arise from a hypothesis about the priority
or independence of syntax. Instead, the whole instruc-
tional practice became oriented toward semantic goals
from the moment that Heiner began to produce sound
combinations; that is, the child should be able to
understand and produce meanings. The practice of syntax
was the means to this goal, because I had been able to
arouse little interest in Heiner by showing him and
naming single items, and had so far not accomplished
much in doing so.
Of the most commonly occurring constructions of
young childrens 2-word sentences,
38
the 2 that I have
emphasized with Heiner are the demand-wish and the
describing of a simple event or situation. Heiner has not
learned to ask questions. It will be a very important step
to get him to do so. First, he must be conditioned for
question sentences. It will not be crucial that he use the
form of the question sentence. It is more about the ability,
in addition to the demand-wish and the description,
to produce a third important speech act: questions in the
context of situations and event correlations. Heiner
understands and answers questions, but he has not been
motivated to ask them. [He often answers a stereotyped
yes to questions, even when he means no. We take his
yes to mean that he understands that he has been asked
a question that requires an answer, but he still cannot
respond appropriately.] Because of the importance of
demands, I conclude that we should practice where
questions rst. He learned the demand speech act by
himself, after he learned the corresponding sentence type
through conditioning; thereby, the nonverbal could be
converted into a speech-dependent interaction. It is still
dicult to be sure whether each of his utterances about
things and actions is a speech act of description, since
these types of utterances occur exclusively in response to
prompted questions. During instruction, at least, I could
see the certain necessity that language develops not only
through semiotic means as a symbol system, but also for
understanding in an event-based corelational manner.
It follows from this report that by means of
behavioral therapy methods, it is possible to build
language, even in a child with severe autism, and even
when the instruction begins relatively late in development.
The severity of Heiners impairment was apparent in all
clarity when, at the age of 9
3
4
, he could at last be tested
(using Kaplan
26
), and his developmental level was shown
equivalent to a child of 2.5 years. Through imitation
lessons combined with language therapy, Heiner de-
nitely learned to observe, and thereby achieved a better
and more structured relationship with his surroundings.
Through the learning of word meanings, a whole new
world opened to himor perhaps it was the other way
around! In forming sentences, he was able to set up
relationships between himself and his environment, and
between things and people. Even if his language remains
Thomke and Boser Cog Behav Neurol

Volume 24, Number 3, September 2011
164
|
www.cogbehavneurol.com
r
2011 Lippincott Williams & Wilkins
now and forever rudimentary, there is much that has been
won in terms of interhuman understanding. One must
caution that conditioning therapy may have achieved
nothing more than a sort of language dressage. Yet in
this artificial way, Heiner finally has a way of making
himself understood. It is also difficult to unlock a
languages sound system and sound relationships and to
produce the syntactic relationships between those sound
patterns; but this is a less fundamental aspect of the
lesson. Only once a child actually produces its own speech
acts can the language fulfill its task of facilitating an
understanding with the surrounding world and thereby
fulfill its social role.
[The most important factor in Heiners acquiring
language appeared to be our refusal to accommodate any
of his nonverbal requests. Heiner learned to consider
language less as a conditioned, reexive production of
sounds, words, and sentences, like a parrot, and more as a
symbolic action, a specic act that could bring about a
specic result.] The importance of this factor has been
partially overlooked in previous reports of language
initiation in autistic children, or the diculty of the task
has been underestimated. Many medical clinicians lack a
basic understanding of the science of language. For
example, Kehrer and Ko rber
44
do not clearly describe the
transition from conditioned speech forms to meaningful
use of language. In a later overview article, Kehrer
45
also
leaves this most important problem open. It is not enough
to conclude in a few words that trained echolalic speech
must gradually be turned into a communication language
through behavioral therapy. Language therapy is a highly
complex task that must be conducted in a highly
methodological but nondogmatic manner through a
collaboration among psychologists, doctors, speech
pathologists, behavioral therapists, and parents. The
ongoing puzzle of language acquisition must be tied to
the therapy. This work has the potential to achieve as
signicant ndings as in aphasia research, ndings that
could further improve therapy.
Updates
Hellmut Thomke, translated by KB
1972 to 1974
Heiners intense home treatment lasted for 2 years
and 3 months, from age 6 to 8. Each week for the rst 18
months, he had two 1-hour sessions with the behavioral
therapist, with my wife and me looking on, and another
12 half-hour sessions just with me. For the nal 9 months,
I trained him alone, gradually lengthening the sessions
and expanding their scope. My own job and other family
obligations limited my available training time.
1974
At age 8, Heiner went to a special weekday
boarding school for cognitive development and language
training. The school asked me to stop my home
instruction because it would not be good to subject
Heiner to 2 simultaneous training methods. I soon
realized, however, that Heiners language was regressing.
So when he came home on weekends, I restarted my own
method, sometimes sitting with Heiner as I had done
before, but, more often, taking him on long walks. The
length of time we spent walking would be hard to
reconstruct. However, these walks gave us a natural
setting for using language. Heiner learned to throw
stones, run, sit on a bench, climb a tree, watch the trains
go by, see a plane or a bird y, pick berries. He also
learned to dierentiate large from smallstones, trees,
etc. He was always required to describe the thing or
action with words. Primarily because we could work
together only on weekends, Heiner improved much less
during this period than he had during the earlier, more
concentrated training years.
2004
At age 38, Heiner was doing quite well. He looked
young for his age, almost child-like. He showed fewer and
less bothersome overt signs of autism, such as hand
apping and whirling. Well socialized and calm, he
behaved himself without problem on the street, in
restaurants, and elsewhere in public. He had no sleep
problems.
He still could not live alone. During the week, he
lived and worked in a home for low-functioning adults
with autism. He was at home with us every weekend and
for about 4 week-long holidays a year.
Although Heiner could not live alone, his early
training had given him some language independence. His
active expressive vocabulary included about 470 words. His
passive vocabulary, though much bigger, did not lend itself
readily to tallying. Even though he had been trained only in
high German, he understood words in Swiss dialect. He
seemed to understand most things that happened day to
day, like cooking, gardening, and shopping. He still liked
music. He had also grown to enjoy listening to compact
discs of dramatized fairy tales and childrens stories with
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
165
added music and sound eects. He could answer simple
questions about the stories, like, Which animals appear?
He spoke mostly in 1-word sentences when no one required
more of him. We still had to prompt him even for some of
his 1-word sentences. He used words spontaneously only
when particularly fascinated by something, when the
context absolutely required it, or when someone insisted
on it. He still did not initiate much speech, and he tended
only to whisper. Because his articulation remained poor, I
continued to train him in pronunciation. He seemed to feel
very disappointed when he tried to say something but could
not articulate it properly.
At his weekday group home, Heiner liked using
pictures to communicate. In 2004, the sta there had just
begun trying to improve his communication with an
electronic device similar to a DynaVox (DynaVox Mayer-
Johnson, Pittsburgh, PA). The machine displayed icons
depicting things and situations. Pressing on an icon made
the machine speak the wish, for example, I want to
drink.
That year we took Heiner back to the Bern University
clinic and had him tested for nutritional allergies and for
fragile X syndrome. All the tests were negative.
To summarize my thoughts about Heiner in 2004:
I believe that his early training was responsible for his
continued understanding and use of language. Our most
important accomplishment had been improving his
language comprehension. I found behavioral operant
conditioning useful not only for language but also for
decreasing Heiners fears about things like going to the
dentist. I wish that his intensive therapy could have
started earlier and continued longer. Finally, I still felt
disappointed by the lack of early support for conditioning
methods when he was very young. Because of the
political milieu among speech-language professionals
in Switzerland, for several years they had emphasized
facilitated communication almost exclusively.
2011
At age 45, Heiner still lives in a group home. There
he helps in the kitchen, with house chores, and in the
garden. He can use tools like a saw, hammer, screwdriver,
and drill. He is clean and orderly. He can take a bath once
a week, ride, draw very simple pictures, and play simple
music, as on a xylophone or drum. He behaves himself
without fail. He has good rapport with the people who
look after him, but less so with his housemates, most of
whom have more intense disabilities than he and who
speak not at all or very little. He still spends weekends at
home with us, and is at home for longer vacations 4 times
a year. He joins my wife and me when we go to a
restaurant or attend a classical concert. At home he is
very helpful, but needs rest breaks during which he pulls
back to his room.
He can say roughly 500 words, although his
canned utterances still require prompting. He continues
to prefer to use pictures or gestures rather than words.
I believe that as he ages, his understanding of language
continues to improve.
ACKNOWLEDGMENTS
The authors thank Hans Huber Verlag (Bern,
Magazines) for permission to translate and republish
Dr Thomkes paper.
This research was supported by the Cognitive
Neurology Gift Fund and by the Therapeutic Cognitive
Neuroscience endowment and gift funds.
HT: I thank Dr Boser for giving such great attention
to the case of my son Heiner and for taking my 1977 paper,
and carefully and most informedly translating it.
KB: My deep appreciation to Dr Thomke for
allowing his sons story to be retold and for updating
Heiners progress. Thanks to my colleagues who inspired
this project through their interest in learning how nonverbal
autistic children have been helped to learn phrasal language
after age 6: Erin Pickett, Olivia Pullara, Jessica OGrady,
and especially Barry Gordon, without whose perseverance
this paper would not have been seen in print. Thanks to
Sarah Wayland for advising on International Phonetic
Alphabet notation. Thanks to Juane Hein for reviewing
the manuscript. Thanks to Edie Stern for her detailed and
tireless eorts to prepare the paper for publication.
REFERENCES
Introduction
1. Thomke H. Sprachaufbau bei einem autistischen Kind: U

berlegun-
gen zum Spracherwerb und zur Sprachtherapie. [Language-con-
struction in an autistic child: thoughts on language acquisition and
speech therapy.] Schweiz Z Psychol Anwend. [Swiss Journal of
Psychology and Its Applications.] 1977;36:118.
2. Brown JL. Prognosis from presenting symptoms of preschool
children with atypical development. Am J Orthopsychiatry.
1960;30:382390.
3. Lovaas OI, Berberich JP, Perloff BF, et al. Acquisition of imitative
speech by schizophrenic children. Science. 1966;151:705707.
4. Rimland B. Infantile Autism: The Syndrome and its Implications for a
Neural Theory of Behavior. New York: Appleton-Century-Crofts; 1964.
5. Pickett E, Pullara O, OGrady J, et al. Speech acquisition in older
nonverbal individuals with autism: a review of features, methods,
and prognosis. Cogn Behav Neurol. 2009;22:121.
6. Bourret J, Vollmer TR, Rapp JT. Evaluation of a vocal mand
assessment and vocal mand training procedures. J Appl Behav Anal.
2004;37:129143; quiz 143144.
7. Hingtgen JN, Coulter SK, Churchill DW. Intensive reinforcement of
imitative behavior in mute autistic children. Arch Gen Psychiatry.
1967;17:3643.
8. Koegel RL, ODell M, Dunlap G. Producing speech use in
nonverbal autistic children by reinforcing attempts. J Autism Dev
Disord. 1988;18:525538.
9. Koegel RL, ODell MC, Koegel LK. A natural language teaching
paradigm for nonverbal autistic children. J Autism Dev Disord.
1987;17:187200.
10. Martin R. Out of Silence: A Journey into Language. New York: H.
Holt; 1994.
11. Marshall NR, Hegrenes JR. Programmed communication therapy
for autistic mentally retarded children. J Speech Hear Disord.
1970;35:7083.
12. Miller A, Miller EE. Cognitive-developmental training with elevated
boards and sign language. J Autism Child Schizophr. 1973;3:6585.
13. Miranda-Linne` F. Individuals with autism spectrum disorders:
teaching, language, and screening. Comprehensive summaries of
Uppsala dissertations from the faculty of social sciences. Acta Univ
Ups. 2001;103:196.
Thomke and Boser Cog Behav Neurol

Volume 24, Number 3, September 2011
166
|
www.cogbehavneurol.com
r
2011 Lippincott Williams & Wilkins
14. Rutter M, Greenfeld D, Lockyer L. A five to fifteen year follow-up
study of infantile psychosis. II: social and behavioural outcome. Br J
Psychiatry. 1967;113:11831199.
15. Rutter M, Rodefeld W. Teaching Language to Autistic Children.
Springfield, IL: Department for Exceptional Children, Illinois Office
of Education; 1974.
16. Windsor J, Doyle SS, Siegel GM. Language acquisition after
mutism: a longitudinal case study of autism. J Speech Hear Res.
1994;37:96105.
17. Welch MG. Appendix I: retrieval from autism through mother child
holding therapy. In: Tinbergen N, Tinbergen EA, eds. Autistic Children:
New Hope for a Cure. London: Allen & Unwin; 1983:322326.
18. Bondy AS, Frost LA. The PECS. Behavior. 2001;25:725744.
19. Newsom C, Rincover A. Autism. In: Mash EJ, Barkley RA, eds.
Treatment of Childhood Disorders. New York: Guilford; 1989:286346.
20. Eldevik S, Hastings RP, Hughes JC, et al. Meta-analysis of early
intensive behavioral intervention for children with autism. J Clin
Child Adolesc Psychol. 2009;38:439450.
21. Heflin LJ, Simpson RL. Interventions for children and youth with
autism: prudent choices in a world of exaggerated claims and empty
promises. Focus Autism Other Dev Disabl. 1998;13:194211.
22. Stahmer A, Collings N, Palinkas L. Early intervention practices for
children with autism: descriptions from community providers. Focus
Autism Other Dev Disabl. 2005;20:6679.
23. Odom SL, Brown WH, Frey T, et al. Evidence-based practices for
young children with autism: evidence from single-subject research
design. Focus Autism Other Dev Disabl. 2003;18:176181.
24. Hess K, Morrier M, Heflin J, et al. Autism treatment survey:
services received by children with autism spectrum disorders in
public school classrooms. J Autism Dev Disord. 2008;38:961971.
25. Lenneberg EH. Biological Foundations of Language. New York:
Wiley; 1967.
26. Kaplan EL. Intonation und Spracherwerb. [Intonation and language
acquisition]. In: Bu hler H, Mu hle G, eds. Sprachentwicklungspsychologie.
[Language acquisition psychology.] Weinheim: Beltz Verlag; 1974:152
174.
27. McNeill D. The Acquisition of Language. New York: Harper &
Row; 1970.
28. Skinner BF. Verbal Behavior. New York: Appleton-Century-Crofts;
1957.
29. Chomsky N. A review of B.F. Skinners verbal behavior. Language.
1959;35:2658.
30. Osgood CHE, Sebeok TA. Psycholinguistics: A Survey of Theory and
Research Problems. Baltimore: Waverly Press; 1954.
31. Ho rmann H. Psychologie der Sprache. [The psychology of
language.] 2 Auflage Berlin: Springer Verlag; 1970.
32. Jakobson R. Child Language: Aphasia and Phonological Universals.
Paris: Mouton; 1968.
33. Wendeler J. Neuere Forschungsergebnisse. [New research findings.]
In: Wing JK, ed. Fruhkindlicher Autismus: Klinische, padagogische
und soziale Aspekte. [Early child autism: clinical, pedagogic and
social aspects.] Weinheim: Beltz Verlag; 1973:283308.
34. Leuninger H, Miller MH, Mu ller F. Linguistik und Psychologie. Ein
Reader. Bd.I: Psycholinguistische Untersuchungen sprachlicher Per-
formanz. Bd 2: Zur Psychologie der Sprachentwicklung. [Linguistics
and psychology. A reader. Vol 1: Psycholinguistic investigations of
language performance. Vol 2: On the psychology of language
acquisition.] Frankfurt a. M.: Athena um Fischer Taschenbuch
Verlag; 1974.
35. Searle JR. Speech Acts. Cambridge: Cambridge University Press; 1969.
36. Bever TG. The cognitive basis of linguistic structures. In: Hayes JR,
ed. Cognition and the Development of Language. New York;
1970:270362.
37. Braine MDS. The ontogeny of English phrase structure: the
first phase. Language. 1963;39:114.
38. Slobin D. Cognitive prerequisites for the development of grammar.
In: Ferguson C, Slobin D, eds. Studies of Child Language
Development. New York: Holt, Rinehart & Winston; 1973.
39. Leuninger H, Miller MH, Mu ller F. Psycholinguistik: Ein For-
schungsbericht. [Psycholinguistics: A research report.] Frankfurt a.
M.: Athena um Fischer Taschenbuch Verlag; 1972.
40. Bloom L. Language Development: Form and Function in Emerging
Grammars. Cambridge, Mass: MIT Press; 1970.
41. Stern C, Stern W. Die Kindersprache: Eine psychologische und
sprachtheoretische Untersuchung. [Child language: A psychological and
language theory-based investigation.] Leipzig: J.A. Barth Verlag; 1907.
42. Vygotsky L. Thought and Language. Cambridge, MA: MIT Press;
1962.
43. Sinclair H. Some remarks on the Genevan point of view on
learning with special reference to language learning. In: Hinde R,
Stevenson-Hinde J, eds. Constraints on Learning. New York:
Academic Press; 1973.
44. Kehrer HE, Ko rber HP. Sprachbehandlung durch Verhaltensther-
apie bei autistisch-mutistischen Kindern. [Language treatment
through behavioral therapy with autistic-mute children.] Acta
Paedopsychiatr. 1971;38:217.
45. Kehrer HE. Verhaltenstherapie bei kindlichem Autismus. [Behav-
ioral therapy in child autism.] Z Kinder Jugendpsychiatr. [Journal of
Child and Adolescent Psychiatry.] 1974;2:233247.
Translated Paper
Cog Behav Neurol

Volume 24, Number 3, September 2011 Language Construction in a Mute Autistic Child
r
2011 Lippincott Williams & Wilkins www.cogbehavneurol.com
|
167