1. INTRODUCTION
The Dr. Leo Kannerhuis in Oosterbeek, the Netherlands
was founded in 1974 as the first specialized clinic in treating
autistic people in the Netherlands. In the same period a few
centres for ambulant assessment of and help for autism were also
established. For a long time, however, professional services
in all parts of the country were limited. Particularly for adult
autistic persons there existed no adequate housing and working
facilities. Many of these people were inappropriately placed
in institutions for mentally handicapped or in general psychiatric
hospitals.
The Dr. Leo Kannerhuis has as its target-group high
functioning autistic adolescents between the ages of 14 - 21 years.
This is a notoriously difficult phase for autistic youngsters
for several reasons: the school facilities come to an end, the
autistic youngsters lose contact with their peers and they are
unable to further their development independently. They have
no real social perspective. Mood and behaviour disregulations
may also arise in this phase.
Treatment in the dr. Leo Kannerhuis has a dual purpose:
1 . Learning effective skills and stimulating more independent adaptation to social reality;
2. Treatment of behaviour disorders and dysfunctional
adaptation patterns.
Most of the youngsters admitted to the dr. Leo Kannerhuis during the last twenty years
were very retarded in their social skills development and had serious behaviour problems
as well. Some of them had already been hospitalised
in psychiatric clinics for children. When admitting a youngster,
the dr. Leo Kannerhuis makes no great demands regarding the level
of intellectual functioning. The criterium is that at least the
visual-perceptual test-scores are above IQ = 85 and the verbal
scores above IQ = 70. A verbal IQ between 55 and 70 is acceptable
under certain conditions acceptable. This means that in our residential
group there is a considerable variation in intellectual level.
Method of treatment in the dr. Leo Kannerhuis: Youngsters
live in small groups (6 individuals) formed on the basis of the
level of social functioning. In the group there is a climate
of acceptation of the autistic handicap. Social stimuli and demands
are structurally offered at a comprehensible level. There is
a program to train self-help and daily skills, and communicative
and social skills, and there is also job-training and freetime
activities. After an internal program advanced youngsters get
the opportunity to learn to function in external real social situations,
such as public transport, shopping, banking and working. During
the residential treatment there is usually intensive contact and
working cooperation with the youngsters' parents and family.
Some data:
The present capacity of the dr. Leo Kannerhuis is
42 places, divided over 7 groups. The average clinical time of
residence is about 4 years.
For practical reasons the time of residence is partly
determined by the possibilities of finding an adequate adult living-facility.
Survey of 125 outplacements over 20 years:
- back to own family 21 (17%);
- independent living with professional help and supervision 14 (11%);
- group of high functioning autistic persons 11 (9%);
- group of mildly mentally handicapped 30 (25,5%);
- group of moderate mentally handicapped 9 (7%);
- workhome for seriously handicapped autistic persons 26 (21 %);
- general psychiatric hospital 7 (5,5%);
- other 5 (4%).
Changes in the course of 20 years since the foundation
of the dr. Leo Kannerhuis.
In the Netherlands the professional services for
autistic people have increased and are still increasing. On the
one hand living facilities for autistic people have been established.
These are differentiated according to the degree of the autistic
handicap and the level of social functioning. Because of this
development the possibilities of outplacement of the clinic have
increased and the duration of clinical stay can be shortened.
Placement in a psychiatric hospital, which occurred out of necessity,
is no longer needed.
Return to the parents' home has become much less
frequent or occurs merely as an in-between stage. On the other
hand the possibilities of ambulant help have increased. The regional
centres have been reinforced and in a number of places training-programs
for autistic adolescents have been set up. Consequently more
autistic youngsters with a relatively mild handicap can find their
way in their own region and no longer need clinical treatment.
Still missing are day-centres where adolescents with more serious
problems can be treated while staying at home. The dr. Leo Kannerhuis
recently planned to set up a day-treatment centre for its own
region. This centre can work together with the clinic and take
over some tasks.
During the last few years, however, we have seen not a decrease but rather a strong
increase of referrals. The reasons for this could be:
1. Institutes for health services have become more familiar with autistic disorders and can detect them earlier.
2. The extension of autistic disorders with pervasive
developmental disorders or atypical autistic disorders.
From the beginning the dr. Leo Kannerhuis has admitted
not only the classic Kanner-type (aloof, passive) autistic, but
also the Asperger-type adolescents. Now however we are confronted
with young persons with very a-typical and complex psychiatric
problems. For this reason we have been obliged to clarify our
admission criteria. Our point of view is that the autistic disorder
should be dominant in the problem complex, i.e. a primary serious
handicap in social intelligence and competence. Furthermore,
the treatment is mainly directed at improving of handicap.
II. 20 YEARS OF SKILL TRAINING IN THE DR. LEO KANNERHUIS
An important part of the treatment is skill training.
Regular education
In the first years the youngsters followed part-time-programmes
at different schools in the neighbourhood as: IVO-MAVO (secondary
school for lower general education), ITS (Technical School), LOM-MAVO
(special school for children with educational and pedagogical
problems), Lagere Tuinbouwschool (Agricultural School).
In general our experiences were disappointing which has led to the following conclusions:
* A relatively high social competence is a prerequisite for attending a school.
* Both the teachers and the other students at the school should be tolerant of the autistic students.
* Schools do not prepare the autistic youngsters for a simple job on the labour market.
* External school attendance must not have a therapeutical intention; their teachers will be overcharged.
* Only part-time external school attendance is in
accordance with our treatment.
THE TRAINING PROGRAMME
Training domains at the dr. Leo Kannerhuis:
1. Job Training
2. Social Skills Training
3. Self-help Training
4. Leisure Time Training
1. Jobtraining
We became conscious of the need to prepare the youngsters for a limited number of jobs only. In this period the job training was gradually extended with:
- working with wooden and metal materials
- working in a garden and greenhouse
- manual skills and working with textiles
- administrative activities
- restaurant, catering and domestic activities.
Job training consists of 4 stages:
1. Education and job-specific skill training
2. General job skill training and social skill training
3. Starting with a real job, facilitated by job coaching in a sheltered workshop
4. Becoming a 'worker' in attitude, identity and
future perspective.
Training took an average of 1.000 hours in three
years. This job training programme was quite successful. Job
training prepares the youngsters for a sheltered workshop.
In the future more than one half of the youngsters
will de dependent on the organisation of day-care-centres for
the mentally handicapped for their daily activities. The job
training programme for this subgroup is slightly different: more
relaxed, stereotype interests are used to motivate skill training
and technical skill training starts at a lower level with a developmentally-oriented
designed programme.
This programme proved suitable for autists with a
mental handicap and persons with Asperger syndrome.
2. Social Skill
Training
Programmes we used are:
Our experiences:
3. Self-help Training
Our experiences:
4. Leisure Time Training
This training consists of: new skills, clubs in the
community, parties, outings, holidays
Our experiences:
Conclusions of 20 years of skill training
Be careful not to overestimate the capacity to integrate
experiences and the amount of skill training. Select only basic
skills. Although some skills do not integrate properly, they
can serve as useful protheses.
III RESEARCH IN
THE DR. LEO KANNERHUIS
There have been several research projects in the dr. Leo Kannerhuis during the past 20 years.
1. Face Processing Strategies in Autistic Individuals
Teunisse did series of face processing strategy experiments
with our autistic youngsters. He presented the results yesterday
at this congress.
2. Predictors of Progress in Social Understanding / Successful Treatment
The Kanner autistic person has a characteristic intelligence profile: the verbal and social
IQ's are low and there is a high to excellent visual perceptual IQ.
In the first research project (Berger 1983) we tried
to determine whether our treatment caused a shifting, an improvement,
in IQ after some years. We were not so much interested in the
visual perceptual IQ, but mostly in the verbal and social IQ's.
Berger tested 25 patients who were treated in our hospital and
an control group of 12 youngsters on the waiting list for our
clinic. The IQ's were measured after a minimal of 2 years of
clinical treatment.
Results:
The visual perceptual IQ does not change in any way. This is the case in both groups. The verbal IQ does not change either in the treatment group nor in the control group. The social IQ improved in 15 of the 25 persons (60%). In the control group there was no change.
Berger found some other data:
The improvement of the social IQ is independent of:
An improvement in social intelligence does not mean
that the autistic person improves his social competence. The
level of social understanding does not imply the same level of
social competence. In another study Berger found that cognitive
shifting and progress in social understanding are positive related.
The relation between cognitive shifting and progress in social
competence is a subject for further study. The relation between
social understanding and social competence is another part of
our research projects.
3. Results of Treatment in Skill training, Self-help training etc.
In 1982 Janssen did a validation study in our institute.
In 25 autistic adolescents there was a significant correlation
between improvement in social intelligence and progress in social
competence compared with a control group of 20 persons studied
over 5 years. Measured by the Dolderse Schaal, the Wing's Childrens'
Handicaps, Behavior and Skills Schedule.
Results:
The adolescents who received trainings in our institute
have more social skills and less infantile behaviour. However
there was no improvement in the factors of "has some care
for other persons" or "the sensoric and motoric disabilities".
The treatment makes the adolescent more willing to make contact
with other persons.
Another study (Huskens) was performed in 1994. In
a group of 12 adolescents Huskens compared the behaviour and competence
of 12 adolescents before and after the start of the treatment.
There was no significant improvement in social competence. On
the level of maladaptive behaviour, measured by the CBCL and the
Vineland Maladaptive Behavior Scale, there was a significant decrease
of this behavior.
During last 2 years we did a pilot study in which we annually measured the skills in the domains of
measured by SRZ-P, Vineland, CBCL. (sheets)
IV DISCUSSION
How can the results of the treatment be measured?
What are the most important domains to investigate social intelligence,
social competence, working abilities, etc.? What are the best
instruments for measuring the developments for this high functioning
group of autistic adolescents?
We discovered that the scoring of the Vineland gave
us some problems because our autistic adolescents have some deficits
in their abilities. The Vineland is a developmental scale, so
you cannot measure the items which fall out. Our adolescents
usually score too high.
Plans for further investigations:
We are planning a study to investigate which cognitive strategies are important for an autistic person to profit from our treatment (Berger).
We will develop our training programmes in modules
so that we can measure the steps the youngsters learn. There
will be an evaluation of every training module; this is already
the case in our biking and banking programmes, but it will also
de added to communication or TOM training. We planned to do this
at the beginning of the treatment, as out-patient, in the day-care
or at the residential treatment. We will measure the level the
adolescent has at that moment so he can start the training at
that level.
Mrs. Drs. F.H.Th.M. Aerts,
Child- and adolescent psychiatrist
Dr. Leo Kannerhuis
Behandelingstehuis voor autistische jongeren
Jhr. Nedermeijer van Rosenthalweg 16
6862 ZV Oosterbeek
Telefoon 026 - 333 30 37