Journal of Autism and Developmental Disorders, VoL 19, No. 4, 1989

Daily Life Therapy: A Japanese Model for Educating Children With Autism

Kathleen Quill, Susan Gurry, and Anne Larkin Lesley College

The controversial practice o f Daily Life Therapy, as demonstrated at the Boston Higashi School in Massachusetts, is reviewed. Five fundamental prin- ciples o f Daily Life Therapy are examined: instruction that is group-oriented; routine activities that are highly structured; instructional techniques that center on learning through imitation; a method for reducing children's lev- els o f upproductive activity through rigorous physical exercise; and a curric- ulum that focuses on movement, music, and art. These central features o f Daily Life Therapy are discussed in light o f current theory, research, and educational practices in autism. Empirical questions raised by this unique treatment mode are outlined.

A unique approach to the treatment of autism is being developed in the Boston area as a result of an international cooperation between Japan and the Unit- ed States. The Boston Higashi School is bringing to American society the philosophy and methods of Dr. Kiyo Kitahara, who reports unprecedented progress in the education and integration of autistic children with nondisa- bled peers at her private school in Tokyo (Kitahara, 1983).

Daily Life Therapy is the name given by Kitahara to the educational model that she developed over a 20-year history of teaching autistic and typical children. She developed her methods for teaching children with autism in- dependent of the abundant literature on Western educational and medical theories available in Japan. In recent years, Kitahara visited schools for au- tistic children in several other countries and compared the methods and results of those programs to her own model. She began to articulate her Daily Life Therapy concept to parents and professionals worldwide, and became con- vinced that her educational model could be successfully implemented in other cultural settings. Three monographs about Daily Life Therapy (Kitahara,

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626 Quill, Gurry, and Larkin

1983, 1984a, 1984b) were translated into English and generated considerable interest and controversy among parents and professionals in fields of medi- cine, psychology, and education. As a result of intensive efforts, in Septem- ber 1987, the Boston Higashi School was established as the International Division of the Musashino Higashi Gakuen School, serving 70 autistic chil- dren from 18 states and 6 countries. Unlike the integrated program in Tokyo, the Boston Higashi School serves autistic children in a segregated educational environment.

This paper is a preliminary review of the educational philosophy and methodology employed at the Boston Higashi School. This review of Daily Life Therapy assumes that the lack of nondisabled peer models at the Boston program effects the dynamics of Daily Life Therapy instruction and the process of skill acquisition among the autistic children. Although the inter- vention is influenced by the lack of nondisabled peer models, the fundamental principles and practices are preserved (Kitahara, 1987).

Information about Daily Life Therapy was gathered through weekly observations at the school from October through December 1987. All com- ponents of the school-day curriculum for one preschool, one elementary, and one secondary class were observed. Each author was assigned to a specific class and conducted weekly 1-hour observations of the program. During each session, descriptive notes on the nature of the class, curriculum, and instruc- tional methods were recorded. Each observer completed a total of 8 obser- vations over the 3-month period, totaling 24 hours of program time. This paper describes the central features of the program and discusses Dally Life Therapy in light of Western theory, research, and educational practices in autism.

PRINCIPLES OF DAILY LIFE THERAPY

Daily Life Therapy, as described by Kitahara, consists of three main elements: establishing a "rhythm of life" and "stabilizing the child's weak emotions" through a program of physical training; removal of the child's "spirit of dependence" through group education; and fostering the child's intellectual development through continuous repetitions of the same actions (Kitahara, 1983).

The practice of Daily Life Therapy, therefore, appears to be founded in Eastern philosophy, which accepts a relationship between an individual's mind, body, and spirit, and Japanese pedagogy, which focuses on group edu- cation and group performance. Dally Life Therapy seems to exist as a com- plete system, designed to address not only the content of what children learn, as in a traditional curriculum, but also the development of their social and

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emotional well-being. It appears to be as much a philosophy of education as a curriculum for children with autism.

We have operationalized Kitahara's ideology into an educational model that appears to consist of five fundamental principles: (a) instruction that is group-oriented, (b) routine activities that are highly structured; (c) instruc- tional techniques that focus on learning through imitation; (d) a program of rigorous physical exercise; (e) a curriculum that focuses on a variety of art forms. There is a great deal of theory and research in autism that both supports and challenges these principles of Daily Life Therapy, and there- fore their investigation is warranted.

Group Instruction

Central to our Western philosophy of special education is intervention that addresses the needs of the individual child. For children with autism, there is a recognition of the tremendous diversity among children, and the need for individualization of assessment and treatment (Schopler & Reich- ler, 1979). Historically, the most common strategy for teaching children with autism has been individualized instruction (Handleman, I981; Schopler, Reichler, & Lansing, 1980). However, reliance on individualized instruction does limit the amount of teacher-child instructional time (Snell, 1983) and opportunities for social interaction (Brown, Holvoet, Guess, & Milligan, 1980).

Group instruction with persons with severe disabilities refers to activi- ties in which two to four children are taught in close physical and/or tem- poral proximity (Reid & Favell, 1984). Empirical investigation into the use of various small-group instructional techniques with autistic children is limit- ed. Two studies of concurrent group instruction, in which all children were taught the same motor imitation task simultaneously, found that group in- struction had a disruptive effect on learning for half of the autistic children and the amount of observational learning from peers was Iow (Handelman & Harris, 1983; Harris & Handelman, 1980). Studies of sequential group in- struction, where each child was taught a language or academic task individu- ally in a rotating fashion within a group, found that autistic children generally stopped responding whenever the teacher attended to a different child (Koe- gel & Rincover, 1974; Rincover & Koegel, 1977). Use of tandem individual- to-group instruction has been successfully implemented with autistic children (Newson, 1981; Rincover & Koegel, 1977; Rotholz, Delquadri, & Hall, 1986, cited in Rotholz, 1987). In the tandem model, the teaching situation begins with individual instruction, continues using individualized instructional materials, and gradually increases group size through systematic operant

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procedures that increase unsupervised on-task behaivor. A continum ap- proach towards group instruction is advocated.

In contrast to our Western focus on individual instruction, Daily Life Therapy is completely group-oriented. The development of a strong group spirit is the foundation of Japanese education, and true of the Dally Life Therapy approach to educating children with autism. At the Boston Higashi School, the classroom group size ranges from 6 to 10 children. Children are grouped primarily by chronological age, secondarily by skill level. Within a given class, every child of that age group is participating with his/her peers in all activi- ties in precisely the same manner. The group functions as a single unit, and the performance expectations are uniform across the group throughout the day. Inherent in this group process is the underlying premise that individual children will gather information from each other as well as the teacher.

In the classroom, the average student:teacher ratio is 8:1. There is one primary teacher who independently teaches academic curricular subjects to the group. However, the majority of the school day centers around special subjects, such as music, art, physical education, and school assembly, dur- ing which time the special subject teachers and primary teacher work together to facilitate the group process. During these times, the student:teacher ratio is approximately 8:2.

The group instruction process simulates a traditional American regu- lar education environment and could be categorized as a concurrent~sequen- tial group instruction model. In the classroom, children are seated at individual desks that face the primary teacher. Group instruction is given and group responses are elicited. These responses, verbal or motor, axe modeled by the teacher. Once instruction is given, assistance in the form of physical prompts, nonverbal prompts, and/or verbal prompts is given, when need- ed, to individual children. The primary teacher rapidly circulates among the group when assisting individual children. The gradations of prompting and fading of prompts are similar to those techniques employed by Western edu- cators, although the use of physical prompts seemed to dominate the teachers' instructional style during our observation period. During special subject ac- tivities, the special subject teacher elicits desired responses, and both the spe- cial subject teacher and the primary teacher provide the prompts to individual children.

Attention to challenging behaviors such as aggression, self-injury, and self-stimulation involves the exclusive use of redirection; that is, the child is physically prompted back into the group. For example, when a child throws his meal tray while walking to his seat, an adult immediately hands him another tray, and the child continues walking in line to his seat. When a child slaps his face, the adult quickly prompts the child's hands back into the po- sition required of the group at the moment. The adult's use of redirection

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includes little or no verbal or affective response. As the Japanese seem more interested in group achievement than the specific performance of individu- als within the group, it appears that their objective is to minimize any dis- ruption to the flow of the group process.

During our visits, we observed an increase in children's attending to instructions, and a significant decrease in challenging behaviors among many children. In the group setting, there appeared to be high rates of behavioral control but generally low rates of appropriate responding to instructional requests. While behavioral control was established in the form of children following the flow of the group, active participation in group activities and production of desired responses was not observed in most of the children.

The group process is intriguing and appears effective in facilitating at- tention to teacher instruction and behavioral control in the group of autistic children currently enrolled at the school. The children's ability to maintain self-control in the group appears due to the uniformity inherent in the group

�9 patterning, the high level of predictability of behavioral expectations, and the intensity of the adult prompting. As the behavioral expectations are made explicit by the group at every moment, the children quickly become integrated into the group dynamic.

In further exploring this group instruction model, a distinction between behavioral control and skill acquisition in a group setting needs to be ad- dressed. Specifically, our observations raise two general questions for fur- ther study: (a) What specific skills are being acquired by the autistic children in the group settings; and (b) are individual rates of learning and variations in abilities across children addressed and measured within this group instruc- tion model.

Independence Through Routine

One central characteristic of autism is the children's communicative, social, and adaptive behaviors which are dominated by repetitive, stereotyped routines. Children with autism typically behave in a perseverative manner in self-stimulation, play, language usage, and style of social interaction. They are frequently described as having difficulty adapting to changes in their daily routine.

Western special educators have begun to recognize that children with autism learn more easily and have fewer behavior problems if there is some predictability to their daily and weekly routine (OUey, 1987). Many teachers provide daily schedules and a structured classroom environment, incorporat- ing behavioral technology in their organization and presentation of instruc- tion. However, how structure and routine is defined and implemented varies

Quill, Gurry, and Larkin

greatly among special educators, as there is little research available to guide these important decisions.

At the Boston Higashi School, autistic children's reliance on predicta- ble routines is addressed by providing them with highly structured day. A predictable routine is provided across and within all daily activities. Since the majority of the children are in the residential program, they sleep and eat at specific times, exercise on a fixed schedule, and engage in all activities on a predefined schedule. To assist the children through the daily routine, there is a series of specific routines that are associated with all transitions from one activity to the next. For example, the children perform a sequence of motor exercises to begin each lesson. The routinized nature of Daily Life Therapy exists further within each lesson. For each lesson or activity, there is a restricted set of instructional materials presented and a limited set of behavioral responses elicited from the children. For example, in the elemen- tary and secondary classes, all academic lessons involve the use of worksheets. In music class, there is one song that the children practice singing every day for a month. In gym class, children engage in the same sequence of physical activities for a month or more.

Superimposed on this level of routine and structure is the group dy- namic; that is, all the children in one class are engaged in the same activity at the same time. The combination of group instruction and a highly struc- tured routine of activities strengthens the predictability and the patterning of the children.

While Daily Life Therapy appears successful in achieving group par- ticipation and behavioral control, the use of rigid routines with autistic chil- dren in American special education classrooms often results in patterns of cue dependency and difficulty with skill generalization (Quill, 1987). There- fore, questions that are raised from observation of this highly routinized pro- gram are twofold: First, is flexibility built into the routine; and second, can generalization to home and other environments be achieved?

Learning Through Imitation

The capacity to imitate is an important developmental achievement. A failure to imitate is associated with autism (Volkmar, 1987). Although some autistic children engage in verbal imitation as a communicative strategy, as in echolalia, they rarely imitate motor behaviors spontaneously (Sigman, Un- gerer, Mundy, & Sherman, 1987). Poor performance has been reported in motor imitation tasks, including body imitation (DeMyer, 1972), sequential movement patterns (Wing, 1976), and imitation of gestures and gross motor movements (Jones & Prior, 1985).

Daily Life Therapy 631

Attempts to teach imitation skills have been common in special educa- tion settings. Most typically, the use of operant procedures have been ap- plied on a individual basis (Lovaas, 1977). The relative success of imitation training seems related to a child's cognitive abilities. The successful use of normal peer modeling for the facilitation of imitation has been reported (Charlop, Schreibman, & Tryon, 1983; Egel, Richman, & Koegel, 1981) but is rarely translated into educational practice.

Learning through imitation appears central to the Dally Life Therapy model. Equal emphasis is placed upon gross motor imitation, visual-motor imitation, and verbal imitation for the acquisition of all skill areas. Gross motor imitation is integrated into all physical education activities and the routine motor exercises that precede each lesson. Visual-motor imitation is fostered through art lessons and worksheets that the children complete for academic lessons. These worksheets focus on the children's ability to trace and copy and are used exclusively to teach and reinforce language and academic con- cepts. This sharply contrasts to the use of functional experiences and manipulative materials that dominate instruction in American classrooms. Verbal imitation of speech and song is incorporated into all activities and lessons. Children are prompted to model the desired verbal responses presented by the teacher. Examples include reciting/repeating reading word lists and arithmetic facts, and singing the song of the month multiple times a day. The complexity of the elicited responses varies and is dependent on the age and general abilities of the children. Nonverbal children are not given an alternative means of responding, but are encouraged to vocalize word ap- proximations.

The use of nondisabled peer models is a crucial element of Kitahara's program in Japan that is lacking at the Boston school. Although autistic chil- dren have been shown to model nondisabled peers for the acquisition of skills, the use of observational learning among autistic peers has not been substan- tiated. Research will need to systematically examine the nature of group im- itation training at the Boston segregated program and describe its effects on the children's acquisition and use of a variety of verbal and nonverbal skills.

Physical Exercise as a Central Feature

A major problem in educating children with autism is their high rate of unproductive activity and stereotypic behavior which interferes with their ability to display appropriate behaviors and stay on task. Recent medical research has suggested that children with autism may be in a physical state of chronic hyperarousal, releasing high levels of beta-endorphins (Hardy,

632 Quill, Gurry, and Larkin

1986). Autistic children have been shown to benefit from pharmacological treatment that helps in the regulation of the response to adrenal hormones (Hardy, 1987; Radey, 1987). Behavioral research has addressed the use of physical exercise with autistic children as a positive means to reduce self- stimulatory behaviors (Kern, Koegel, Dyer, Blew, & Fenton, 1982; Kern, Koe- gel, & Dunlap, 1984; Watters& Watters, 1980), reduce out-of-seat behavior (Gordon, Handleman, & Harris, 1986), and increase appropriate play and academic responding (Kern et al., 1982).

Dally Life Therapy incorporates the use of vigorous physical exercise as a central feature of the curriculum. The program of intense physical exer- cise, dominated by running, appears to function as a means to decrease the children's undesirable behaviors by the natural release of beta-endorphins, and therefore, facilitates the children's ability to attend and learn (Hardy, 1987). During the first months in the program, children ran outside for 20 minutes, 2-3 times a day. Children who are resistant to running are physi- cally guided through the running course by an adult. An additional daily gym period includes gymnastics, aerobic exercises, and martial arts. The chil- dren engage in outside play for another hour, which involves soccer, basket- ball, biking, and climbing on play equipment. For the preschool children, the rigor of the exercise program is modified. Long walks are substituted for running and regular playground equipment is used for outside play. Their gym activities include roller skating, biking, and sprinting, along with move- ment games requiring motor imitation.

The Boston Higashi School provides an avenue to further examine the precise effects of physical exercise on a large group of autistic children with a wide range of stereotypic behaviors, self:injurious behaviors, and attentional deficits. In additon, the precision with which the exercise is structured into the Daily Life Therapy curriculum offers an opportunity to empirically exa- mine the effects of exercise on on-task behaviors across a range of skill areas.

Curriculum That Focuses on Ar t Forms

American special education aims to teach children with autism the func- tional skills they need to become active members of their family and com- munity. The language, communication, self-care, vocational, and social-leisure skills that make up an individual child's curriculum plan are carefttUy selected according to developmental and ecological considerations.

In the months observed at the Boston Higashi School, the emphasis on art, music, and movement made up the majority of the curriculum for the children. There are numerous reports of autistic children displaying in- terest in these activities, and they can be quite talented in art (Selfe, 1977) and music (Applebaum, Egel, Koegel, & Imhoff, 1979). Art, music, and move-

Daffy Life Therapy 633

merit lessons are highly structured. Instruction involves a high degree of behavior- al patterning and repetition, for example, copying a displayed picture, imitat- ing a drum beat, or imitating a set of motor exercises. On a daily basis, chil- dren at the Boston Higashi School perform their musical and movement skills during school assemblies and for school visitors. The children's art work is displayed throughout the school. In this way, Daily Life Therapy is designed to focus on the children's strengths, in the hope of developing avenues for self-expression and building self-esteem.

SUMMARY

There has been a tremendous increase in knowledge and services for children and adults with autism and related disorders over the past decade. Yet, despite this growing understanding and improved educational practice, integration of autistic children is disturbingly limited (Biklen, 1987), and au- tism remains a generally devastating disorder to family and community (Co- hen & Donnellan, 1987).

A careful examination of Daily Life Therapy as an educational philosophy and methodology seems warranted after initial observation at the Boston Higashi school. Research needs to examine the nature of the instruc- tional processes employed, and the precise effects of the treatment on autis- tic children, particularly in the area of social and behavioral functioning. Specifically, the nature of group instruction needs to be carefully examined. It is possible that for autistic children, some learning is best acquired in large- group settings, such as behavioral control, imitation, and social skills, whereas other tasks or skills require individual instruction. Daily Life Therapy can assist us in beginning to unravel these questions. That is, in our Western ef- forts to scientifically address autistic children's acquisition of functional skills through individualized programming, we may have inadvertently com- promised their social development, now recognized as central to the autistic syndrome. In contrast, the Daily Life Therapy model seems to focus on the social and behavioral manifestations of autism and may be compromising other areas of development. There is an apparent absence of both develop- mental and functional considerations in their curriculum design. Keeping in mind that we observed the initial stages of Kitahara's intervention model, there may be validity to her programmatic priorities.

Additional questions regarding the relationship between physical exer- cise and the incidence of problem behaviors is of enormous interest to the medical and educational community. Finally, there are many unresolved is- sues with respect to the applicability of this educational model in our Ameri- can culture. Is the polarity of Eastern and Western philosophies of education too broad for compromise; or can these principles of Daily Life Therapy

634 Quill, Gurry, and Larkin

be m o d i f i e d a n d i n c o r p o r a t e d in to o u r specia l e d u c a t i o n p r o g r a m s in a w a y

tha t faci l i ta tes o u r ra te o f success wi th ch i ld ren wi th au t i sm? D a i l y L i f e The r -

a p y has o p e n e d m a n y d o o r s o f i nqu i ry , a n d o f f e r s A m e r i c a n p r o f e s s i o n a l s

t he cha l l enge o f e x p l o r a t i o n .

R E F E R E N C E S

Applebaum, E., Egel, A. L., Koegel, R. I., & Imhoff, B. (1979). Measuring musical abilities of autistic children. Journal of Autism and Developmental Disorders, 9, 279-285.

Biklen, D. (1987). The integration question: Educational and residential issues. In D. J. Cohen & A. M. Donnellan (Eds.), Handbook of autism and pervasive developmental disor- ders. New York: Wiley.

Brown, F., Holvoet, J., Guess, D., & Mulligan, M. (1980). The individualized curriculum se- quencing model: Small group instruction. Journal of the Association for the Severely Handicapped, 5, 352-367.

Charlop, M. J., Schreibman, L., & Tryon, A. D. (1983). Learning through imitation: The ef- fects of peer modeling on acquisition and generalization in autistic children. Journal of Abnormal Child Psychology, 11, 355-366.

Cohen, D. J., & Donnellan, A. M. (Eds.). (1987). Handbook of autism and pervasive develop- mental disorders (p. xvi). New York: Wiley.

DeMyer, M. (1972). The nature of the neuropsychological disability in autistic children. Jour- nal of Autism and Childhood Schizophrenia, 2, 264-287.

Egel, A. L., Richman, G. S., & Koegel, R. L. (1981). Normal peer models and autistic chil- dren's learning. Journal of Applied Behavior Analysis, 14, 3-12.

Gordon, R., Handleman, J. S., & Harris, S. L. (1986). The effects of contingent versus non- contingent running on the out-of-seat behavior of an autistic boy. Child and Family Be- havior Therapy, 8, 37-44.

Handleman, J. S. (1981). A model for self-contained classes for autistic-type youngsters. Edu- cation and Treatment of Children, 4, 61-70.

Handieman, J. S., & Harris, S. L. (1983). A comparison of one-to-one versus couplet instruc- tion with autistic children. Behavioral Disorders, 9, 22-26.

Hardy, P. M. (1986). The use of beta-blockers in the treatment of self-injury. Presented at the Boston Center for the Study of Autism, Boston, MA.

Hardy, P. M. (1987). The psychopharmacology of autism. Presented at the Summer Institute on Autism, Lesley College, Cambridge, MA.

Harris, S. L., & Handleman, J. S. (1980). Programming for generalization: Educating autistic children and their parents. Education and Treatment of Children, 3, 51-63.

Jones, V. & Prior, M. (1985). Motor imitation abilities and neurological signs in autistic chil- dren. Journal of Autism and Developmental Disorders, 15,37-46.

Kern, L., Koegel, R. L., Dyer, K., Blew, P. A., & Fenton, L. R. (1982). The effects of physical exercise on self-stimulation and appropriate responding in autistic children. Journal of Autism and Developmental Disorders, 12, 399-419.

Kern, L., Koegel, R., & Dunlap, G. (1984). The influence of vigorous versus mild exercise on autistic stereotyped behaviors. Journal of Autism and Developmental Disorders, 14, 57-67.

Kitahara, K. (1983). Daily life therapy (Vol. 1). Tokyo: Musashino Higashi Gakuen School. Kitahara, K. (1984a). Daily life therapy (Vol. 2). Tokyo: Musashino Higashi Gakuen School. Kitahara, K. (1984b). Daily life therapy (3/ol. 3). Tokyo: Musashino Higashi Gakuen School. Kitahara, K. (1987). Personal communication. Koegel, R. L., & Rincover, A. (1974). Treatment of psychotic children in a classroom environ-

ment: Learning in a large group. Journal of Applied Behavior Analysis, 7, 49-59. Lovaas, I. O. (1977). The autistic child. New York: Irvington Press. Newson, C. D. (1981). School. In O. I. Lovaas (Ed.), Teaching developmentally disabled chil-

dren: The me book. Baltimore: University Park Press.

Daily Life Therapy 635

Oiley, G. (1987). Classroom structure and autism. In D. J. Cohen & A. M. Donnellan (Eds.), Handbook of autism and pervasive developmental disorders. New York: Wiley.

Quill, K. A. (1987). Autism: Innovations in curriculum development. Presented at the Summer Institute on Autism, Lesley College, Cambridge, MA.

Ratey, J. (1987). The use o f beta-blockers in the treatment o f maladaptive social behaviors. Presented at the Boston Center for the Study of Autisn~, Boston.

Reid, D. H., & Favell, J. E. (1984). Group instruction with persons who have severe disabili- ties: A critical review. Journal o f the Association for the Severely Handicapped, 9, 167-177.

Rincover, A., & Koegel, R. L. (1977). Classroom treatment of autistic children: Individualized instruction in a group. Journal o f Abnormal Child Psychology, 5, 113-126.

Rotholz, D. A. (1987). Current considerations on the use of one-to-one instruction with autis- tic students: Review and recommendations. Education and Treatment o f Children, 10, 271-278.

Schopler, E., & Reichler, R. (1979). Individualized assessment and treatment for autistic and developmentally disabled children. Vol. 1. Psychoeducational profile. Austin, TX: Pro-Ed.

Schopler, E., Reichler, R., & Lansing, M. (1980). Individualized assessment and treatment for autistic and developmentally disabled children. Vol. 2. Teaching strategies for parents and professionals. Baltimore: University Park Press.

Selfe, L. (1977). Nadia: A case of extraordinary drawing ability in an autistic child. New York: Academic Press.

Sigman, M., Ungerer, J. A., Mundy, P., & Sherman, T. (1987). Cognition in autistic children. In D. J. Cohen & A. M. Donnellan (Eds.), Handbook on autism and pervasive develop- mental disorders. New York: Wiley.

Snell, M. E. (1983). Implementing and monitoring the IEP: Intervention strategies. In M. E. Snell (Ed.), Systematic instruction of the moderately and severely handicapped. Colum- bus, OH: Merrill.

Volkmar, F. R. (1987). Social development. In D. J. Cohen & A. M. Donnellan (Eds.), Hand- book on autism and pervasive development disorders. New York: Wiley.

Watters, R. G., & Watters, W. E. (1980). Decreasing self-stimulatory behavior with physical exercise in a group of autistic boys. Journal o f Autism and Developmental Disorders, 10, 379-387.

Wing, L. (Ed.). (1976). Early childhood autism (p. 21). Oxford, England: Pergamon.